Method Essay Example

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CHAPTER 3—METHODOLOGY

Introduction

This chapter elaborates upon the research methods used in this study. A mixed methods approach, consisting of a survey, focus group and semi-structured interviews, was applied to answer the research questions with the aim of exploring the views, perceptions and opinions of neonatal intensive-care unit (NICU) nurses with respect to evidence-based practice. This chapter reports on the research aims and objectives, as well as the research design, including mixed methods research, triangulation and the setting. Each phase of the study, including methods of data collection and analysis, is also described in detail. Finally, the ethical issues of the present study are addressed.

Purpose of the Study

Sackett et al. (2000) describes evidence-based practice (EBP) as the integration of the best research evidence with clinical expertise and patient values. As such, the views of practising nurses are of importance when it comes to the determination of EBP. As mentioned in the literature review (Chapter 2), the aim of this study is to elucidate upon the attitudes and beliefs of Saudi Arabian neonatal intensive-care unit (NICU) nurses by identifying the factors that facilitate and hinder EBP. The use of EBP by the nurses will also be reviewed. Kangaroo mother care (KMC) is used to explore the organisation facilitators and barriers to the implementation of research evidence in nursing practice.

Aims and Objectives of the Research Study

Aims

  • To gain a deeper understanding of how nurses working in NICU conceptualise EBP and their experiences of putting EBP into practice.

  • To identify the opinions and roles of nurse managers in understanding and facilitating EBP.

  • To solicit the opinions of mothers and nurses in relation to an evidence-based case study, viz-a-viz the implementation of KMC.

Objectives

  1. To explore the various beliefs held among NICU nurses in Saudi Arabia about what constitutes EBP.

  2. To inquire into experiences of nurses implementing EBP in the NICU setting.

  3. To explore nurses’ perceptions of the facilitators and barriers to learning about and implementing EBP.

  4. To explore the opinions and roles of nurse managers in understanding and facilitating EBP.

  5. To assess the acceptability of the KMC intervention among neonatal nurses in Saudi Arabian hospitals.

  6. To assess the acceptability of the KMC intervention among mothers of infants in Saudi Arabian NICUs.

Research Design

This study employs a four phase mixed methods research design, involving the concurrent use of qualitative and quantitative methods. Exploratory research methods are used to provide new insights into how NICU nurses in Saudi Arabia perceive their utilisation of research, and to increase our knowledge of the facilitators and barriers to EBP (Burns & Groove 2001). According to Creswell (2003), the mixed method design is ideal for conducting translational and implementation research.

The use of mixed methods approach in research

Mixed methods research, or methodological triangulation, can enhance the validity of a study by merging two or more research methods to provide a more in-depth understanding of a research area (Polit & Beck 2004). A mixed methods study is defined as,

a research design with philosophical assumptions as well as methods of inquiry. As a methodology, it involves philosophical assumptions that guide the direction of the collection and analysis of data and the mixture of qualitative and quantitative approaches in many phases in the research process. As a method, it focuses on collecting, analyzing, and mixing both qualitative and quantitative data in a single study or series of studies (Creswell & Plano-Clark 2007, Pp 5).

Thus, the combination of qualitative and quantitative research methods has become increasingly common (Bryman 2006).

In nursing research, the mixing of quantitative and qualitative research methods is controversial. The argument goes that mixed methods research strengthens the validity of a study, making up for any weakness in the research design and elucidating a research problem more than either single approach can (Creswell & Plano-Clark 2007; Polit & Beck 2004). On the other hand, each research approach has its own weakness; quantitative research cannot provide a deeper understanding of the subjective experiences, and qualitative research is easily affected by bias and the results are difficult to generalise (Creswell & Plano-Clark 2007). Nonetheless, it should be pointed out that the combining of two research methods does not compensate for poor research design (Burns & Groove 2005).

In addition to the above, the use of mixed methods in research has several distinct advantages (Creswell & Plano-Clark 2007; Polit & Beck 2004). Firstly, the use of mixed methods enhanced the validity of a study where the research models or hypotheses are supported by multiple and complementary data. Secondly, combining quantitative and qualitative methods permits multiple perspectives and interprets the world, thereby reflecting different aspects of reality. Thirdly, mixed methods research can facilitate the identification of new avenues of research when investigators find inconsistencies in the quantitative and qualitative data.

On the other hand, there are several disadvantages: the views of two research methods were different which lead to claims related to potential incompatibility (Burns & Groove 2005). Mixed method research is not commonly used because of the difficulties in designing a cohesive qualitative and quantitative study. Polit and Beck (2004) recommend that mixed method research
requires the researchers to have the ability to deal with complex design, measurement and data collection techniques, as well as volumes of data.

Despite these advantages and disadvantages, the mixed method approach to research fulfils a range of functions. Mixed methodologies provide a strong basis for the development of research instruments, for the generation of hypotheses, for understanding relationships and for linking these relationships with correlations (Polit & Beck 2004). Moreover, Polit and Beck (2004) suggest that the mixed method approach is important for building and refining theories.
In such designs, used qualitative methods to explore and get depth understanding of the reasons for achievement or failure to implement EBP or to recognise approaches for facilitating implementation while using quantitative methods to exam and approve hypotheses based on a theoretical model angle and get a extent of understanding predictors of successful implementation (Teddlie & Tashakkori 2003). The present study uses a mixed method design for understanding and overcoming barriers to implementation of EBP by using KMC as model and monitoring effects of the context on system change and EBP implementation.

Triangulation

This section will briefly outline the methods of triangulation and how triangulation can enhance the general rigour of the present study. Moreover, potential problems associated the use of triangulation will also be highlighted.

As noted earlier, multiple or mixed methods research can facilitate the collection and interpretation of data that can lead toward a more accurate representation of reality (Denzin 1994; Foss & Ellefsen 2002). Taking this argument further, Denzin and Lincoln (2000) suppose that if there is a truth, it is to be found in unexamined phenomenon, and that diverse methods of investigation are needed to elucidate upon such truths. On this basis, it can be argued that the combination of multiple methods in a single study adds depth and breadth to the investigation. Thus, triangulation facilitates the in-depth understanding of a phenomenon having been investigated from multiple perspectives (Denzin & Lincoln 2000)

Therefore, triangulation methods are employed in this study so as to offer a sense of completeness, meaning that the phenomenon is approached from a number of vantage points to gain a more holistic view of its nature and related issues. Consequently, a more coherent picture emerges from the data and the overall credibility of results are maximised. Denzin (1994) suggests two methods of triangulation; the first, the within method of triangulation, involves the use of different strategies within the same method (e.g. the survey method, but using different scales to measure the same empirical unit). In this study, data was collected from different hospitals using different measure. The second, between method triangulation, involving the use of different methods to examine a single phenomenon. Data was collected via multiple methods, such as interviews, observations, questionnaires and focus groups. Both forms of triangulation have been evaluated in terms of their suitability and applicability for the present study. Consequently, as was the case in the present study, the exact method of research or study design should be guided by the research questions themselves (see Figure 1).

method

Overview of research questions and study methodsFigure 1.

Research setting

The research setting for this study comprises four regional hospitals in Jeddah, Saudi Arabia: the King Abdulaziz Red Sea and Research Center Hospital (KAAH), Maternity and Children Hospital (MCH), Al Aziziah Maternity and Children’s Hospital (ACH), and Al Thager Hospital. All four participating hospitals had similar characteristics, dissimilar sites potentially affecting participant characteristics. Each of the four hospitals is under of Ministry of Health. In addition, they had in-patient paediatric health and intensive care facilities.

Each of the four hospitals also had the same admission criteria for NICU: (a) premature babies at or less than 34 weeks gestation, (b) babies requiring medication or resuscitation during delivery, and (c) babies weighing less than 2500 grams at birth. Common NICU clinical cases include congenital anomalies, jaundice, prenatal asphyxia, major birth defects and respiratory distress syndrome. These ailments and their severity determine how long the infant stays in the NICU. As such, length of stay can vary from hours to weeks or months. The heads of the neonatal units are neonatologists who are supported by fellow medical officers, clinical officers and nurses, as well as various other care givers. Many of the medical procedures that babies require in the NICU can involve some pain and discomfort to the infant. Overwhelmingly, it is the nurses who are tasked with performing the majority of these painful procedures on the infants.

As shown in Table 1, the study hospitals have different staffing levels, which is dependent on NICU bed capacity. In MC hospital there are 53 admission beds cared for by 140 staff members; at KAA hospital there are currently 20 beds and 45 staff members in the NICU. The NICU in AC hospital has 14 admission beds with 30 staff; while Al Thager Hospital has 5 beds and 15 staff members. (See Table 4.1)

Table 4.1

NICU Bed Capacity and Staffing

Hospital

Incubator Capacity

Staff Number

Maternity and Child

King Abdulaziz Red Sea

Al Aziziah

Al Thager

Current NICU practice & KMC

The patients’ rights and their families policy (CBAHI 2005) are one of the policy in the Ministry of Health hospitals and Central Board for Accreditation of Healthcare Institutions (CBAHI) Standard, where cultural and personal values are respected and the patient and family are recognised as counterparts in the health care process. The NICU staff encourages mother-infant bonding in accordance with the CBAHI neonatal intensive care unit standards, specifically standard #14. Moreover, the NICU nurses strive to improve their knowledge of how best to care for premature babies in order to improve survivability. Regarding reviews done on various hospitals, KMC was informally introduced by a number of consultants and nurses across several sites following a symposium held in the Kingdom of Saudi Arabia (KSA) in 2010. Despite being aware of KMC, neither the consultants nor the nurses were teaching the method to the mothers with babies in the neonatal units. KMC is a widely recognised, evidence-based practice, endorsed by the World Health Organization and leading experts in new-born health (World Health Organization 2005). Nonetheless, the adoption and implementation of KMC at a country-level has been limited. Consequently, the NICUs at the participating hospitals have limited experience of KMC, and the procedure has not been implemented on a large scale, routinely used, or included in and formal protocols. KMC widely recognised for use internationally yet not implement in Saudi it was considered to be a good example to explore attitude, belief, barrier and facilitators to EBP in clinical practice in Saudi.

Each of the four phases of this project will now be outlined.

Phase One

Aim

To gain a deeper understanding of how nurses working in neonatal intensive care units conceptualise EBP and their experiences in practice.

Design

An exploratory and descriptive mixed methods design was used. First phase Ia, a survey of all neonatal nurses working in the four participating hospitals was conducted. Secondly phase Ib, focus groups were held with the NICU nurses.

Inclusion criteria:

  • Neonatal nurse graduates (diploma, degree or above),

  • Registered nurses (RN) with licensure accredited by the Saudi Commission for Health Specialties,

  • Nurses who are engaged in clinical practice,

  • Any cultural background, and

  • More than one year experience (for focus groups).

Exclusion criteria:

  • Non-NICU nurses (i.e. those working in other departments),

  • Nurses in administrative positions (i.e. non-clinical nurses),

  • Nursing aids,

  • Student nurses, and

  • Nurses with less than one year of experience (for focus group).

Phase Ia: Survey

This quantitative study employed a descriptive cross-sectional design. Data were collected to measure research utilisation (RU) among NICU nurses (i.e. dependent variable) and individual and context factors (i.e. independent variables). Data were collected using a paper-based, self-report survey. Self-report surveys are often used to elucidate social and behavioural variables and the relationships between these variables. The response of a representative sample is thought to be indicative of the opinions and attitudes of the whole population from which the sample was drawn.

Sample

The questionnaire was completed by 220 nurses (RNs and Licensed Practical Nurses) working in four hospitals in Jeddah, Saudi Arabia. There were 235 participants identified, with 230 being eligible based on the inclusion criteria. Thirteen did not complete questionnaires, leaving 207 participants whose data contributed to the current analysis. Participant selection was based upon the inclusion/exclusion criteria described above.

Research Instruments

Tools used for this part of the study include the Research Utilization Survey, the Alberta Context Tool and a section recording socio-demographic and professional information.

Research Utilization Survey (Estabrooks, 1999)

Used to measuring various types of research and the use or non-use of research findings in practice. The original instrument contained 90 items spread over five sections. With Estabrooks permissions, the original 90 item survey reduced to 39 items: 25 items measuring individual and contextual factors, and 14 items measuring types of research use and different aspects of research evidence.

The modified Research Utilization Survey was chosen for this study and comprises four items, each reflecting a particular kind of research utilisation: (a) instrumental, (b) conceptual, (c) persuasive, and (d) overall (see Table 2). It contains 22 questions divided into three sections: research use, kinds and sources of practice knowledge, and organizational supports. This self-report survey had been used by Kenny (2002) and Connor (2006) and was determined to be compatible with the conceptualisation of research utilization, as proposed by Estabrooks (1997, 1999a) The internal consistency of each subscale item in the original instrument was tested and indicated satisfactory Cronbach’s α scores ranging from 0.72 to 0.85 (Estabrooks 1997) and in the shorten version was ranging from 0.75 to 0.93 (Kenny 2002) or 0.74 to 0.89 (Yoder et al. 2014).

Scales and subscale of the Research Utilization Survey

Definition / Sample item

Direct Research

Utilisation(instrumental RU)

Instrumental research use

Definition: Using observable research-based practices when care for patients. By this we mean that practice may be guided by guidelines, Protocols, routines, care plans or procedures that are based on research.

Overall in the past year, how often did you use research in this direct way in some.

7-Point Likert Scale (Never to Nearly Every Shift).

Indirect Research

Utilisation

(conceptual RU)

Conceptual Research Use

Definition: Thinking about research-based knowledge and then using it to inform your clinical decision-making

Overall in the past year, how often did you use research in this non- direct way in some aspect of your nursing practice?

7-Point Likert Scale (Never to Nearly Every Shift).

Persuasive

Research

Utilisation

(symbolic RU)

Persuasive Research Use

Definition: Using research findings to win an argument or make a case to someone regardless of whether you have made a thorough assessment of the research

Overall and including all of the categories of people in previous question, in the past year how often have your used research in this pervasive way?

7-Point Likert Scale (Never to Nearly Every Shift).

Overall/General

Research Use

Overall/General Research Use

Some organisational investigators have argued that research use is much more general and have suggested the following definition:

Definition: The use of any kind of research findings, in any kind of way, in any aspect of your work as a professional in your role (this is inclusive of the three kinds of research use described above).

7-Point Likert Scale (Never to Nearly Every Shift).

Trust research

Evidence

How much faith do you have that nurse research will produce research that is. . .

  1. relevant…

  2. easily used…

  3. can safely be used…

5-Point Likert Scale (None to A Great

Suspension

How willing are you to implement research when it contradicts something you…

How often do you actually implement research when it contradicts something you…

  1. learned prior to nursing school?

  2. learned in nursing school?

  3. learned in your place of work?

5-Point Likert Scale (Very Unwilling

to Very Willing).

Interpersonal

Relationships

Supportive of

Degree to which the following people are supportive of you using research in your practice:

  1. Other nurses in your area

  2. Your immediate supervisor

  3. Nursing administration

  4. General administration

  5. Physicians

  6. Other health professionals

5-point Likert Scale

(not at all supportive to very supportive)

Practice.

How often have you avoided using research in this direct way because you did not believe you had the authority to do so, even though you were convinced of the usefulness of the research?

5-Point Likert Scale (Never to Nearly Every Shift)

Scoring reversed so that higher score reflects higher authority score.

Organisational

Resources to

support RU

To what extent are the following organisational factors present in your workplace?

  1. Nurses/others with research skills

  2. Paid time allotted for participation in various research activities

  3. Attendance at research and clinical conferences encouraged

  4. A group or committee to review and critique research

  5. Money from internal and /or external sources for research

5-point Likert Scale

Importance of

Access to

Organisational

Resources

Do you think that better access to the above is important to whether or not you use research?

5-Point Likert Scale

(Not At All

Important to Extremely Important).

Time for RU

Activities.

In a normal workday is there ever time to do any of the following:

  1. Use the library

  2. Read ( Journals/text)

  3. Reflect on your practice

  4. Participate in projects

  5. Participate in research

5-Point Likert Scale

(Not At All to

Always).

TThe Alberta Context Tool (ACT) (Estabrook et al., 2009).

The ACT was developed for adult acute care and later adapted for paediatric acute care, residential long-term care and community health. It is used to measure individual healthcare provider’s perceptions of context. The definition of each dimension and sub-dimension for all ten ACT concepts is described below (see Table 3).

Dimensions and sub-dimensions of the ACT

Definition

Leadership

The actions of formal leaders in an organisation (unit) to influence change and excellence in practice; items generally reflect emotionally intelligent leadership.

5-Point Likert Scale

The way that “we do things” in our organisation and work units; items generally reflect a supportive work culture.

5-Point Likert Scale

Evaluation

The process of using data to assess group/team performances and to achieve outcomes in organisations or units (i.e. evaluation).

5-Point Likert Scale

Social Capital

The stock of active connections among people. These connections are of three types: bonding, bridging, and linking.

5-Point Likert Scale

Informal Interactions

Information exchanges that occur between individuals working within an organisation (unit) that can promote the transfer of knowledge.

5-Point Likert Scale

Formal Interactions

Formal exchanges that occur between individuals working within an organisation (unit) through scheduled activities that can promote the transfer of knowledge.

5-Point Likert Scale

Structural / Electronic Resources

The structural and electronic elements of an organisation (unit) that facilitate the ability to assess and use knowledge.

5-Point Likert Scale

Organisational Slack (3 concepts)

The cushion of actual or potential resources which allows an organisation (unit) to adapt successfully to internal pressures for adjustments or to external pressures for changes.

  Availability of adequate staffing levels to provide patient care 

5-Point Likert Scale

  Availability and use of adequate space to provide patient care and share best practice knowledge 

5-Point Likert Scale

  Availability of time to provide patient care and share best practice knowledge 

5-Point Likert Scale

The validity and reliability of ACT has been tested several times in different healthcare settings and among different healthcare professionals. Individual responses to the tool have been aggregated to provide team or unit scores of organisational context (Cummings et al. 2010; Estabrooks et al. 2009, 2011a, 2011b). In general, more positive organisational contexts are associated with higher reports of research use in practice (Cummings et al. 2010).
Internal consistency reliability using Cronbach’s alpha coefficients was reported; alpha coefficients ranged from a low of .54 (for structural and electronic resources) to a high of .91 (for leadership and evaluation) Structural, electronic resources, formal interactions and organizational slack-space had alpha coefficients less than the standard. According to Estabrooks, the lower coefficients may be due to these items addressing concepts that are broader, and perhaps more subject to individual interpretation, than the items in the remaining context concepts (Estabrooks et al. 2009). A subsequent validity assessment was conducted on responses obtained from healthcare aides in residential long term care settings (Estabrooks et al. 2011a). The overall pattern of the ACT data (which were assessed using confirmatory factor analyses) was consistent with the hypothesized structure of the ACT. Additionally, eight of the ten ACT concepts were related to instrumental research utilization at statistically significant levels, supporting ACT validity.

Demographics.

In addition to the instruments described above, the survey obtained basic demographic information. Participants were asked to identify their age, education level, primary role, experience, type of unit, length of work in this unit and employment status.

Pilot Study

The main reason for undertaking this pilot study is to test the feasibility of instruments and ensure that the research design is appropriate (Burns & Grove 2007). The pilot study was conducted four weeks before the main study. Although the instruments had been piloted previously by Estabrooks, to assess relevance to a Saudi context they required retesting as it was being used on a different population. Johnson and Christensen (2012) state that a questionnaire or survey must be pilot tested “to determine whether it operates properly,” and that this must be done “before using it in a research study” (p. 183). The RU and ACT were first piloted with 20 volunteer nurses from a paediatric unit. They provided feedback on the questions, ease of administration, length and clarity of the survey. None of the volunteers completing the pilot survey were eligible for inclusion in the actual data collection. Pilot participants reported no problems with ambiguity or difficulty completing the questionnaire. No any changes of the questionnaire were suggested for the main study.

Data Collection

After ethical approval from the School Ethics committee (14.02.01.V2), the researcher sent a letter to the Directors of Nursing of each of the participating hospital (n = 4) in order to seek access to the NICU nurses. This was followed by a phone call to the Directors of Nursing to arrange for the delivery of the questionnaire. However, before distributing the questionnaires, it was important to have an in-depth discussion about the research with the Nursing Director or Unit Manager. During this meeting, the Nursing Director was given the opportunity to query anything with regard to the study. Four days before the distribution of the questionnaires, a brief letter was again sent to the Nursing Director and Unit Manager to remind them of the importance of the survey. The questionnaire was coded before being distributed. Each hospital was coded differently to distinguish it from different hospitals during the analysis.

The questionnaire (including: information sheet, consent form, invitation letter to participate in a focus group and an envelope used to return the questionnaire) were distributed among 230 NICU nurses in May, 2014. Potential participants were requested to complete the survey and return it in a sealed box located in the Nursing Director’s office of each hospital. This box was then collected by the researcher. The nurses were asked to complete and return the survey within a two-week period. In a bid to increase the response rate, follow-up procedures were planned. First, the researcher made a personal connection with the Nursing Director/Unit Manager of each hospital to encourage participation. Second, a reminder letter was sent every two weeks to the two hospitals whose nurses had not returned the survey.

Data Analysis

Descriptive statistical analysis:

All data collected from the participants were entered into Statistical Package for the Social Sciences (SPSS, version 19.0) for coding and data screening. Data were cleaned and corrected for any error by rechecking the original questionnaires. Frequency distribution, cross tabulation and t-test were used to explore the normal distribution of the sample

Research Utilisation (RU) : Data from responses the surveys were used to measure and compare the frequencies of four types of RU. Each type of RU was measured using the same 7-point Likert scale. The mean score and SD for each type of RU were calculated t-test, and the Chi-squared statistical test, depending on the nature of the data, to determine if there were any statistically significant differences between the individual attitudes, beliefs and organisational culture.

Alberta Context Tool: The survey measured contextual factors. Data measuring the contextual factors were analysis to determine if there were any statistical differences between the measures of these contextual factors reported by each group. Similar to the testing of the measures of RU, t-tests were carried out to examine the calculated means of the ordinal and interval data, and a chi-square statistic was used to examine the frequency distribution of the categorical data.

Logistic Regression Analysis: Logistic regression is a type of generalised linear model that is used to predict an event based on known factors. In this study,
logistics regression was used because having a categorical outcome variable. To predict whether NICU nurses used research based on individual factors (e.g. age, gender, education, and other demographic data) or context factors (e.g. time for research, level of authority, leadership, culture, and other context factors)

Phase Ib: Focus Groups

Focus groups are one of the most commonly used methods of data collection in education research (Johnson & Christensen 2012). The purpose of focus groups is to provide “in-depth and rich information about participants; worldviews and their personal perspectives and subjective meanings” (Johnson & Christensen 2012, p. 429). The focus groups allowed for a more complete exploration of the attitudes and beliefs of the nurses in regard to EBP. In addition, one of the benefits of using focus groups is the “explicit use of group interaction to produce data and insights that would be less accessible without the interaction found in a group” (Morgan 1997, p. 2). The intention of the group was that, by hearing from others about their beliefs, nurses would be encouraged to be honest and participate in an open dialogue about the topic and their personal experience. Rather than being too directive, “the focus group interview allows the participants in the group to comment, explain, disagree, and share attitudes and experiences” (Curtis & Redmond 2007, p. 25).These Phase1 focus groups involved neonatal nurses and was focused on the topic of using KMC in NICUs.

Sample

Purposive sampling was used to recruit NICU nurses, with 6–8 participants in each focus group, one group in each participates hospitals. Participants were approached on a voluntary based and selected for the purpose of the study based on inclusion/exclusion criteria

Interview Schedule

The researcher used a focus interview schedule (appendix1) to guide the group discussion. The group discussions needed to be guided and directed so that they would remain focused on the topic of interest. The focus group was to be semi-structured and response-led.

Data Collection

The focus group session were conducted in the discussion or seminar room to ensure a comfortable and convenient environment. Focus groups were taken about 60 minutes. At the commencement of each scheduled focus group session, the researcher introduced herself and provided name badges for the participants and thanked the participants having agreed to be involved in the study

Focus group sessions began with participant signing a consent form (a copy of the signed consent form was returned to each participant) and completing the demographic information sheet (see Appendix ). The meeting began informally so as to create a friendly environment so that the participants would not feel anxious or nervous and providing a short orientation as to how the discussion would be conducted. This is important as it gives the participants an opportunity to express their views on the questions. Participants were seated facing each other around tables with name cards (first name only) for identification purposes. Sessions were recorded both by tape and transcription. Participants introduced themselves then presented with a series of questions to gain insight into their knowledge, views and application of KMC. The focus group guide was intended to provide structure without rigidly dictating the line of questioning. The researcher included prompts and encouraged participants to expand on their initial responses and followed up on ideas that the participants raised themselves. In between, participants were asked about the clarity of the messages and for suggestions as to how to make them more easily understood. At the end of each focus group, the researcher provided the group with a summary of the discussion, additional clarification, and correction and strengthening of the data. In order to strengthen the analysis process and gather the most appropriate data, the researchers reviewed the recording made on the first day and reflected on the procedures employed in the focus groups.

Data Analysis

Thematic analysis is a method for “identifying, analysing and reporting patterns (themes) within data” (Braun & Clarke 2006, p. 79). Thematic analysis is a useful method to analyse qualitative data and provides a rich, detailed and complex account of the data (Braun & Clarke 2006; Cassell et al. 2005; Fereday & Muir-Cochrane 2006). Thematic analysis has been shown to be a flexible and effective method of analysis for interview data as it does not ascribe to any pre-existing theoretical framework (Attride-Stirling 2001; Braun & Clarke 2006; Tuckett 2005). Therefore, its use in this study would be suitable and beneficial.

The data collected from all the focus groups were transcribed by the principal investigator, during this process the initial thoughts and ideas were noted down as this is considered an essential stage in analysis (Riessman 1993). The transcribed data was then read and re-read several times. In addition, the transcriptions were read while listening to the recordings of the interviews several times over to ensure the accuracy of transcription. The subsequent coding built upon the notes and ideas generated through transcription and data immersion. These codes recognised within the data that the researcher considered pertinent to the research question. The third stage involved searching for themes; these explained larger sections of the data by combining different codes that may have been very similar or may have been considered the same aspect within the data. All initial codes relevant to the research question were incorporated into a theme. Braun and Clarke (2006) recommend the development of thematic charts to help in the generation of themes. These helped the researchers to develop a more complete picture of the data and to consider the links and relationships between the themes. The final stage or the report production stage involved choosing examples from the transcripts to illustrate components of these themes. These quotations clearly identified issues within the theme and presented a simple example of the point being made.

Phase II Interviews

Interviews are the most commonly used method of data collection in qualitative research (Gillham 2005; Holloway & Wheeler 2002; Taylor 2005), aiming to understand the world from the perspective of the participants. Interviews attempt to capture participants’ feelings, experiences and ideas. Face-to-face semi-structured interviews were chosen as the qualitative method of data collection in this phase of the study.

Although interviews often contain informal questions and the tone of the interview is generally conversational, interviews are more than conversation and the questions asked in the interviews provide structure (Holloway & Wheeler 2002; Taylor 2005).

The purpose of this phase was to identify views, beliefs and attitudes of nursing managers (Nursing directors, Nursing educators, NICU Unit managers) toward EBP, discover the barriers to use of EBP and to facilitate the use of EBP in their practice.

Semi-structured interviews with nursing managers.

Inclusion criteria:

  1. Graduate nurses (diploma, degree or above),

  2. Registered nurses (RN) with licensure accredited by the Saudi Commission for Health Specialties

  3. Nurses from any cultural background, and

  4. Working in and administrative positions (Nursing Directors, Unit Managers and Nursing Educators).

Exclusion criteria:

  1. Nurses engaged in clinical practice,

  2. Nurses working in NICU or other departments,

  3. Nursing aids, and

  4. Student nurses.

Purposive sampling was used to obtain participants for this study because the study design precluded the use of random sampling. Purposive sampling involved the researcher making a conscious decision about which individuals and which hospital sites would best provide the desired information (Burns & Grove 2007; DeVaus 2002). This type of non-probability sampling was chosen in order to provide the researcher with the most useful data.

Researchers choose participants capable of giving a richness of information suitable for detailed research (Patton 1980). The interviews were conducted with the Nursing Director, Unit Manager and Nursing Educator of each participate hospitals. The participants were purposefully selected because of their unique expertise in their respective fields.

Interview Schedule

The interviews were semi-structured one-to-one open-ended interviews and response-led. The interview schedule (appendix) for managers was composed of two parts. The first part consisted of six questions (Q1–Q6) that probed their perceptions, opinions, concerns and issues related to EBP. The second part (Q7–Q11) focused on their opinions about the barrier and facilitator to EBP implementation. Questions focused on the respondents’ expectations and perceptions.

Data Collection

The researcher made appointments to interview respondents via e-mail , face -to-face or through phone calls, depending on the preferences of the participants. Before commencing the interviews the researcher introduced themselves to the participants and the study was briefly explained. Participants were then asked to sign a consent form.

Interviews with Nursing Educators, Nursing Directors and Unit Directors were conducted in their offices or in a room available at their hospital. The participant chose the venue of the interview because it was the most suitable place and accessible for them to spend time for the interview. During one of the interviews there was constructing in the hospital and the ambient noise made this interview very difficult to implement. Reschedule of this interview was hard as its reschedule twice before. Researcher makes sure to provide an environment that is trustworthy. At the same time, be sensitive to the power hold over participants. Two of the interviewers are known by researcher, because researcher work in one of participate hospital Researcher avoids setting up a situation in which participants think they are friends. At the end of the interview, the interviewer offered the respondent more contact if anything was not clear or needed to be clarified.

Field notes:

Field notes were taken immediately after each interview in order to get an understanding of the depth of the interviews and for later reflection following the interviews. Field observations provided additional information, such as the length of the interview, the atmosphere during the interviews, the ideas that emerged, a brief summary of the interview performance, personal questions and keywords used throughout the interviews.

Data Analysis

The collected data was analysed using a broad interpretive and qualitative approach relying on the principles of thematic analysis. Segments of data were grouped topically by identifying persistent words, phrases, concepts and themes.

The interviews with the participants were listened to and data transcribed in order to get sense of the ideas being presented. This was followed by the identification and extraction from each transcript the statements and phrases pertinent to the phenomena being studied. Meanings were then formulated from the more significant statements which were then organised into themes, and these themes evolved into theme clusters. A colour coding system was used to highlight specific themes/categories in order to perform a preliminary analysis.

Phase III: Mothers Focus Groups

Kitzinger (1999) observes that focus group discussions are a useful method for exploring knowledge and experiences, group discussions can take place among mothers who’s their infant in same NICU and as a consequence have a relationship with one another before and after the interview. In addition, focus groups are useful for determining the cultural norms that pertain to a certain topic (Kitzinger 1995). With this group discussion familiarity among mothers is acknowledged or encouraged. This phase involved semi-structured discussions to highlight the use of KMC in NICUs through interaction among mothers.

Phase III aimed to explore mothers’ perceptions, knowledge, attitudes, practices and beliefs regarding the skin-to-skin Kangaroo care technique used in the NICU.

Qualitative focus group discussions were used as the primary method of data collection. Video elicitation or prompting, a method in which the participants watch and reflect upon a video presentation (Nastasi 1999), was used to guide discussion. The video defined and demonstrated KMC, and explained how it is used in NICU. Prior to watching the video, the participants were asked a few initial questions to identify their existing knowledge of KMC. This approach helps to gain a better understanding of the feelings and thoughts of people with regard to a given product or service.

Inclusion criteria:

  1. Mother’s baby is admitted to the NICU and is clinically stable,

  2. Mothers willing to participate, and

  3. Mothers of any cultural background.

Exclusion criteria:

  1. Material history of severe medical or psychological problems,

  2. Mothers whose baby has a severe congenital malformation,

  3. Non-Arabic speaking mothers, and

  4. Mothers unwilling to participate.

Participants were recruited by way of purposeful sampling. There were four focus groups, one group in each of the participating hospital, with 3-4 participants in each group. The participants were mothers who either had an infant in the NICU or had recently been discharged from the NICU.

Interview Schedule

The researcher used a focus group interview guide (appendix) with which to structure the group discussion. The group discussions needed to be guided and directed so that they would remain focused on the topic of interest. The focus group was otherwise to be semi-structured and response led.

Data Collection

The researcher sent a letter to the NICU manager, requesting him/her to talk to mothers and to invite them to participate in the study. The Unit Manager at each NICU informed eligible mothers and their partners about the study, verbally and in writing, after their baby had been stabilised. The first three to four mothers who consented to participate in the study were invited to participate in the focus group. The eligibility of the participants was subsequently assessed according to the inclusion criteria. A meeting with the participating mothers, together with their spouses, was organised in the neonatal and postnatal unit with a view to explaining the study and soliciting feedback from the participants, including answering and questions that they might have had about the study. During the aforementioned meeting, participants were organised into focus groups to ensure that they could comfortably deliberate upon the issues in the study. Mothers were asked to consent to audio recording of the focus group sessions. They were again informed that they could withdraw from the study at any time and that their confidentiality would be maintained. It was also made clear that their infant treatment and care would not be affected by withdrawal from the study. The discussions resulted in the solicitation of in-depth opinions from participants. Before the discussions started, a short talk about KMC and its use was had, and video containing information about KMC was also shown. This ensured that the participants understood the KMC intervention and that they were aware of its strengths and weaknesses, how to apply it, as well as the possible limitations that might be faced with its implementation. As each focus group session began, the researcher collected demographic information from the participants and thanked them for their involvement in the study. After each focus group had finished, the researcher gave a copy of the summary of the discussion to each member, which helped in making corrections, clarifications and data cleaning.

Data Analysis

Data were analysed using thematic analysis. The notes were transcribed and coded by the use of thematic analysis. After the coding, category relationships were examined and the data grouped according to themes. The participants’ data was checked throughout the group interview. To do this, a summary of interpretation of what the particular participant said during the group interviews was given to the participant. Participants were then asked whether the researcher correctly understood their perspective. This activity was conducted at the end of the session. Ultimately, the group was asked to verify the summary of all ideas from the participants before the close of the group focus interviews.

Regarding study rigour, to enhance the credibility by using a semi-structured schedule that allowed for questions and thus participants understood, the participants have a copy of their transcripts for review and comment on the data summaries. In order to assess the dependability the researcher was the only person who was involved in interviews, focus group, and who conducted the data analysis, which allowed the collected data to be stable. During the data collection and data analysis, external review of collected data and the report from the data analysis were conducted with the supervisor. Conformability enhanced by provides the research supervisors with the researcher document of data analysis process, including the interview transcript, data analysis records. The transferability enhanced by provide participant quotations and possibility to transfer this study to another setting.

Phase IV: Case Study Observation

The final phase of this study influenced by the result of the previous phases and more details will add after analysis of phase I-III.

This phase is concerned with the initiation of KMC in NICUs in order to assess how EBP can be implemented in these settings. Case studies have distinctive advantages and also disadvantages. The case study approach was utilised because this study examines the contemporary situation of EBP implementation in relation to NICU nurses in Saudi Arabia. Additionally, the aim of this study is not to develop a theory, but to gain an understanding of the situation in NICU in terms of the impact of research utilisation.

In this phase, KMC serves as a case study example to explore organisation facilitations and barriers to the implementation of research evidence in practice.

Case studies often have been used to expand upon the understanding of individuals, groups and organisations, and social and political phenomena relevant to different disciplinary areas, such as psychology, sociology, business, economics and medicine (Yin 2009).

Moreover, the use of a case study allows for observations in an attempt to evaluate the gap between the nurse’s knowledge of EBP and actual practice as it occurs in the natural setting. Potential factors that might interfere with such practice, along with the nature of the interaction between nurses and parents/mothers were also illuminated. That is, observing this work provides valuable data from a first-hand perspective and is therefore of obvious importance.

The literature offers three types of observations for the evaluation of this work, including complete observer, complete participant and non-participant observation (Miles & Huberman 1994).
The first two types were judged as unsuitable. This is due to the fact that it would not be possible in a hospital setting to be completely detached from what is being observed without both nurses’ and mothers’ awareness. This could raise ethical issues (e.g. permission to undertake the observation). At the same time, as complete participant observation could minimise the Hawthorne effect, it has been considered as unsuitable. For its full success, the researcher needs to conceal his identity (McPherson & Leydon 2002). Thus, additional ethical issues would emerge particularly when it comes to patients’ privacy and confidentiality.

The researcher chose one NICU for the observation. All NICU nurses and mothers were invited to take part in this phase.

Data Collection

Permission from the Nursing Unit Manager or Nursing Director of the hospital was sought and a meeting was held between the researcher, NICU nurses and mothers. The participants were given a brief of the plan of the case study phase, which involved making observations of how the hospital implemented KMC with infants. Each participant was given a consent form, as well as an information sheet to ensure that they consented to the observation being recorded.

Observation was conducted during the implementation of KMC and carried out openly. A face-to-face contact was made with senior nurses and related information about the research and ethical issues was provided. The unit managers were asked to inform the researcher in advance (if possible) about expected mother availability in the unit. With the help of nurses, only mothers who were psychologically and physically able to take part in the research were invited for participation. Each mother and her infant’s with allocated nurse were offered information (verbal and written) about the research and ethical issues of significance such as confidentiality and consent form. After the researcher obtained access, researcher was spending some time in the NICU with a view to observing nurses daily in their shifts. The researcher seated himself in a location that minimised the distortion of what was being observed but without losing the picture about what went on. With both nurses’ and mothers’ permission, the conversations between them were digitally recorded. Doing so could aid the analysis process by offering essential data about issues of significance related to topic. Reflective notes were made immediately at the hospital after observation about the nature of interaction between nurses and mothers, in particular body language (e.g. body gesture, eye contact and facial expressions) and the context of the interaction. The researcher will follow the dress-code of nurses with an aim of bending into the environment.

Data Analysis

Data from the interviews, questionnaires and focus group discussions provided input into the formulation of a theory underlying the implementation of EBP by nurses. Moreover, observation aims to capture the full picture of the implementation process and EBP usage in practice. Perhaps, data obtained by observation would ascertain whether what nurses’ say they do is what they actually do in reality. However, in this study both “accounts” are valid in their own right and just represent different perspectives on the data. Therefore, observations could serve as a complementary database for the above methods. As the notes were semi-structured, objective analysis was applied in order to quantify the data. However, in this study both “accounts” are considered to be valid in their own right and simply represent different perspectives of the data. However, given the “live” and dynamic nature of observational data, activity analysis also was adopted.
This means that observational manuscripts were guided and regulated by asking basic questions such as what was the context. What were the nurses doing? What types of activities were carried out? Were there problems during the interaction between nurses and mothers? Who participated in the interactions (e.g. mothers alone)? Who dominated the interaction? How do the interactions fit with the theoretical background of this study?

After data analysis, the researcher intends to integrate ethical considerations as detailed in the next section. The consideration ensures that participants are taken care of, and that the procedure is appropriate as recommended (Grbich 1999; Morse 1994; Roberts & Taylor 1998).

Ethical Considerations

The permission for carrying out the research was sought from the Institutional Review Board, the School of Nursing and Midwifery Research Ethics Committee at Queen’s University Belfast, and Saudi Arabia’s Ministry of Health. Further permission was also sought from the following hospitals: ACH, MCH, Al Thager Hospital, and KAAH. All participants were informed the time required for the study and the purpose of the study. Participants were also informed that they were free to withdraw from the study at any time and to refuse to answer any questions that they deemed inappropriate, without negative repercussions.

Before the start of every stage of the study, participants were requested informed consent to the participation by signing a consent form. Further, they were requested to allow the researcher to make recordings during the interviews, focus group and observation. Participants were informed that their participation was voluntary and that they could cease their participation in the study at any time, or request the researcher to stop recordings if need be. They were also given a copy of the consent form that they had signed.

Confidentiality

Participants were assured that their information would be kept safe and that the answers that they gave during the study would be coded. The notes taken during the interviews, focus group and observations were de- identified and the audiotape of interviews and focus groups was held on a digitally secure (i.e. encrypted) hard drive and the original destroyed. The researcher was also mindful that some individual participants could potentially be identified from their clinical setting, demographic data or even their position.

Data storage

According to the data storage policy of the Queen’s University Belfast, all research hard-copy data must be kept with the register in a cabinet that is locked and secure in the researcher’s office. Access to this data was limited by ensuring that it was protected by passwords in the School of Nursing and Midwifery for a period of not less than five years. Data were stored in a locked filing cabinet in the researcher’s workplace office in Saudi Arabia. All de-identified hard-copy data were transported by the researcher in secure packaging and eventually stored in locked offices within the School of Nursing and Midwifery.

Conclusion

Ethical approval was applied for in the four of the phases of this study. Such approval enhances the efficacy of the study and the credibility of the results. The entire process of the study was considered during the early protocol writing stage to ensure that the research was mindful of its ethical obligations throughout all stages. The use of best methods and procedures throughout the study ensures that the results are both unbiased and clear. The processes used in the study were transparent because informed consent was sought by the researcher in the recruitment of all research participants.

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