Nsg 7100-Theoretical Framework Research Proposal Paper

NSG 71020 Theoretical Framework Research

CONCEPTUAL FRAMEWORK

Integration of the RNAO Best Practice Guidelines (BPGs) Into an Undergraduate Nursing

Curriculum

NSG 7100 – Theoretical and Philosophical Perspectives in Nursing

Muhammad Arsyad Subu

PhD of Nursing Student University of Ottawa

[email protected]

University of Ottawa, School of Nursing

December, 2011

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mailto:[email protected]


INTRODUCTION (1-2 Pages)

In November 1999, the Registered Nurses Association of Ontario (RNAO) launched the

Best Practice Guidelines (BPGs) program. The RNAO BPGs program is a program with funding

from the Government of Ontario. The purpose of this multi-year program is to support Ontario

Nurses by providing them with Guidelines for client care. There are currently 44 published

guidelines as well as a Toolkit and Educator's Resource to support implementation. To date, 16

of these publications are available in French and continue to translate materials on an ongoing

basis (RNAO, 2011). BPGs are systematically developed statements (based on best available

evidence) to assist practitioner and patient decisions about appropriate health care for specific

clinical (practice) circumstances" (Field & Lohr, 1990). The BPGs are based on a review of a

large body of research findings and recommend the most current and evidence-based information

about concerns of nursing issues.

The main purpose of BPGs is to support nurses by providing guidelines for client care.

BPGs have emerged as an important tool to facilitate knowledge transfer of credible research

evidence (Thompson, et al, 2006). The BPGs program aims to bridge the gap between research

and practice and ensure that the most current available knowledge is put to use for the benefit of

the public who receive nursing care (RNAO, 2005). BPG should be thought of as decision

making tools within the context of patient preferences, wishes, ethics and feasibility (RNAO,

2002). The mandate of the BPG is the commitment to improve and maintain the highest

standards of evidence based practice (EBP). This will be achieved through the: 1)

implementation, evaluation and dissemination of BPGs; 2) assessment, implementation and

evaluation of care pathways; 3) continued evaluation of community nursing standards; and 4)

ensuring sustainability of the above actions.

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RATIONALE FOR STUDY

Excellent Care for All Act, Bill 46 (Chapter 14 Statutes of Ontario, 2010) point (12.c.)

mentions that…“the functions of the council are to promote healthcare that is supported by the

best available scientific evidence by making recommendations to healthcare organizations and

other entities on standards of care in the health system, based on or respecting clinical practice

guidelines and protocols, making recommendations, based on evidence and with consideration of

the recommendations “(The Legislative Assembly of Ontario, 2010).

Since it was launched, the BPGs proliferation of has promises in clinical practice, improves

patient care and outcomes as well as offers potential cost savings. Some researchers mentioned

that BPGs implementations in some clinical settings facilitate better sustainable practices and

improve patient outcomes. Therefore, attention needs to be given to better understanding the use

of BPGs by nurse educators where they provide teaching-learning process. Furthermore, BPGs

implementation by nurse educators needs to be explored in the context of the educational settings

in order to derive the maximum benefits for the students, clients, and organization.

Understanding these variations will lead to establish better methods for introducing and

transferring the BPGs to the educational settings and facilitate organizational learning that lead

to better teaching-learning process and the best students’ outcomes.

For the past decade, the nursing discipline has embraced evidence based practice to optimize

patient care. The main purpose of BPGs is to support nurses by providing guidelines for client

care. BPGs have emerged as an important tool to facilitate knowledge transfer of credible

research evidence (Thompson, et al, 2006). The BPGs program aims to bridge the gap between

research and practice and ensure that the most current available knowledge is put to use for the

benefit of the public who receive nursing care (RNAO, 2005). Important points for learners

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include: 1) Systematic development; 2) Best available evidence; and 3) BPG as decision tools.

BPG should be thought of as decision making tools within the context of patient preferences,

wishes, ethics and feasibility (RNAO, 2003). The mandate of the BPG is the commitment to

improve and maintain the highest standards of evidence based practice. This will be achieved

through the: 1) implementation, evaluation and dissemination of BPGs, 2) assessment,

implementation and evaluation of care pathways, 3) continued evaluation of Community Nursing

Standards, and 4) ensuring sustainability of the above actions.

Nursing programs require the ability to transfer knowledge to the students for their

learning with the best evidence. It is important to consider that the courses being taught in

classrooms, clinical, and laboratory settings are based on the best available evidence. The

integration of evidence based practice (EBP) in nursing undergraduate nursing curriculum will

explore the potency of available educational resources. The integration of BPGs throughout

curricula will promote student acceptance of the philosophy and underlying BPGs values as a

natural part of their approach to the nursing profession. These values include having an evidence

base for practice, integrating systematic reviews of evidence into recommendations for practice,

critical selection of appropriate recommendations for the client and the context, and transferring

knowledge to the real world of nursing care (RNAO, 2005).

In clinical settings, many studies showed that BPGs improves patient outcomes, impacts

patient referrals, creates partnership & offers cost savings (i.e. Brouwers, et al, 2004; Campbell,

et al, 2010; Coutts, 2003; Delvin, et al, 2002); Ellis, et al, 2007; Higuchi, et al, 2011; Hogan &

Logan, 2004; & Ploeg, 2004). In addition, many studies described knowledge translation (KT)

& Knowledge Utilization (KU) of evidence-based strategies in nursing disciplines. For example

KT was described (Davis et al., 2003; Glasgow, et al., 2003; Jacobson, et al., 2003; Nutley, et

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al, 2003; Ohlsson, 2002) and KU was mentioned by (Backer, 1991; Greenhalgh, et al, 2005;

Grol, 2000; Grol & Grimshaw, 2003; Rogers, 2005). However, little is known how these

strategies are used in nursing curriculum development.

STATEMENT OF THE PROBLEM (8-10 Pages)

For the past decade, the nursing discipline has embraced evidence based practice (EBP)

to optimize patient care. There is also a growing recognition of the importance of EBP in nursing

curriculum to ensure that students' learning needs are provided as effectively and efficiently as

possible. Addressing deficiencies in the dissemination and transfer of research-based knowledge

into routine nursing practice is high in nursing discipline internationally.

The Best Practice Guidelines have been piloted in some Best Practice Spotlight

Organization (BPSOs). BPSOs are health care and academic organizations selected by the

Registered Nurses' Association of Ontario (RNAO) through a request for proposals process to

implement and evaluate the RNAO's best practice guidelines. Some selected nursing programs as

BPSOs in Canada and the United States implement BPGs in undergraduate nursing curricula

(RNAO, 2011).

It is essential that sustainability of BPGs implementation needs to be maintained in order

to achieve a high level in a nursing education program. Some studies have been conducted to

investigate the integration of BPGs in clinical settings and these studies show that BPGs

improves patient outcomes, impacts patient referrals, creates partnership & offers cost savings.

However, after an intensive literature search, little has been said that BPGs are systematically

integrated in an undergraduate nursing curriculum. In addition, the barriers and facilitators in

integrating the Best Practice Guidelines in clinical practice have been mentioned in some

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articles. But, very little is discussed related to the barriers and facilitators of BPGs

implementation in an undergraduate nursing program.

LITERATURE REVIEW

Today, Evidence Based Practice (EBP) has a popular movement in influencing

knowledge development in educational and clinical nursing practice. Nursing discipline exists in

a world in which an evidence-base for professional practice is essential. EBP is in the forefront

of many contemporary discussions of nursing education and nursing practice. The impetus for

EBP in nursing comes from payor and healthcare facility pressures for cost containment, greater

availability of information, and greater consumer savvy about treatment and care options

(Youngblut & Brooten, 2001). EBP has gained momentum in nursing, and definitions vary

widely. The term "best practice" has been used to describe "what works" in a particular situation

or environment. When data support the success of a practice, it is referred to as a research-based

practice or scientifically based practice. It is important to keep in mind that a particular practice

that has worked for someone within a given set of variables may or may not yield the same

results across educational environments. EBP is a collection of facts that are believed to be true.

EBP in nursing is important because it promises to provide a research base that is directly

relevant to practice. Evidence should be generated and validated in multiple forms (Melnyk &

Fineout-Overholt, 2011).

Nursing must be the discipline that uses knowledge and evidence generated from multiple

sources as an integral part of evidence-based nursing recommendations (Carper, 1978). EBP will

integrate research findings into decision making in nursing practice. One of the goals of EBP is

to reduce practice pattern variation (Melnyk & Fineout-Overholt, 2011). EBP demands changes

in educating students, more practice-relevant research, and closer working relationships between

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clinicians and researchers. EBP also provides opportunities for nursing care to be more

individualized, effective, streamlined, dynamic, and to maximize effects of clinical judgment.

EBP encompasses multiple types of evidence such as research findings, research reviews and

evidence-based theory and the integration of that evidence with clinical expertise and client

preferences and values (Melnyk & Fineout-Overholt, 2011). With the current emphasis on

evidence-based practice in health care and the explosive growth in practice guidelines, it is

critical that careful planning be given to strategies for successful implementation (Ploeg, et al,

2007).

Development of a nursing curriculum needs to be put in serious attention if the nursing

profession is expected to be progressive. The rapid global transcendence of nursing degrees over

other health-care professions triggered most nursing schools to adopt more progressive evidence

based approach to the nursing curriculum. The term nursing curriculum is defined as the total of

philosophical approaches, curriculum outcome statements, overall design, courses, teaching

learning strategies, delivery methods, interaction, learning climate, evaluation methods,

curriculum policies, and resources (Iwasiw et al, 2009). The curriculum, whether in the academic

setting or as the learning strategy for a practice setting, is the overall plan for the education of

learners in the institution or program.

Many authors have called for changes to the curriculum to ensure a levelled building of

EBP competencies over the course of a baccalaureate program (Ciliska, 2005, Fineout-Overholt

et al., 2005, Fineout-Overholt & Johnston, 2005; Mazurek- Melnyk, 2011; Miner Ross, et al.,

2009). It has been my observation that this is not happening in a systematic way at this time,

though it simply may not be evident due to a lack of description or mapping of concepts and EBP

activities in the curriculum. According to Iwasiw, et al (2009), faculty support for curriculum

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development is mandatory for the process to begin and for a successful outcome to be achieved.

This is gained through open and thoughtful consideration of the reasons for curriculum

development and honest attention to factors that could be limiting. Attention to the values of

individual and collective faculties, an extent curriculum development might be necessary, and

the timeframe for the undertaking will influence whether approval is gained. The impetus and

decision to proceed must be thoughtfully reviewed since curriculum development is intensive,

extensive, and requires ongoing faculty dedication and involvement.

The gap between research evidence on interprofessional collaboration and nursing

practice is wide and well documented. However, among nurse educators, there is a growing

commitment to infuse their nursing curriculum with evidence-based practice. Whitehurst (2003)

defined evidence-based education as "the integration of professional wisdom with the best

available empirical evidence in making decisions about how to deliver instruction. The Canadian

Nurses Association, CNA (2010) released a position statement indicating that educators must

support those graduating from basic and continuing nursing education programs to acquire

competencies to provide evidence-informed nursing.

The turn to evidence over the past decade has far reaching implications for the study of

knowledge translation within the nursing discipline. This distinction in the context of practice

shifts the focus of knowledge translation from understanding a knowledge-to-action process to

an overwhelming emphasis on adherence to evidence-based practice guidelines. It is in the

forefront of many contemporary discussions of nursing research and nursing practice. The

practice of effective nursing, which is mediated through the contact and relationship between

individual practitioner and client, can only be achieved by using several sources of evidence.

The multiple bases of evidence are those from more acknowledged research and clinical

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experiences, and less informed clients, clients and providers, and local context and environment

(Rycroft-Malone, et al., 2004).

Curriculum implementation begins when the first course is introduced and continues for

the life of the curriculum. Successful implementation is dependent on faculty adoption of the

curriculum tenets and congruent teaching-learning approaches. Also, successful implementation

of the curriculum is dependent on forethought as the curriculum is being designed. The essential

aspects of preparing for the implementation are informing stakeholders; marketing; attending to

contextual agreement and logistics; and planning on going faculty development (Iwasiw, et al.,

2009).

Undergraduate nursing programs require the ability to transfer knowledge to the students

for their learning with the best evidence based practice. It is also important to consider the

courses being taught in classrooms, clinical, and laboratory settings are based on best available

evidence. Integration of EBP in an undergraduate nursing curriculum will explore the potency of

available educational resources. For nurses (educators and clinical instructors), the integration of

best research evidence is important with educational and clinical expertise, and students or client

values. EBP helps nurses provide high-quality client care based on research and knowledge. It is

important that nurses with the most current and comprehensive resources translate the best

evidence into the best nursing research, education, administration, policy and practice (Rycroft-

Malone, Bucknall, Melnyk, 2004).

RNAO BPGs are congruent with the practice standards and provide the best available

knowledge for practice. It has provided an Educator's Resource and a Toolkit for integrating the

Best Practice Guidelines for educational purposes. This guideline has been developed to assist

educators in both academic and practice settings to incorporate BPG into learning events, to

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promote evidence-based practice to nurse students and faculties in academic settings, and to help

nurses in practice settings (RNAO, 2005). Both the Educator's Resource and the Toolkit to be

used to plan and implement as well as to evaluate a comprehensive strategy for BPG

implementation in both academic and practice settings. The integration of BPG throughout

curricula will promote student acceptance of the philosophy and underlying BPG values as a

natural part of their approach to nursing. These values include: having an evidence base for

practice; integrating systematic reviews of evidence into recommendations for practice; critical

selection of appropriate recommendations for the client and the context; and transferring

knowledge to the real world of nursing care (RNAO, 2005). Strategies to integrate BPG content

into the practice setting will be different from approaches for the academic setting. In the

practice setting, it is important to recognize that some nurses have learned about EBP in their

undergraduate education; however, they may not have had recent exposure to BPGs. For others,

client care based on evidence may be a new concept. Implementing BPGs recommendations may

require that these nurses change their approach and EBP has not been a key in the delivery of

nursing care. Nurses rated knowledge of the client as an individual, and their own experience,

more highly than research as the basis for decision making related to client care (Gerrish &

Clayton, 2004; RNAO, 2006).

The knowledge translation and knowledge utilization concepts have gained popularity as

a viable solution to address the "research-practice gap." The discussion around knowledge

translation is on the transfer or dissemination of research findings into education and nursing

practice. Reviews of dissemination, implementation, and impact of practice guidelines in nursing

show the following factors might influence implementation: a combined strategy of opinion

leaders and in-service lectures, group culture or belief systems, time and resources, computerized

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reminders of recommendations, documentation systems, inter-professional partnerships, and

strategic commitment (Cheater & Closs 1997; Thomas et al, 1998; Thomas et al, 1999).

However, these conclusions are based on a small number of studies; some with significant

methodological limitations.

Attention to the sustainability of BPGs programs is increasing. Sustainability of

application of BPGs in an undergraduate nursing curriculum needs to be maintained in order to

achieve a high level in a nursing education program. Planning for BPGs sustainability requires a

clear understanding of the concept of sustainability and operational indicators that may be used

in monitoring sustainability over time. The reason for consistency to sustain of BPGs

implementation is that it leads to the highest quality of care and clients outcomes. The literature

provides descriptions of a number of strategies to promote the integration of evidence-based

practice in nursing clinical education (de Cordova, et. al., 2008, Eaton, et. al., 2007, Higuchi et.

al., 2006, Miner-Ross et. al., 2010, Ritchie, et. al., 2010, and Stone & Rowles, 2007). Examples

of these strategies described include: workshops for clinical instructors and/or students to

promote critical appraisal and the use of BPGs in education; clinical practices; and having the

students conduct evidence-based projects during their clinical rotations.

Many authors have discussed the potential barriers to research utilization. Some of the

articles report the results of data-based surveys on the perceptions of nurses in clinical,

administrative, or academic positions. Others are firsthand reports of informal or formal

utilization experiences. The numbers of barriers are identified and the consistency among the

reports is striking. Several papers have also discussed the barriers and facilitators to the

implementation of evidence based practice in nursing education (Ciliska, 2005, Mazurek

Melnyk, 2008, Schoales Lada, 2006). EBP must be consistently threaded throughout both

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didactic and clinical courses where real life case examples provide the framework for the EBP

process and continual reinforcement through the professional program leads to lifelong learning

skills to improve practice (Fineout-Overholt & Melnyk & Shultz, 2005). Newton (2009) stated

that the challenge of translating research findings into clinical practice has been an explicit

concern to the discipline and profession of nursing for decades. Barriers to effective use of

research include the gap between research and practice goals; the relevance or perceived

relevance of research; poor access to research or not having time to absorb it; and research-

unfriendly organizational settings (Hemsley-Brown, 2004). It is helpful to draw on Rogers'

seminal work diffusion on innovation. Rogers (2005) defined diffusion as "the process by which

an innovation is communicated through certain channels over time among the members of a

social system."

The barriers and facilitators in integrating Best Practice Guidelines in clinical settings

have been mentioned also in some articles. Few researchers have examined barriers and

facilitators experienced by other health care providers including nurses, administrators, or project

leaders who have implemented clinical guidelines (Ploeg, et al., 2007). The RNAO (2005)

predicted some facilitators that may influence the integration of BPGs in any setting: 1)

accreditation expectations; 2) professional practice standards: 3) changes to entry practice

requirements; 4) increased awareness and appreciation of evidence-based practice (EBP); social

accountability for quality outcomes; and fiscal accountability for quality outcomes. In acute,

long-term, community, extended care and home care settings. The most commonly reported

barriers were staff time, workload and resource constraints; lack of access to equipment and

resources; and; staff resistance to change (Ploeg, et al., (2007). The four most commonly

reported facilitators were: (1) presence of change champions, local facilitators, local leaders

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and/or specialist nurses; (2) staff training, education, and problem solving related to guidelines;

(3) strong unit or organizational leadership; and (4) collaboration with multidisciplinary teams

(Ploeg, et al., 2007).

In summary, nursing programs require the ability to transfer knowledge to the students

for their learning with the EBP. It is important to consider that the courses being taught in

classroom, clinical, and laboratory are based on EBP. The integration of BPGs throughout

curricula will promote student acceptance of the philosophy and underlying BPGs values as a

natural part of their approach to nursing profession. These values include having an evidence

base for practice; integrating systematic reviews of evidence into recommendations for practice;

critical selection of appropriate recommendations for the client and the context; and transferring

knowledge to the real world of nursing care (RNAO, 2005). In clinical settings, many studies

showed that BPGs have benefits for patients and organizations (i.e. Brouwers, et al, 2004;

Campbell, et al, 2010; Coutts, 2003; Delvin, et al, 2002); Ellis, et al, 2007; Higuchi, et al, 2011;

Hogan & Logan, 2004; & Ploeg, 2004). Little has been said that BPGs benefits in nursing

programs. Also, many authors mentioned the barriers and facilitators in integrating Best Practice

Guidelines in clinical practice. In nursing program, very little is discussed related to the barriers

and facilitators of BPGs implementation. In addition, many studies described knowledge

translation (KT) & Knowledge Utilization (KU) of evidence-based practice strategies in nursing

disciplines. For example KT was described by (Davis et al., 2003; Jacobson, et al., 2003;

Nutley, et al, 2003; Ohlsson, 2002) and KU was mentioned by (Backer, 1991; Greenhalgh, et

al, 2005; Grol, 2000; Grol & Grimshaw, 2003; Rogers, 2005). However, little is known how

these KT and KU strategies are used in nursing curriculum development. It is important that

these phenomena need to be explored.

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RESEARCH QUESTIONS

It is essential that sustainability of BPGs implementation needs to be maintained in order

to achieve a high level nursing education program. This study has three questions:

1. How the BPGs recommendations are integrated in overall curriculum design (theory and

clinical courses) in undergraduate nursing program?

2. What are the barriers and facilitators of BPGs implementation in undergraduate nursing

curriculum?

3. How the curriculum changes have been sustained based on BPGs recommendations?

A qualitative case study method will be used in this study. A Case study is one approach that

supports deeper and more detailed investigation of the type that is normally necessary to answer

(how, what and why) questions (Yin, 2004, 2008; Clardy, 1997; Shavelson & Townes, 2002).

Process in conducting a case study follows the same general process as other research: plan,

develop instruments, train data collectors (if necessary), collect data, analyze data, and

disseminate findings (Neale, Thapa & Boyce, 2006, Yin, 2008).

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CONCEPTUAL FRAMEWORK (15-20 Pages)

Quantitative Methods Paradigm

Qualitative and quantitative approaches are rooted in philosophical traditions with different

epistemological and ontological assumptions.

Epistemology- is the theory of knowledge and the assumptions and beliefs that we have about

the nature of knowledge. How do we know the world? What is the relationship between the

inquirer and the known?

Ontology- concerns the philosophy of existence and the assumptions and beliefs that we hold

about the nature of being and existence.

Paradigms- models or frameworks that are derived from a worldview or belief system about the

nature of knowledge and existence. Paradigms are shared by a scientific community and guide

how a community of researchers act with regard to inquiry.

Methodology- how we gain knowledge about the world or "an articulated, theoretically

informed approach to the production of data" (Ellen, 1984, p. 9).

Most qualitative research emerges from the 'interpretivist' paradigm. While we describe the

epistemological, ontological and methodological underpinnings of a variety of paradigms, one

need not identify with a paradigm when doing qualitative research.

As Bryman (2004) articulates (see chapter 1) the tension between interpretivist and positivist approaches in a political debate about the nature, importance and capacity of different research methods.

Up until the 1960s, the 'scientific method' was the predominant approach to social inquiry, with little attention given to qualitative approaches such as participant observation.

In response to this, a number of scholars across disciplines began to argue against the centrality of the scientific method. They argued that quantitiative approaches might be appropriate for studying the physical and natural world, they were not appropriate when the object of study was people. Qualitative approaches were better suited to social inquiry.

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To understand the tension between paradigms one must understand that this tension - the either or approach that emerged in the context of a debate about the capacity and importance of qualitative methods.

Byrman and others, most recently Morgan (2007), argue for a more pragmatic approach; one that is disentrangled from the entrapments of this paradigm debate, one that recognizes the ties or themes that connect quantitative and qualitative research, and one that sees the benefits of blending quantitative and qualitative methods.

Bryman, A. (2004). Quantity and Quality in Social Research. London: Routledge. First published in 1988.

Ellen, RF. (1984). Introduction. In RF Ellen (Ed.), Ethnographic Research: A guide to general conduct (research methods in social anthropology) (pp. 1-12). London: Academic Press

Morgan, DL. (2007). Paradigms lost and paradigms regained. Journal of Mixed Methods Research. 1(1), 48-76.

The Interpretivist Paradigm

Interpretivist views have different origins in different disciplines. Schultz, Cicourel and

Garfinkel (phenomenology/sociology), the "Chicago School of Sociology" (sociology), and Boas

and Malinowski (anthropology) are often connected with the origin the interpretivist paradigm.

The interpretivist paradigm developed as a critique of positivism in the social sciences. In

general, interpretivists share the following beliefs about the nature of knowing and reality.

Relativist ontology - assumes that reality as we know it is constructed intersubjectively through the meanings and understandings developed socially and experientially.

Transactional or subjectivist epistemology - assumes that we cannot separate ourselves from what we know. The investigator and the object of investigation are linked such that who we are and how we understand the world is a central part of how we understand ourselves, others and the world.

By positing a reality that cannot be separate from our knowlege of it (no separation of subject and object), the interpretivist paradigm posits that researchers' values are inherent in all phases of the research process. Truth is negotiated through dialogue.

Findings or knowledge claims are created as an investigation proceeds. That is, findings emerge through dialogue in which conflicting interpretions are negotiated among members of a community.

Pragmatic and moral concerns are important considerations when evaluting interpretive science. Fostering a dialogue between researchers and respondents is critical. It is through

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this dialectial process that a more informed and sophisticated understanding of the social world can be created.

All interpretations are based in a particular moment. That is, they are located in a particular context or situation and time. They are open to re-interpretation and negotiation through conversation.

Methodology

Interpretive approaches rely heavily on naturalistic methods (interviewing and observation and analysis of existing texts).

These methods ensure an adequate dialog between the researchers and those with whom they interact in order to collaboratively construct a reality.

Generally, meanings are emergent from the research process.

Typically, qualitative methods are used.

View of Criteria for 'Good' Research

Interpretivist positions are founded on the theoretical belief that reality is socially constructed and fluid. Thus, what we know is always negotiated within cultures, social settings, and relationship with other people.

From this perspective, validity or truth cannot be grounded in an objective reality.

What is taken to be valid or true is negotiated and there can be multiple, valid claims to knowledge.

Angen (2000) offers some criteria for evaluating research from an interpretivist perspective:

Careful consideration and articulation of the research question

carrying out inquiry in a respectful manner

awareness and articulation of the choices and interpretations the researcher makes during the inquiry process and evidence of taking responsibility for those choices

a written account that develops persuasive arguments

evaluation of how widely results are disseminated

validity becomes a moral question for Angen and must be located in the 'discourse of the research community'

ethical validity - recognition that the choices we make through the research process have political and ethical consideration.

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o Researchers need to ask if research is helpful to the target population

o seek out alternative explanations than those the researcher constructs

o ask if we've really learned something from our work

substantive validity - evaluting the substance or content of an interpretive work

o need to see evidence of the interpretive choices the researcher made

o an assessment of the biases inherent in the work over the lifespan of a research project

o self-reflect to understand our own transformation in the research process

Resources

Angen, MJ. (2000). Evaluating interpretive inquiry: Reviewing the validity debate and opening the dialogue. Qualitative Health Research. 10(3) pp. 378-395.

Blumer, H. (1969). Symbolic Interactionism. Englewood Cliffs, NJ: Prentice-Hall.

Berger, PL & Luckmann, T. (1967) The Social Construction of Reality. Garden City, NY: Doubleday and Company.

Blumer, M. (1984). The Chicago School of Sociology: Institutionalization, Diversity, and the Rise of Sociological Research. Chicago: University of Chicago Press.

Cicourel, AV. (1964). Method and Measurement in Sociology. New York: Free Press.

Garfinkel, H. (1967). Enthnomethodology. Englewood Cliffs, NJ: Prentice-Hall.

Glaser, B. & Strauss, A. (1967). The Discovery of Grounded Theory: Stragegies for Qualitative Research. Chicago: Aldine.

Guba, EG and Lincoln, YS. (1994). "Competing paradigms in qualitative research." In NK Denzin and YS Lincoln (eds.) Handbook of Qualitative Research. pp. 105-117.

Lyotard, J. (1979). The Postmodern Condition: A report on Knowledge. Theory and History of Literature. Volume 10. Minneapolis, MN: University of Minnesota Press.

Malinowski, B. (1967). A Diary in the Strict sense of the Term. New York: Harcourt, Brace & World.

Schutz, A. (1962). Collect Papers, Volume 1, The Hague, Martinus Nijhoff. See in particular: "Commonsense and scientific interpretations of human action" pp. 3-47; "Concept and theory formation in the social sciences" pp. 48-66; "On multiple realities" pp. 207-259.

Wittgenstein, L. (1958). Philosophical Investigations (GEM Anscome transl). Third Edition. Englewood Cliffs, NJ. Prentice-Hall.

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http://books.google.com/books?hl=en&lr=&id=tSi7KiOHkpYC&oi=fnd&pg=PP13&sig=YqsrlNtwte1BiQQiLKUJ29ep0OA&dq=this+discovery+of+grounded+theory&prev=http://scholar.google.com/scholar%3Fq%3Dthis%2Bdiscovery%2Bof%2Bgrounded%2Btheory%26num%3D100%26hl%3Den%26lr%3D

http://books.google.com/books?id=JSeLqab3u7sC&dq=The+Chicago+School+of+Sociology:+Institutionalization,+Diversity,+and+the+Rise+of+Sociological+Research&pg=PA1&ots=3pRMw0pTo5&sig=RqmCYNyInRZQGLJyqhC4CZiqXcI&prev=http://www.google.com/search%3Fnum%3D100%26hl%3Den%26lr%3D%26q%3DThe%2BChicago%2BSchool%2Bof%2BSociology%253A%2BInstitutionalization%252C%2BDiversity%252C%2Band%2Bthe%2BRise%2Bof%2BSociological%2BResearch%26btnG%3DSearch&sa=X&oi=print&ct=result&cd=1

http://books.google.com/books?id=JSeLqab3u7sC&dq=The+Chicago+School+of+Sociology:+Institutionalization,+Diversity,+and+the+Rise+of+Sociological+Research&pg=PA1&ots=3pRMw0pTo5&sig=RqmCYNyInRZQGLJyqhC4CZiqXcI&prev=http://www.google.com/search%3Fnum%3D100%26hl%3Den%26lr%3D%26q%3DThe%2BChicago%2BSchool%2Bof%2BSociology%253A%2BInstitutionalization%252C%2BDiversity%252C%2Band%2Bthe%2BRise%2Bof%2BSociological%2BResearch%26btnG%3DSearch&sa=X&oi=print&ct=result&cd=1

http://books.google.com/books?hl=en&lr=&id=lhdyvDMUeLMC&oi=fnd&pg=PR9&sig=THL0JnPKH6d694U8iCLwd5FGVUs&dq=Symbolic+Interactionism&prev=http://scholar.google.com/scholar%3Fq%3DSymbolic%2BInteractionism%26num%3D100%26hl%3Den%26lr%3D%26sa%3DG

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10947483&query_hl=3&itool=pubmed_docsum


Interpretive Case Studies

It is recognised that case studies can follow either quantitative or qualitative approaches

(Doolin, 1996; Stake, 1994) or any mix of both (Yin, 2003). Walsham (1995b) goes one step

further and highlights the value of interpretive case studies. In qualitative and interpretive case

studies the researcher is directly involved in the process of data collection and analysis

(Creswell, 1998; Klein & Myers, 1999; Morgan & Smircich, 1980; Morse, 1994); however, in

the latter, the researcher, through a close interaction with the actors, becomes a “passionate

participant” (Guba & Lincoln, 1994, p. 115). Even though this aspect might be regarded as a

pitfall, I contend that it is one of this approach’s advantages. It provides an opportunity to get a

deep insight into the problem under study because “[a]n interpretive explanation documents the

[participant’s] point of view and translates it into a form that is intelligible to readers” (Neuman,

1997, p. 72).

Indeed, interpretive research makes it possible to present the researcher’s own

constructions as well as those of all the participants (Guba & Lincoln, 1994; Neuman; Walsham,

1995a). This trait of interpretive case studies, however, puts an additional onus on the researcher,

as the scenario described in the next paragraph illustrates. If the interpretive researcher wants to

create an integral and persuasive piece of research around this phenomenon, each participant’s

different perspectives should be included.

The conceptual framework serves as an anchor for the study and is referred at the stage of

data interpretation (Yin, 2008). The conceptual framework serves several purposes: (1)

identifying who will and will not be included in the study; (2) describing what relationships may

be present based on logic, theory and/or experience; and (3) providing the researcher with the

opportunity to gather general constructs into intellectual “bins (Miles & Huberman, 1994). A

19


conceptual framework will include all the themes that emerged from data analysis. Yin (2008)

suggested that returning to the propositions that initially formed the conceptual framework

ensures that the analysis is reasonable in scope and that it also provides structure for the final

report.

The scope of the case study is bounded and the findings can rarely be generalized, but the

case study can provide rich and significant insights into events and behaviours. It can “contribute

uniquely to our knowledge of individual, organizational, social, and political phenomena” (Yin,

1984, p. 14). This approach serves my constructivist/feminist research paradigm and the theoretical

framework of organizational culture and change (Schein, 2004; Wheatley, 2007) embedded in that

paradigm. Qualitative case study research is supported by the pragmatic approach of Merriam,

informed by the rigour of Yin and enriched by the creative interpretation described by Stake.

Case study provides descriptive details about how our workplaces function, and can increase

understanding of a particular phenomenon. Examples of case study research might include the

exploration of how a class of students learns a new language, the study of how a group of coworkers

accepts new technology or the investigation of how women leaders in higher education function as

the assumptions of the organizational culture are challenged by globalization. The in-depth focus on

the particular within a bounded system can help provide a holistic view of a situation. It is a view that

includes the context as well as the details of an individual. Case studies do provide a humanistic,

holistic understanding of complex situations, and as such are valuable research tools. However,

unless the researcher fully understands case study and its place in the research process, and is

confident in the research paradigm from whence s/he works, the debates on its merits will obscure

the strength and direction of the research endeavor.

Stake is an interpretivist

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In his early work on case study methodology, Stake (1978/2000) maintained that “case

studies are useful in the study of human affairs because they are down-to-earth and attention-

holding” (p. 19). This approach to research makes sense to readers because it resembles our

understanding of the naturalistic world through our personal experiences. Stake commented that

“case studies will often be the preferred method of research because they may be epistemologically

in harmony with the reader’s experience and thus to that person a natural basis for generalization” (p.

20). However, Stake also acknowledged a negative bias towards case study. He observed, “The more

episodic, subjective procedures, common to the case study, have been considered weaker than the

experimental or co-relational studies for explaining things” (p. 20). Stake concluded that when the

purpose of the research is to provide “explanation, propositional knowledge, and law … the case

study will often be at a disadvantage. When the aims are understanding, extension of experience, and

increase in conviction in that which is known, the disadvantage disappears” (p. 21).

Stake (1995) believed that the most important role of the case study researcher was that of

interpreter. His vision of this role was not as the discoverer of an external reality, but as the builder of

a clearer view of the phenomenon under study through explanation and descriptions, “not only

commonplace description, but ‘thick description’” (p. 102), and provision of integrated

interpretations of situations and contexts. This constructivist position, Stake claimed, “encourages

providing readers with good raw material for their own generalizing” (p.102).

In recent discussions of case study, Stake (2005, 2008) continued to focus on the importance

of the role of researcher as interpreter, and he commented that if the case is “more human or in some

ways transcendent, it is because the researchers are so, not because of the methods” (2005, p. 443).

He acknowledged that the case itself may be studied qualitatively or quantitatively, analytically or

holistically, through measures or by interpretation, but the critical factor is that the case is a system

with boundaries, and with certain features inside those boundaries. The work of the researcher is to

21


identify “coherence and sequence” (2005, p. 444) of the activities within the boundaries of the case

as patterns. The case needs to be organized around issues – complex, situated, problematic

relationships – and questions around these issues will help deepen the theme of the case. Stake

(2005) noted that the contexts of the case, whether they are social, economic, political, ethical, or

aesthetic, are important to consider, and they “go a long way toward making relationships

understandable” (p. 449). The researcher must be “ever-reflective”, considering impressions, and

deliberating on materials and recollections. He furthered, “The researcher digs into meanings,

working to relate them to contexts and experience. In each instance, the work is reflective” (p. 450).

He confirmed his earlier views on the significance of the concept of generalizability of case study

research, when he noted, “The purpose of case study is not to represent the world, but to represent the

case … the utility of case research to practitioners and policy makers is in its extension of

experience” (1994, p. 245).

While he agreed that both qualitative and quantitative research could be undertaken through

case study, Stake (1978/2000, 1994, 1995, 2005, 2008) is clearly grounded in an interpretivist

paradigm. His creative discussion of the characteristics of case study has informed many qualitative

researchers in the meaning making of their experiences and observations within a bounded context.

Sustainability Model

In order to achieve a high level in a nursing education program, one important thing needs to

be considered is sustainability of BPGs implementation in nursing curriculums. Sustainability is

the result of effective preparation and implementation and it needs to be planned. In addition,

improvement programs will only succeed if the same effort is put into their sustainability as their

launch. The NHS Institute for Innovation and Improvement (2005) described sustainability as

‘when new ways of working and improved outcomes become the norm’. A more detailed

description, which includes the notion of ‘steady state’, in addition to promoting the desirability

22


of continued improvement, is as follows: ‘Not only have the process and outcome changed, but

the thinking and attitudes behind them are fundamentally altered and the systems surrounding

them are transformed as well. In other words the change has become an integrated or mainstream

way of working rather than something ‘added on’. As a result, when you look at the process or

outcome one year from now or longer; you can see that at a minimum it has not reverted to the

old way or old level of performance. Further, it has been able to withstand challenge and

variation; it has evolved alongside other changes and perhaps has continued to improve over

time. Sustainability means holding the gains and evolving as required - definitely not going

back”.

Sustainability is continued use of an idea (Ackerlund, 2000). Sustainability needs to be

planned, to be builds on implementation activities, and to be influenced by factors at an

individual, organizational and external level. According to Shediac-Rizkallah & Bone (1998),

underlying concepts of sustainability is behavioural and organizational change that includes

project design (duration, financing, training, and type); organization (strength, integration with

programs, champions and leaders); and community (socio-economic infl uences and community

participation). In addition, there are five themes were identified that impact on guideline

sustainability: change factors, organizational factors, implementation factors, leaders, and

passion.

In an attempt to substantially increase the sustainability of improvements for patients and

healthcare services, NHS Institute for Innovation and Improvement (2010) developed

sustainability model and guide ha for use by individuals and teams who are involved in local

improvement initiatives. The development of the model based on the premise that the changes

individual and teams wish to make fulfill the fundamental principle of improving the patient

23


experience of health services. Another important impact that can be gained by using this model

is the effective achievement of change which creates a platform for continual improvement. This

sustainability model consists of ten factors relating to process, staff and organization that play a

very important role in sustaining change in healthcare.

The conceptual framework serves as an anchor for the study and is referred at the stage of

data interpretation (Yin, 2008). Further, he suggested that returning to the propositions that

initially formed the conceptual framework ensures that the analysis is reasonable in scope and

that it also provides structure for the final report. This section will discuss NHS Sustainability

Model as framework that will guide the study.

In order to achieve a high level in a nursing education program, one important thing

needs to be considered is sustainability of BPGs implementation in nursing curriculum. In an

attempt to substantially increase the sustainability of improvements for patients and healthcare

services, NHS Institute for Innovation and Improvement (2010) developed sustainability model

and guide for use by individuals and teams who are involved in local improvement initiatives.

Many authors have defined concept of “sustainability”. For example, Rogers (2005) defined

sustainability as “the degree to which an innovation continues to be used after initial efforts to

secure adoption is completed”. The NHS Institute for Innovation and Improvement (2005)

described sustainability as ‘when new ways of working and improved outcomes become the

norm’. The concept of sustainability refers to the continuation of programs (Shediac-Rizkallah

& Bone, 1998). Sustainability is the result of effective preparation and implementation and it

needs to be planned. A sustained program is a set of durable activities and resources aimed at

program-related objectives (Scheirer, 1994). The NHS Sustainability Model consists of ten

factors relating to process, staff and organizational issues, which play a very important role in

24


sustaining change in healthcare. The Model has been developed with and for the NHS using a

co-production approach.

Recently, sustainability model is used worldwide. It is implemented inter professional

shared decision making, patient decision aids, and diversity in nursing in Australia, Chile, Italy,

Jamaica, Malta, South Africa, UK and the USA (RNAO, 2011). Sustainability is continued use

of an idea (Ackerlund, 2000). Sustainability needs to be planned, to be builds on implementation

activities, and to be influenced by factors at an individual, organizational and external level.

According to Shediac-Rizkallah & Bone (1998), underlying concepts of sustainability is

behavioural and organizational change that includes project design (duration, financing, training,

and type); organization (strength, integration with programs, champions and leaders); and

community (socio-economic infl uences and community participation). In addition, there are

five themes were identified that impact on guideline sustainability: change factors, organizational

factors, implementation factors, leaders, and passion (Shediac-Rizkallah & Bone, 1998).

The goal for using the NHS Sustainability Model is to develop an easy-to-use tool to help

improvement teams: self-assess against a number of key criterion for sustaining change,

recognize and understand key barriers for sustainability, relating to their specific local context,

identify strengths in sustaining improvement, plan for sustainability of improvement efforts, and

monitor progress over time.

Sustainability Model (Maher et al, 2007; 2010)

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NHS SUSTAINABILITY FACTORS

The development of the NHS sustainability model based on the premise that the changes

individual and teams wish to make fulfill the fundamental principle of improving the patient

experience of health services. Another important impact that can be gained by using this model

is the effective achievement of change which creates a platform for continual improvement. By

holding the gains, resources - including financial and most importantly human resources - are

effectively employed rather than being wasted because processes that were improved have

reverted to the old way or old level of performance. Sustainability model consists of ten factors

relating to process, staff and organization that play a very important role in sustaining change in

healthcare. Addressing sustainability requires planning for “scaling up” knowledge use,

including adequate human capacity, supportive financial, organizational, governance, and

regulatory structures. Issue of “boutique Interventions” designed for a specific setting but not

feasible or applicable in a large scale due to resources or relevance (Simmons et al., 2006;

26


Hanson et al., 2003). It is intended to provide a user-friendly practice-based guide to the key

factors that need to be considered for sustained organizational change (NHS, 2010). There are

some factors to consider in the development of a sustainability action plan. The following is

NHS sustainability model that consists of ten factors (Higuchi, et al, 201; Maher et al, 2007,

2010) related to process, staff and organizational issues, which play a very important role in

sustaining change in healthcare.

Process Sustainability Factors

1. Benefits

The focus on improving the students’ experience and journey through care is essential.

The sustainability of a change will be greatly enhanced if, in addition to this, the staff can

also recognise a benefit in their own role which may manifest itself in certain tasks becoming

easier or making their role feel more rewarding. The likelihood of sustaining the change is

reduced if jobs become harder, processes are less efficient or work flow becomes more

complex. Even if the reality is that none of this happens, it may never the less be perceived to

do so.

This section suggests some techniques to help recognise if the staff feel that the change is

making their jobs more difficult (real or perceived) and suggests some actions to improve

roles and efficiency of the process. Benefits beyond helping patients ensure that the change

does bring benefits to staff, patients and the organisation. It is important because it will raise

awareness of the impact on staff roles and responsibilities. It will illustrate areas of concern

and areas for celebration. It is essential to consider that it needs to be clear about the purpose

of the change. Also, need to ask staffs for their input ideas and opinions in order to get

Benefits beyond helping patients. The benefit of guidelines implementation such as

27


classroom courses (research/theory courses) and clinical/lab courses and making the faculty

workloads easier have been communicated to staff.

2. Credibility of evidence

Credibility of evidence and benefits is about ensuring that there is evidence that the

change will produce benefits that are obvious to all key stakeholders. It is important because

evidence of benefits above and beyond those gained through the existing process will give

people reason to support, accept and participate in the change. It illustrates the differences

between the existing and new process. It also identifies the benefits for patients, staff and the

organisation and communicates those benefits in a way that meets the needs of these different

audiences.

New processes are more likely to be sustained if there is evidence to support their advantages

over the existing or old processes. Staffs need to be able to understand and believe that the

new process has benefits and are more likely to support the change if at least some of these

are immediately obvious. The material that follows offers suggestions on what you can do if

the benefits are not immediately obvious or if there is limited evidence supporting the

advantages and value of the change. Put yourself into the position of the organisation or staff

who will be affected by the change. Why would they support the proposed change initiative?

It is important to be able to identify the beneficial impact of the intended change otherwise

there is little or no incentive for participation and involvement. The harder it is for people to

see the benefits for the patients, themselves and the organisation, the harder it will be to

convince them to accept the proposed or new change. There are two key elements, which will

help to demonstrate the evidence and benefits for this change. The first is identifying the

benefits and the second is being able to effectively communicate the evidence. The more

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difficult it is to appreciate the benefits of a new or revised process, even if there is evidence

to support it, the less likely staff will be to engage in the process of change. The more the

benefits are immediately obvious, the more likely that staff will support the new change.

Benefits of the change related to guideline implementation are credible, widely

communicated, immediately obvious, supported by evidence, and believed by stakeholders.

Credibility and beliefs concerning knowledge gained from guideline recommendations or

other related evidence. The monitoring of new evidence and its incorporation into practice.

3. Adaptability

Adaptability of improved process refers to the extent that the changes from guideline

implementation process can adapt to link with and even support other organizational change,

and whether the changes that are occurring during guidelines adoption will continue even if

specific individuals or groups leave the project.

Adaptability is about ensuring that the change can continue in the face of ongoing changes in

staff, leadership, organisation structures, etc. it is important in ensuring that your

improvement is flexible to the surrounding systems will help make it sustainable and become

a platform for continuous improvement. Need to be aware of potential organisational or staff

changes and look for the opportunities these could bring and be prepared to change the

original improvement plans. Adaptability can be very important in determining whether a

new or improved process will be sustained over the long run. There are three situations where

this adaptability can be very important: during the design stage when you want to use an idea

from outside the organisation but must adapt it to fit within your organisation; during a

period when your organisation changes (e.g. changes in people, location, structure) and the

29


relevance of the new or improved process is being questioned; and over time as the new

process itself becomes a candidate for further improvement.

Changes from guideline implementation process link with existing organizational processes

(e.g. permanent agenda item on key committees). Creating synergy within multiple change

processes.

4. Monitoring Progress

Monitoring progress refers the development of new systems or the revision of current

systems to measure improvement as a result of guideline implementation and whether

organizations also ensure that mechanisms are in place to continue monitoring progress

beyond the guideline implementation project, and whether the results of guideline

implementation are communicated to staffs and the organization.

Effectiveness of the system to monitor progress is about Ensuring that a system is in

place to continually and effectively monitor the progress of change. It is important in

measuring keeps us informed about success and identifies further areas for improvement. In

the absence of feedback, serious flaws or ‘slipping back’ may go unnoticed. In order to get it,

need to find out what is already being collected by others and to build measurement into

current reporting systems. Communicate the impact and benefits widely.

When the improvement has completed its pilot testing and begins full-scale

implementation, a baseline will have been established that will allow determining whether

the desired level of improvement has occurred. The message within this section is that both

measurement and communication must continue if need to sustain or ‘hold the gains’. If staff

are not able to identify and document either ongoing improvement or slippage they will be

unable to either take corrective action or think about how the process could be improved

30


even more. There is a resonance in the saying ‘we manage what we measure’. More than just

maintaining position, measurement and communication help the team to look toward ongoing

improvement of their processes beyond the point when the change is implemented.

In order to increase the likelihood of sustainability, measures should be routinely

collected in order to illustrate what is happening (e.g. are we continuing to achieve the

reduction in waiting time?). Reviewing the measures that were used during the design and

testing phases of the project is a good place to start when deciding what to measure to

support the improvement beyond the formal end of the project or initiative. However, you

should aim to collect data that will give you the best picture and keep things simple and

minimal. Think about which measures were most useful during the implementation phase;

which was the best measure in terms of identifying overall improvement; which measure did

the team relate to most; and which measure would give the senior leadership team the best

information overall.

The development of new system or the revision of currents system to measure

improvement as a result of guideline implementation and whether organization also ensure

that mechanisms are in place to continue monitoring progress beyond the guidelines

implementation project, and whether the result of guideline implementation are

communicated to client, staff, the organization, and wider healthcare community.

Staff Sustainability Factors

1. Staff involvement and training to sustain the process

Training and involvement is about ensuring that key staff at all levels are affected by

change, can contribute by being involved from the outset and trained in any new skills

needed. Staffs who feel valued are more likely to be motivated to make change work and an

31


aggressive resistance can be detrimental. It is essential to work as a multi-level team, ask,

listen, value and act on staff comments and concerns, and regularly communicate in ways

that will meet the needs of multiple audiences.

Giving front line staff the opportunity to think and work differently to solve old problems

in new ways is the only way to deliver the improvements set out in the NHS Plan. Staffs need

to be involved in decisions which affect service delivery. Individual employees within your

organisation play a crucial role in healthcare improvement whether they accept and

participate in the change, resist it or simply ignore it. Having a team of staff who willingly

take on change and do all they can to make it work is key for success and continuous

improvement, but unfortunately this ideal is often absent from many organisations. One of

the main reasons cited for hesitancy and resistance by staff is lack of involvement.

Involvement can be defined as motivating, training, informing and enabling staff to

contribute to the improvement process. ‘Employees improve their performance through

experiencing more control over and involvement in their work, leading to an increase in

personal commitment to management aims’ (Cunningham, Hyman & Baldry, 1996).

Meaningfully involving frontline healthcare staff is considered one of the biggest

challenges facing healthcare organisations looking to make improvements. Staffs are

involved in the guidelines implementation project, and whether staffs help to identify any

knowledge or skill gaps that will inform the guideline implementation process, and any

required changes to the introduction of the guidelines. This factor also includes whether there

are staff development initiatives to ensure that the staff members are confident and

competent in new way of working as a result of guideline implementation.

2. Staff behaviours toward the change process

32


An important first step towards understanding scepticism about sustainability is to try to

understand why staffs believe the change will not sustain. There may be many potential

reasons and these need to be understood at the level of the individual and can relate to

complex personal, organisational and social reasons. One very important fact to remember is

that sceptics often have a very good reason why they believe the change will not sustain and

these should be considered constructively. Some scepticism about sustainability of the

change may originate from staff involvement during the change itself and the points listed

below should be considered.

Behaviours is all about reducing scepticism by increasing belief in the change and

helping staff to feel empowered in their work. It is important to consider that negative beliefs

lead to negative outcomes. It is also important to meet regularly with staff to identify barriers

and concerns, as well as to use data and stories to demonstrate the positive impact of the

improvement. The staffs, their feelings, attitudes and beliefs are central to any effort to

achieve and sustain a change. One important aspect is the extent to which the staffs

themselves believe that the change will actually be sustained. ‘Scepticism at any level is

important in practical terms because it may manifest itself as resistance’ (Modernisation

Agency, 2002).

The staffs, their feelings, attitudes and beliefs are central to any effort to achieve and

sustain a change. One important aspect is the extent to which the staffs themselves believe

that the change will actually be sustained. ‘Scepticism at any level is important in practical

terms because it may manifest itself as resistance’ (Modernisation Agency, 2002).

Staff members are encouraged to share their ideas about the change process and whether

the change process is modified based on staff feedback. In addition, staffs believe that the

33


changes from guidelines implementation will result in a better way to do things, and whether

staff are trained and empowered to see if additional improvements should be recommended.

3. Senior Leaders

Senior administrator leadership is about engaging senior leaders and encouraging them to

engage in mutually - respectful interactions with staff and take responsibility for sustaining

change. Engaging senior administrative leaders is needed to ensure responsibility and their

interaction with staff. It is it important that a respected leader who has invested in the

improvement will be influential and help overcome barriers. It is essential to: identify the

significance of the leader’s involvement, identify the benefits of the improvement, and

regularly communicate these in a meaningful way. Countless change programmes have

faltered despite well-argued logic because people in positions of power and authority

wavered in their support.

Roles and actions of organizational leaders (e.g. school’s senior administrators such as

school’s chief Executive Officer) are highly involved and visible in their support of guideline

implementation, use their influence to communicate the impact of the work and breakdown

any barriers and the extent that open communication exists between leaders and staff.

4. Faculty and Clinical Leaders

It is about academic faculty and clinical leaders or stakeholders who engage and

encourage involvement in the project’s success. An important factor in ensuring sustainable

change is the engagement of faculty, clinicians, and stakeholders in the redesign and

improvement of services. While evidence suggests that many clinicians are committed to

improving services in principle, present levels of engagement within the clinical field could

still be improved. Clinician scepticism and the relative scarcity of clinicians willing to take

34


on the challenges and responsibility of clinical leadership for improvement are significant

risks to sustaining improvement. Redesigned systems of healthcare delivery almost always

require clinicians to change the way they work, both at an individual level and collectively

within their professional groups. It is therefore vital to engage clinicians in the redesign

process, ensuring that new ways of working take account of clinicians’ priorities and needs

(Kilo, 1999).

Because any profession is most likely to listen to advocates who understand their values

and challenges, a faculty and clinical leaders will be very important in gaining the support of

other faculties or clinicians. Faculties and clinicians are powerful actors in change; without

their support, sustainability will be difficult. Their engagement for individuals or groups of

faculties, clinicians and stakeholders could be described as developing along a range or

continuum.

Roles and actions of faculty and clinical leaders such as nursing faculty, nursing

professional practice leaders, inter-professional leaders, advanced practice nurses, are highly

involved and visible in their support of guideline implementation. It is about faculty and

clinical leaders or stakeholders who engage and encourage involvement in the project’s

success.

Organizational Sustainability Factors

1. Fit with goal and Culture

Fit with organisational strategic goal and culture is about ensuring that there is synergy

between the improvement and organisational goals and vision. It is important that a clear

links with the organisational goals and vision support long-term success for the

improvement. It is important to; identify the relationship between the organisational goals

35


and the improvement; demonstrate the impact of the improvement, and communicate widely

but especially to the senior leadership team.

Individual employees within organisation play a crucial role in healthcare improvement

whether they accept and participate in the change, resist it or simply ignore it. Having a team

of staff who willingly take on change and do all they can to make it work is key for success

and continuous improvement, but unfortunately this ideal is often absent from many

organisations.

Improvement of healthcare services to achieve better quality for patients and better

working lives for staff is a major theme for the sustainability.

In order to achieve improvements change is inevitable and this will include people and

their behaviours, clinical and managerial processes and organisational vision and culture.

Culture includes the values, beliefs and norms of an organisation, all of which influence the

actions and behaviours of the people within that organisation. A helpful way of looking at it

is through these three short statements: culture is about how things are done within

workplace; the way things are done within your team is heavily influenced by shared but

unwritten rules, and cultures reflect what has worked well in the past.

One of the reasons often cited for change initiatives that do not sustain is that there is no

clear vision or strategy which identifies how the change ‘fits’ into the organisation. Therefore

the culture of the organisation is not receptive to the change and the culture does not support

staff to be receptive to change. Every organisation should have a clear stated vision for the

future and goals, which will enable movement from the current state towards the vision state.

The goal of guideline implementation are clear and have been shared widely with staff,

and whether the goals of change are consistent with and support the organizational vision and

36


mission for improvement. Description of organizational culture, strategic goals and aims

related to guideline implementation.

Finally, fit with goal and culture is about ensuring that there is synergy between the

improvement and organisational goals and vision. It is important that a clear links with the

organisational goals and vision support long-term success for the improvement. It is

important to; identify the relationship between the organisational goals and the improvement;

demonstrate the impact of the improvement, and communicate widely but especially to the

senior leadership team.

2. Infrastructure for sustainability

Infrastructure is about ensuring the improvement effort is supported during and beyond

the formal life of the project (i.e Job roles, equipment, funding, and communication). it is

important in order to reinforce the improvement as, ‘the way we do things around here’. The

staffs, their feelings, attitudes and beliefs are central to any effort to achieve and sustain a

change. One important aspect is the extent to which the staffs themselves believe that the

change will actually be sustained. ‘Skepticism at any level is important in practical terms

because it may manifest itself as resistance’ (Modernisation Agency, 2002).

Whether changes have been made to existing policies and procedures, and whether chart

documents and forms are developed or revised to incorporate the newly adopted guideline

recommendation. Infrastructure also refers to whether organisation reviewed the adequacy of

existing resources and communication systems required to support the implementation of

guideline recommendations and have acquired necessary resources or made changes to

existing system.

Barriers and facilitator of Sustainability

37


According to Wakerman et al., (2005), the same factors can be both facilitator and barriers of

sustainability:

1. Relevance of the topic: Is there a well-defined need and priority for the knowledge that is

being implemented? Is there consensus about what knowledge needs to be sustained and

what is needed to create conditions for sustainability? How does the new knowledge fit with

current priorities?

2. Benefits: What are the anticipated outcomes of knowledge implementation from a biological,

economic, psychological, organizational, social, political, or other perspective? How

meaningful are these benefits to the various stakeholders?

3. Attitudes: What are the attitudes of the patient/ client, their family, the public, health care

providers, and relevant decision-makers toward the innovation?

4. Networks: What team or groups can be engaged to facilitate the sustainability of knowledge

use? Are there people who can be engaged to cross disciplines, settings, or sectors of the

health care system?

5. Leadership: What actions might leaders and managers at all levels of involvement take to

support the sustainability of knowledge use? Are there champions for the change? Who is

responsible for continued implementation of the innovation and making modifications as new

knowledge is brought forward? Who will be responsible for ensuring that relevant outcomes

are met?

6. Policy articulation and integration: How will the fit between new knowledge and existing

policies are assessed? How might the knowledge be integrated in relevant policies,

procedures, regulatory and documentation systems?

7. Financial: What funding is required to implement, sustain, and scale up knowledge? What

38


flexibility in funding is necessary and available for reimbursement? Can cost-effective

strategies be used?

8. Political: Who are the stakeholders and what power or support might be leveraged? Who will

initiate scaling up processes? (Buchanan et al., 2007 Davies et al., 2006; Lomas; Maher et al.,

2007; Nolan et al., 2005; Shediac- Rizkallah & Bone, 1998; Sibthorpe & Glasgow, 2005).

Monitoring Sustainability

Monitoring systems and data feedback mechanisms are needed to determine relevant

process and outcome factors to assess sustainability. Four degrees of sustainability are absent,

precarious, weak, and routinization (Pluye, et al., 2004).

RESEARCH METHODS

A qualitative case study approach will be used in this study. The selection of a proper

methodology for the study is driven by coming to understand my research questions. Although

case study method has been described clearly by several authors (i.e. Stake, 1995; Yin, 2004,

2008; Merriem, 1998; Silvermean, 2005) but I do not determine yet to follow one of these

authors to follow or use in this study. Furthermore, I need to make sure that the selection of a

proper case study methodology is driven by coming to understand my research questions: (1)

How the BPGs recommendations are integrated in overall curriculum design (theory and clinical

courses) in undergraduate nursing program?; (2) What are the barriers and facilitators of BPGs

implementation in undergraduate nursing curriculum?; and (3) How the curriculum changes have

been sustained based on BPGs recommendations?

A case study may be considered a methodology, or 'the case' may be considered an object

of the study (Creswell 1998; Stake, 1995). Yin (2004) defined case study as an empirical inquiry

that "investigates a contemporary phenomenon within its real-life context; when the boundaries

39


between phenomenon and context are not clearly evident; and in which multiple sources of

evidence are used". It investigates phenomena within its real life context, especially when the

boundaries between phenomenon and context are not clearly evident (Merriem, 1998).

Components of a case study research according to Yin (2008) are: 1) a study’s questions; 2) its

proposition (if any); 3) its unit(s) of analysis; 4) the logic linking the data to the propositions; &

5) the criteria for interpreting the findings. Components (1, 2 and 3) refer to what data are to be

collected; components (4, and 5) refer to what is to be done after the data have been collected

(Yin, 2008).

Case study focuses on the idea of a bounded unit which is examined, observed, described

and analysed in order to capture key components of the 'case'. The case might be a person, a

group of particular professionals, an institution, a local authority etc. Stake (1995) described this

kind of case study as 'holistic', it captures the essentials of what constitutes this person/this role

etc. In addition, he also offered an alternative form of case study, and this is the model which is

used most frequently by those in education: an instrumental or delimited case study (Stake,

1995).

One of the advantages of case study approach is the close collaboration between the

researcher and the participant, while enabling participants to tell their stories (Crabtree & Miller,

1999). Through these stories the participants are able to describe their views of reality and this

enables the researcher to better understand the participants' actions (Robottom & Hart, 1993). A

case study enables the researcher to answer "how" and "why" type questions, while taking into

consideration how a phenomenon is influenced by the context within which it is situated Yin

(2008). Another unique strength of a case study is its ability to deal with a variety of evidence

collected from documents, interviews, and observations (Stoecker, 1991). Study procedure will

40


be to: (a) describe what will happen in integrating the BPGs in a nursing school, (b) interpret

participants experiences (individually and collectively), and (c) describe the experiences that

participants have within their everyday lives that may have affected their BPG's curriculum

implementation.

Settings and Participants

This study will be conducted at one nursing school that has implemented BPGs in

Ontario. For inclusion criteria, site or setting is a nursing program that integrates or implements

the BPGs recommendation in undergraduate curriculum (theory and clinical courses). This long

inquiry is the case, and it will be a context-sensitive exploration which includes significant

periods of reflection and data collected from a variety of sources.

Participants in this study will be the school's faculty, program leaders (administrative

leaders), clinical partner representatives, and students. In selecting research participant, it is

important to conduct a formal case study screening procedure. The screening can be based on

reviewing documents or querying of people knowledgeable about each candidate. Useful

screening criteria include: the willingness of key persons in the case to participate in your study,

the likely richness of the available data, and preliminary evidence that the case has had the

experience or situation (Yin, 2004).

Data Collection

Data collection is emergent in case study research (Olson, 2009). According to Yin

(2008), rigorous data collection follows carefully articulated steps: the use of multiple sources of

evidence, the creation of a case study database, and the maintenance of a chain of evidence. The

use of multiple sources of data enables the researcher to cover a broader range of issues, and to

develop converging lines of inquiry by the process of triangulation. A case study allows to

41


present data collected from multiple methods (i.e., surveys, interviews, document review, and

observation) to provide the complete story or information (Neale, Thapa, & Boyce, 2006). Tools

used in this type of data collection are usually surveys, interviews, document analysis, and

observation, although standard quantitative measures such as questionnaires are also used.

For data collection procedure, it is important that the researcher use specific tools for

specific data collection. A key demand of the case study method is the investigator's skill and

expertise at pursuing an entire (and sometimes subtle) line of inquiry at the same time as (and not

after) data are being collected. In fact, good case studies benefit from having multiple sources of

evidence (Yin, 2004). A key strength of the case study method involves using multiple sources

and techniques in the data gathering process. Stake, 1995) mentioned that a hallmark of case

study research is the use of multiple data sources, and a strategy which also enhances data

credibility (Yin, 2008). Data will be collected using in-depth case study data collection methods

with participants (lecturers, students, and administrators). There are three data collection tools

and approaches of a case study method that will be used in this study: interview, document

review and observation.

Firstly, a semi-structured interview will be used as a method of data collection. A semi

structured interview provides a clear set of instructions for interviewers and can provide reliable,

comparable qualitative data. It can provide a clear set of instructions for interviewers and can

provide reliable, comparable qualitative data. Questions can be prepared ahead of time (allows

the interviewer to be prepared and appear competent during the interview). Many researchers

like to use semi-structured interviews because questions can be prepared ahead of time. This

allows the interviewer to be prepared and appear competent during the interview. According to

Bernard (1988), semi structured interview allows participants the freedom to express their views

42


in their own terms. Semi-structured interviews also allow informants the freedom to express their

views in their own terms. Semi-structure interviews can provide reliable, comparable qualitative

data (Bernard (1988). It will be used to collect data from faculty, program leaders (administrative

leaders), clinical partner representatives, and students.

Secondly, documents review is also used for data collection. Documents comprise a

variety of written, visual, and physical material those are by-products of human activity that

"document" their activity over time (Merriam, 1998). According to Olson (2009), documents is

a record of human activity, provide a valuable source of data in case study research. Documents

can also provide historical information that lead to a better understanding of the case in question

and can provide a diverse wealth of information from a wide variety of sources. This wealth of

possibilities creates several issues of which researchers need to be aware. Researchers need to be

cognizant that because different documents were created for different purposes, they will present

different points of view. To limit bias, researchers need to have a wide enough variety of

documentary sources to provide a reliable research report. On the other hand, much of the

documentary data may be irrelevant to the present research purpose, and the sheer volume of

documentary data can become overwhelming. Merriam (1998) suggested several things

researcher might need to know about the authenticity of a document: the history of the

document; the document complete, as originally constructed; the circumstances and the purpose

of it is produced; the maker's sources of information; the document represent an eyewitness

account, a second hand account, a reconstruction of an event long prior to the writing, an

interpretation. In this study, documents review will include syllabus (theory, clinical/lab),

assignments, minutes meeting, and report to the RNAO.

43


Thirdly, in order to address the research questions effectively, observation is also used as

forms of data collection. It is required particularly as sustainable development involves the

interaction between the participants and their environment. Observation allows the researcher to

get an in-depth understanding of the social reality and to "see as others see (Bryman, 2008).

Observation involves looking and listening carefully that allow studying people in their natural

setting without their behaviour being influenced by the presence of a researcher. During the data

collection, observation will be focused on teaching-learning processes (during classes, clinical

meetings, and lab sessions).

Data Analysis

According to Miles & Huberman (1994), qualitative data analysis is a continuous

process. The process, including data collection, analysis, and interpretation resulting in the

drawing of conclusions, is both interactive and cyclical in nature. Stake (1995) recognized the

importance of effectively organizing data. It will improve the reliability as it enables the

researcher to track and organize data sources including notes, key documents, tabular materials,

narratives, photographs. Data analysis should be independently conducted for each case study,

both relating back to the objectives and drawing out policy implications. Close familiarity with

each case is required to allow the investigator to draw out its unique patterns and the basis for

rich cross-case comparison (Eisenhardt, 1989).

In case study research, there are two popular types of analysis: structural analysis and

reflective analysis. Structural analysis is the process of examining case study data for the purpose

of identifying patterns inherent in discourse, text, events, or other phenomena. It is used in

conversation analysis, ethno-science, and other qualitative research methods. Yin (2008)

encouraged researchers to make every effort to produce an analysis of the highest quality. In

44


order to accomplish this, he presented four principles that should attract the researcher's

attention: show that the analysis relied on all the relevant evidence, include all major rival

interpretations in the analysis, address the most significant aspect of the case study, and use the

researcher's prior, expert knowledge to further the analysis. Stake (1995) recommended

categorical aggregation as another means of analysis and also suggested developing protocols for

this phase of the case study to enhance the quality of the research. He also presented ideas on

pattern-matching along the lines that Yin (2008). Runkel (1990) used aggregated measures to

obtain relative frequencies in a multiple-case study. Stake (1995) favoured coding the data and

identifying the issues more clearly at the analysis stage. Eisner & Peshkin (1990) placed a high

priority on direct interpretation of events, and lower on interpretation of measurement data,

which is another viable alternative to be considered.

In this research, each data source will be treated independently and the findings reported

separately. Data collected will be analyzed using NVivo software qualitative data analysis. The

software is a new generation qualitative data analysis package that can be used to analyze

interviews, field notes, textual sources, and other types of qualitative or text-based data. It allows

researchers to classify, sort and arrange information; examine relationships in the data; and

combine analysis with linking, shaping, searching, and modeling.

Rigor in case study research

The most influential model used to ensure the rigor of case study research adheres to

what is commonly called the "natural science model" (Eisenhardt & Graebner, 2007). The

natural science model groups a number of research actions under four criteria: construct validity,

internal validity, external validity and reliability (Behling, 1980; Cook & Campbell, 1979).

45


Construct validity is about appropriate definitions and operational measures for the

theoretical propositions being studied. Using several ways to measure the key variables

(constructs) in the study is an important way to overcome possible problems of inaccuracy. The

construct validity of a procedure refers to the extent to which a study investigates what it claims

to investigate, i.e. to the extent to which a procedure leads to an accurate observation of reality

(Denzin & Lincoln, 2005).

Internal validity is about establishing credible causal relationships. Yin (2008) stated that

internal validity or "logical validity" is the presence of causal relationships between variables and

results. Whereas construct validity is relevant mainly during the data collection phase, internal

validity applies also to the data analysis phase, even though many decisions regarding internal

validity are made in the design phase (Yin, 2008).

External validity concerns convincingly specifying the domain to which the findings can

be generalised. This requires carefully choosing the cases and explaining why each case has been

chosen, and its similarities and differences to other cases, in terms of the research questions

guiding the study. External validity or “generalizability” is grounded in the intuitive belief that

theories must be shown to account for phenomena not only in the setting in which they are

studied, but also in other settings. Neither single nor multiple case studies allow for statistical

generalization, i.e. inferring conclusions about a population (Yin, 2008; Lee, 2003).

Finally, reliability refers to the absence of random error, enabling subsequent researchers

to arrive at the same insights if they conducted the study along the same steps again (Denzin &

Lincoln, 2005). According to Silverman (2005), reliability is the degree of consistency with

which instances are assigned to the same category by different observers or different occasions.

According to Yin (2008), it is important to make reference to a case study database, in which

46


data such as interview transcripts, preliminary conclusions, and the narratives collected during

the study are organized in such a way as to facilitate retrieval for later investigators; and to

facilitate the replication of the case study (Leonard-Barton, 1990).

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Nsg 7100-Theoretical Framework Research Proposal Paper

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