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This section concentrates on the data gathered to generate findings and the action research cycles through which innovations were managed and evaluated. An eclectic approach was taken to data collection including the collection of

were qualitative and this matches the exploratory nature of the inquiry reflected by the research questions. This multi-method approach ensures that different

perspectives on the same issue can be explicated and works to minimise the impact of limitations of any one method. For ease of explanation, the main study can be divided into three different phases of data collection. The tools used in relation to each stage are listed in Figure 4.1 below:

Figure 4.1 Phases of data collection

Exploration phase - Describing the IPCC role and uncovering the issues • Participant observer field notes (n=61)

• Interviews (n=33)

• Focus groups (n=4) (labelled A-D15)

• Analysis of IPCC job description and relevant Trust policies (n=83) • Patient profile (n=407)

Action phase - Monitoring the action research cycles • Participant observer field notes (n=37)

• Focus groups (n=10) (labelled E-M in workshops 1 & 216) Reflection phase – Reviewing and reflecting on the study

• Participant observer field notes (n=12) • Focus groups (n=2) (labelled N-P17) • Interviews (n=4)

In practice, the differences between the three phases were not as discrete as they appear. For instance, the exploration phase lasted throughout the study as findings from other phases highlighted further data collection needed to illuminate the IPCC role. Data gathered from monitoring action research cycles also added to

understanding of the role. In action research, data collection needs to be responsive to emerging findings and practice changes, and this can mean that several activities can take place at once, or that data collection takes place in anything but a linear manner. However, three phases are used here to ease explanation.

15 _{See Appendix 3, p. 10} 16 _{See Appendix 3, p. 10} 17 _{See Appendix 3, p. 10}

4.7.1 Exploration phase

This stage consisted of collecting data aimed at describing the characteristics of the IPCC role, the impact of the role on interprofessional working, and the issues and problems associated with the role. A number of different data sources were used to describe the role and these are now described in greater detail.

4.7.1.1 Participant observer field notes

Detail has already been given of my different activities in the practice setting. Other activities were also undertaken with the primary aim of collecting data. I documented field notes in both types of interactions, that is, when the primary aim was to collect data and when the primary aim was another activity, for example, development work. There was a range of activities in which data collection was my primary aim. For instance, I often attended and observed the IPCCs’ weekly meeting with their manager. I attended some weekly interprofessional meetings (n=9) over the course of 12 months to observe the IPCC role within that setting. I attended four of the monthly directorate management meetings. I had frequent, unplanned contact with study participants where I would ‘bump into’ someone in the practice setting and exchange information with them. I also shadowed each of the four IPCCs in practice over 24 half-day sessions. One IPCC was observed for seven sessions, two IPCCs for six sessions each and one IPCC for five sessions. Although the primary aim was to collect data in each of these activities, my relationships with other participants and my role in the wider project often meant that I engaged in interactions with those present and sometimes helped out by, for example, answering the phone in the IPCC office when things were busy. Another example of this interaction is, during the shadowing of an IPCC, if I observed something that I did not understand, I would discuss the issue with the IPCC during the period of observation (but not usually during the event in question). Gold (1958 cited by Hammersley & Atkinson 1995) identifies four distinctive field roles: the complete participant, the participant as observer, the observer as participant and the complete observer. The complete participant conceals their true identity from those being observed, while at the other end of the spectrum, the complete observer has no contact at all with subjects. The degree of participation distinguishes the other two roles of participant as observer and observer as participant, although

distinguishing between these two roles. My role in this study overall most closely matched that of participant as observer in Gold’s typology, whereby I created a role for myself within the group and participated as a member of that group in

developing practice. Alongside this, I made observations of the setting and the people and activities within it. However, as will be discussed below, this may not be a helpful distinction to make.

Gerrish (1997) notes the tensions that nurse researchers can experience between the roles of participant and observer when, for example, she felt emotional discomfort at what she was participating in with the district nurses she was working with, but as a researcher, felt she could not express that discomfort. I found that while action research enabled a closer integration between the two roles of participant and observer (because, for example, of the dual purpose behind many development activities), I still sometimes experienced dissonance during activities when data collection was the primary aim. For example, in shadowing one of the IPCCs, I observed her raise the prospect of nursing home placement with a patient who had not yet been assessed by a social worker or qualified health professional. As a nurse, this shocked me and, had I been a nurse with a clinical role, I would have stepped in and attempted to rectify the situation. Usually, because of the major implications such a move would have for an individual, such a discussion would only have been had with a patient after formal assessments by a social worker and qualified health care staff, and would have been initiated by someone with a formal training in handling such sensitive matters. However, in my role that day as a researcher observing how this IPCC worked in practice, I felt I should not

intervene, as I would not then have seen how that patient interaction ended without my interference. The patient was also not physically at risk and this was an

important consideration in my decision not to intervene. However, this inability to act made me feel very uncomfortable, and represented the tensions between my background and values as a nurse and my role as an observer.

More recent writings on the role of observation (particularly in ethnographic studies) have moved away from the challenge raised by Hammersley and Atkinson (1995) of being a ‘marginal native’, that is to maintain a marginal position in the field that enables access to participants but minimises ‘the dangers of over-rapport’ (p.112). In contrast, Angrosino and Mays de Pérez (2000) dispute that a distance

between observer and observed is possible or desirable, and call for a perspective that uses observation as a ‘context for interaction’ between participants in a collaborative inquiry (p.676). In other words, the interaction itself between ‘researcher’ and ‘researched’ becomes the focus for inquiry.

To return to the example above of the IPCC discussing nursing home placement with a patient, reflecting on this incident with the IPCCs and their colleagues illuminated some of the tensions that are experienced between qualified health and social care professionals and IPCCs because of the IPCCs’ lack of formal training for their work with patients. If I were not a qualified nurse, I may not have realised the significance of what I was observing, and this is an example of how my

individual characteristics framed my observations. Because it was an action research study, I was able to use the incident as a case for reflection with

participants and this helped provide contextual meaning to the observation. It may be, given this and other similar experiences throughout the study, that within an action research context attempting a distinction between participant and observer is not time well spent. The challenge is in identifying what can be learned from what is observed in practice and from how that information is then used.

I recorded my observations and reflections in writing, sometimes at the time the events were happening and sometimes later that day. These records were kept of activities where data collection was the primary purpose and of my wider activities in the project, for example, meetings with the key participants.

These field notes served to record events occurring on a day-to-day basis within the study and those events external to the study that either influenced study progress or the work of the IPCCs. The field notes included my own record of meetings attended and accounts of informal discussions. In this phase, field note entries (n=61) were recorded for the following activities:

• Observations of IPCC work (n=24 half-day sessions)

• Observations of weekly meetings between IPCCs and their manager (n=13 meetings)

• Observations of weekly interprofessional meetings (n=9 meetings) • Records of meetings with participants (n=4 meetings)

• Records of informal interactions with participants (n=3 interactions) • Letter to participant (n=1 letter)

• Records of steering group meetings (n=3 meetings) • Reports/preliminary data analyses (n=4)

The field notes were thus often descriptive of what I had seen and what I had heard, with interpretations and reflections added. The field notes also included

preliminary data analyses carried out as data became available. As Emerson et al. (2001) point out, field notes are a representation of events, persons and places, and a degree of selectivity by the researcher is therefore an unavoidable feature. Emerson et al. note that field notes cannot provide a complete record because of decisions made by the researcher about what is significant enough to record, what can be left out and how observations are framed. These decisions may not always be conscious, and it is therefore important that the researcher is reflexive about the processes of observation and recording field notes. I tried to be reflexive about the decisions I was taking, and the account given here gives some detail about what was included. I made a conscious decision not to record things that people told me that I judged would make them uncomfortable if they were repeated to anyone else, for example, personal details about themselves or someone else that, in my opinion, were unrelated to the study focus.

Where data collection was a primary activity, the consent of those being observed was explicitly sought prior to the observation commencing. The aims behind the observation were explained and individuals were advised that they could halt the observation at any time. In contrast, it was not practical to obtain consent from people for me to ‘observe’ them in activities where development was the primary aim or in encounters that were more informal. The aims of the project had been communicated across the directorate by managers and staff were already aware of my activities. The high profile of the project, plus the familiar presence I

established for myself, obviated the need to regain consent at every encounter. While seeking consent, I negotiated with participants how I might best achieve anonymity of their contributions when findings were reported back. The challenge here was that findings would be reported back locally and far earlier than in other types of research studies, thus leaving participants vulnerable to identification. I

negotiated that names would not be used in reporting (codes were always assigned instead of names in written records) and that findings would be reported in such a way that it would be hard to identify who had said or done something. For

example, it was agreed with the IPCCs that if a report contained their biographical details, these would not include their individual codes (or names). These codes could then be used in another part of the report to report what individual IPCCs said or did with a reduced risk of their identification. Similarly, it was agreed with the clinical director that her words or actions would be attributed in reports to a doctor or a manager, whichever was more relevant at the time. This would help protect her identity. However, as Meyer (2001b) notes, it is not possible to completely guarantee anonymity or confidentiality as participants may talk to others in the field, and this was explained to potential participants prior to inviting their consent. The distinctive job title of two individuals has been used alongside some of their comments in the findings chapters (chapters 5-7) and permission has been sought from these individuals for this to occur.

4.7.1.2 Interviews

One-to-one face-to-face interviews (n=33) were conducted with the following individuals during the exploration phase:

• 8 social workers (including fast response team social worker) • 7 nurses (including fast response team nurse)

• 4 IPCCs • 4 doctors • 3 ward clerks • 3 physiotherapists • 2 operations managers

• 2 speech and language therapists • 1 senior nurse

• 1 occupational therapist • 1 dietician

People were interviewed who either worked in the IPCC role or who worked directly with the IPCCs. In a small number of interviews (n=3), two professionals from the same professional group were present. All other interviews were one-to- one. A questionnaire with open-ended questions was used to guide discussion during the interviews (see Appendix 2, p. 209). Topics covered in the

questionnaire included the role and activities of the IPCC, changes in the role since it started, and advantages and disadvantage to the role. In practice, the

questionnaire was used as a broad framework but participants were also

encouraged to engage in ‘natural’ conversation and the interaction would explore lines of inquiry that came up even if they had not been anticipated for in the questionnaire. Interviewees often asked me questions which I would endeavour to answer. When the opportunity emerged through the interaction, interviews were also used as opportunities to share study findings to date, reflect on these and sometimes to plan developments or further data collection.

Interviews ranged in length from 20 minutes to one hour and usually took place in my office in the Trust or in the interviewee’s office if this was at a suitable distance from their usual place of work. The reason for these chosen locations was to minimise the distractions for the interviewees (and the noise for the audio-tape recordings), although those with bleeps were often called to use the ‘phone during the interview. Once the call was over, the interview was resumed. Most interviews were audio-tape-recorded, transcribed and checked. When a tape recorder was not used (usually if I had not met the interviewee before), individuals were invited to verify my typed-up notes of the interview.

More recent writing on interviewing reflects a recognition that interviewers are as much a participant in the interactions that take place as the interviewee, and interviews are increasingly being seen as ‘negotiated accomplishments of both interviewers and respondents that are shaped by the contexts and situations in which they take place’ (Fontana & Frey 2000, p. 663). Although the interviews in this study had some characteristics of more traditional interview methods (e.g. location of my office, pre-set interview schedule, my usually taking the lead in the ‘flow’ of the interview), the fact that they took place in the context of an action research study meant that, particularly for interviewees involved in other aspects of the study, power relations were different. I would argue that attempts to establish

democracy throughout the study meant that interviews were conducted as a more equal enterprise between myself and other participants. I needed to be reflexive about my role during interviews and take opportunities to negotiate the structure and content of individual interviews with interviewees. (As my relationships developed with other participants over the action and reflection phases of the study, we no longer used interview schedules but instead agreed a brief topic guide at the outset of the interview – see below). The use of interview settings to share study findings and plan further developments is supported by Fontana and Frey’s (2000) recommendation to utilise feminist interview techniques that aim at more

democratic and participatory rather than exploitative purposes (Oakley, 1981). Prior to interviews taking place, potential participants would be phoned or

contacted by letter to be given a brief explanation of the project and the purpose of the interview, and be invited to participate. If they agreed (and no one refused), a mutually convenient date and time would be set. At the arranged meeting, more detail would be given of the project and the interview purpose, and confidentiality and anonymity would be discussed (as above). Participants were advised of their right to halt the interview at any time, and encouraged to stray from the interview schedule when they felt it was relevant. If the interview was to be tape-recorded, participants would be informed that the tape would be transcribed and then stored in a locked cabinet. The written transcript would contain codes not names, and would also be stored in a locked location. If the individual agreed to proceed, permission would then be sought to tape record the interview or make written notes. No one refused to take part.

4.7.1.3 Focus groups

Four focus groups were held with the IPCCs’ interprofessional team colleagues to explore understanding of the IPCC role and explore the issues pertaining to that role. One focus group was held with each of the following groups:

• Social workers (n=12 social workers present) (focus group A) • Dieticians (n=5) (focus group B)

• Nursing ward managers (n=4) (focus group C) • Occupational therapists (n=3) (focus group D)

Appendix Three (p. 211) gives details of each of these focus groups. As with other focus groups later in the study, each group was unique in its membership and the focus of its discussions. As Appendix Three demonstrates, groups varied in their size, membership and whether or not a questionnaire guided discussions. As with the observation and interview strategies used, the purpose of the focus groups often went beyond the mere collection of data. In some focus groups, I took a more explicit lead in asking the questions and facilitating the group by attending to group dynamics and encouraging all points of view. But in other focus groups, my role was much more ‘back-seat’ and consisted of allowing the interactions to develop naturally.

These differences in style were due to a number of factors including the phase of the study, whether or not those group members had been interviewed before in the study (if not, focus was more likely to be data gathering) and whether those group members had gathered together before to discuss these issues (if not, freer

discussion was more likely to emerge). The action research framework enabled this responsiveness and also legitimised the shared learning and developments that resulted.

An important advantage of focus groups is their ability to enable observation of social interactions (Kitzinger 1995). Feminist researchers have also noted how the balance of power within a focus group alters in favour of participants. This helps to encourage freer expressions of ideas and validation of the experience of