El arte como método de trabajo

Does practice change? Jordan (2000) suggests that there is little empirical evidence that continuing professional development has enhanced the quality of care given to patients. However, one may intuitively assume that increasing knowledge and skills of MHNs in the area of diabetes care will enhance the quality of the care delivered. However, as benign as this assumption is, only a well-structured research investigation will determine if it is true.

DeSilets (2006) suggests that skilled educators are experienced at taking the needs of the target audience into consideration when planning any learning activity. However, Nash (2010) asks who is the target audience; the MHN in the

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classroom or the MHSU in their living room? The prevailing orthodoxy of user involvement in mental health makes it difficult for HEIs not to consider the needs of MHSUs in the development of educational courses.

This literature review has examined available evidence regarding MHNs education and training needs and has found that both stakeholder groups have a limited and probably non-strategic input into this. We have seen the inverse relationship that influences MHN education and while protagonists may have the power to dictate curriculum, they may lack the necessary authority to do so. Hussey and Smith (2003) suggest that elements of the curriculum interact and influence each other in supporting active learning, readily reflecting what happens in classrooms. I would expand this to include service users and practitioners who influence and support each other, consciously or unconsciously in the process of learning. It is important therefore that both sets of needs are taken into consideration when developing education programmes.

HE institutions need to ensure that their curricula are contemporary, evidenced based and resonate with the needs of multiple stakeholders. This is no easy task. However, collaboration is the key to achieving a curriculum that resonates with all constituencies. The literature review argues that HEIs need to develop meaningful partnerships for developing post registration curriculum, and that TNA constitutes a way of developing more strategic links with NHS organisations to strengthen commissioning of courses.

The literature review has enabled me to explore issues in the development of MHN education. It has illustrated that traditional power bases have had a disproportionate influence in this process. However, it has also indicated that MHNs and MHSUs are distant voices in this process and have a lot to offer in this area. The literature review has helped to focus the research aims, develop research questions and terms of reference. It has also illustrated the limited research in this area hence this has helped me to refine my area of investigation.

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The literature review has influenced and informed my selection of research method. TNA tools are quantitative in nature and usually address needs from an organisational point of view. They seldom, if ever, contain any input from service users. Therefore, I decided that a Mixed Method Research approach would be employed in exploring MHNs diabetes education and skills needs. This is because MHSUs have unique experiences of diabetes care that can serve to enrich the educational experiences of professionals.

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Chapter 3:

Research Method

Introduction

MHNs education and training needs and influencing factors have been discussed in the literature review. Diabetes is an emerging educational and training need that falls outside of the traditional boundaries of MHN practice. As physical health becomes more of a clinical practice concern, we will require suitable means of exploring training needs. This chapter will outline the development of the methodological framework employed in the study. It will explain the rationale for adopting a mixed-methods research approach, while also critically examining its advantages and disadvantages for this project. It will explain the rationale for the sequential nature of the mixed methods approach. Ethical issues encountered during the research project will also be examined. This chapter will also outline my investigator’s role as an outsider researcher with regard to the both sets of study participants.

Research Paradigms

In order to explain the adoption of a mixed method research approach, it would be beneficial to explore the assumptions of quantitative and qualitative research paradigms. Exploring the philosophical basis of each paradigm will then allow progression onto the rationale for a selecting a pragmatic paradigm approach.

Prior to commencing any research project, researchers must carefully consider the philosophical assumptions of each research paradigm as this will influence the choice of research method. Guba and Lincoln (1994:105) define paradigm as the basic belief system or worldview that guides the investigator and they go on to suggest that each paradigm has different assumptions regarding knowledge and methods of inquiry. These assumptions serve to act as a coda for researchers in

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the field. Polit and Beck (2004:14) have outlined these major assumptions of positivist and naturalistic paradigms see table 3 below.

Traditionally, research is characterized as a dichotomous split between the positivist (quantitative) and the naturalistic (qualitative) paradigms. The quantitative paradigm, Sale et al (2002) suggest, is characterised by empirical research which reduces phenomena to empirical indicators which represent truth; an objective reality that exists independent of human perception, where investigator and investigated are independent of each other. In this objective world, independence is characterised by researchers being immune to the influence of subjects or even their own values.

The qualitative paradigm, on the other-hand, is based on constructivism, where research stresses the socially constructed nature of reality (Denzin and Lincoln 2011: 8). Creswell (2013: 4) suggests that qualitative research is a “means for exploring and understanding the meaning individuals or groups ascribe to a social or human problem.” Qualitative researchers do not begin research with a hypothesis to disprove, rather they seek to provide understanding through the interpretation and explanation of human experience. The emphasis is not on quantifying experience but on constructing meaning from complex human interactions.

To clarify these differences further, Bryman (2012: 28) characterizes the differences between quantitative and qualitative as a “clash reflecting a division between an emphasis on the explanation of human behavior (quantitative) and the understanding of human behavior (qualitative). Sale et al (2002) suggest that these different assumptions about truth and knowledge have resulted in an entrenchment of views characterized by each paradigm having its’ own journals, sources of funding different expertise and of course, different methods. This entrenchment is reminiscent of what Gage (1989) referred to as “the paradigm

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war”; debates about the merits and demerits of qualitative and quantitative research which contributed to an entrenchment of views about the most effective way of conducting research.

Table 3 Major assumptions of positivist and naturalistic paradigms (Polit and Beck 2004)

Assumption Positivist Paradigm Naturalistic Paradigm

Ontologic (What is the nature of reality)

Reality exists; there is a real world driven by real natural causes

Reality is multiple, subjective and mentally constructed by individuals

Epistemologic (The

relationship between the researcher and those being researched)

The researcher is

independent from those being researched

The researcher interacts with those being researched and findings are the creation of the interaction

Axiologic (What is the role of values in the inquiry)

Values are held in check – objectivity is sought

Subjectivity and values are inevitable and desirable

Methodologic (How is knowledge obtained) Seek generalisations Emphasis on discrete concepts Fixed design Quantitative information and statistical analysis Control over context Focus on the product

Seeks patterns

Emphasis on the whole Flexible design

Narrative information and qualitative analysis

Contextualised study

Focus on product and process

One concern with this presentation of assumptions is that it may accentuate the differences, or incompatibility, of combining both research traditions. Howe (1988) disputed the incompatibility thesis (the assumption that mixing qualitative and quantitative methods was incompatible) rather suggesting that no good reason existed, at either the level of practice or that of epistemology, for educational researchers not to use pragmatic approaches to research.

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However, the tension between these contrasting research philosophies can be a constraining force in research. Guba and Lincoln (1988) suggest that the different paradigm assumptions, outlined above, have led to a dichotomy between quantitative and qualitative methods. This in turn has led to conflict in determining which approach constitutes the ‘best’ path to knowledge/truth. Howe and Eisenhart (1990) suggest that a result of this paradigm split is that basic approaches to research are characterized in terms of various dichotomies; facts versus values, objectivity versus subjectivity, fixed categories versus emergent categories, the outsider's perspective versus the insider's perspective. The danger with this is that helpful research findings may be dismissed within a battle over methods or innovative approaches spurned because they too perish on an altar of epistemology.

While these positions appear be irreconcilable, mixed methods research offers us the potential to combine methods and possibly combine paradigms. Rather than seeing research paradigms as dichotomous, Burke Johnson and Onwuegbuzie (2004) visualize them on a continuum with qualitative research anchored at one pole and quantitative research anchored at the other with mixed methods research covering the large set of points in between. This also means the definition of mixed methods can be extended to include the mixing of paradigms. This characterisation is quite appealing as it is within the spirit of mixing rather than compartmentalising methods, which may be why mixed methods research is often described as the third research paradigm (Onwuegbuzie & Leech 2004), helping to bridge the gap between quantitative and qualitative research.

Terry and Cutter (2013) suggest that using a mixed methods research approach allows qualitative data to elicit rich stories from the quantitative data relating to participants’ experiences. In this study a mixed methods design was used to gain insight into MHNs diabetes education and training needs. The quantitative methods permitted a generalized examination (a macro view) of MHNs self- perceived education and skills needs and this was combined with a detailed and in depth view of how MHSUs experienced diabetes care. The latter, qualitative

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method, allowed for a micro view of diabetes care which sought to interpret the meaning of participants’ experiences and endeavour to use this meaning to give deeper understanding to the quantitative data.

Furthermore, Burke Johnson and Onwuegbuzie (2004) suggest that qualitative and quantitative research share similarities about the nature of truth and knowledge, about the role of values in research and how to interact with research participants (see table 4 above). Furthermore, researchers from both paradigms disseminate their research findings following a formula that includes a literature review, a description of methods employed, explanation of data analysis, a presentation of findings, a discussion that usually examines methodological weaknesses and a conclusion that normally has findings or outcomes based on the research. It would not be too ‘strange’ therefore to suggest that both methods can be merged. As Sandelowski (1986) points out, both paradigms also incorporate safeguards that serve to minimize bias and increase validity and reliability. Therefore, having a philosophical framework to guide the research is one of the principles of ensuring rigour, as situating research in a philosophical paradigm will contribute to the study’s overall coherence.