Session: 9am, June 28 at ISCTE-IUL Business School, Lisbon Portugal.
‘Methods for an Australian Public Health Research Project to Obtain Clinical Staff Perspectives of Management Efficacy: Using Participative, Collaborative Ethnography‘.
(Paper Presented in another blog post). Pre-print available here.
Slides Used; EURAM SLIDES
Time Allotted: 10 minutes with questions at the end
Prepared Speech:
“My name is Madeleine Kendrick, and today I will be presenting my paper, ‘Methods for an Australian Public Health Research Project to Obtain Clinical Staff Perspectives of Management Efficacy: Using Participative, Collaborative Ethnography’. My paper is a methods paper detailing the approach used to secure a large, representative sample of clinicians for a PhD thesis in complex adaptive systems and management practices in an Australian Public Health service. I was able to use this methodology to collect over 60 separate interviews; an achievement that few studies on clinical cohorts have reported due to the often challenging and insular culture of clinical practice. The study spans two hospital sites within one health service, multiple layers of the organisational hierarchy, and three clinical specialties.
I wish to contribute my project’s methodology to the international research and practice community in the hope that the things I have learned can benefit future projects. Today I will summarize what I did, what I found, and what I learned from this project. Then I’ll open the floor to your perspectives.
What I did
I used Participative, Collaborative Ethnographic practices during the establishment and design of my research project to foster trust with stakeholders, make network connections with health care leadership, and ensure that my project was guided by issues that mattered to clinicians. By actively soliciting the input of people affected by my research, to help guide the focus and design of the project, I was able to receive advice and mentorship from key individuals who later assisted with my recruitment and sampling. Thus, I was able to use direct-approach sampling to contact a large number of individuals in my target health system via personal introduction or email. By utilizing my contact’s institutional knowledge during the design and recruitment phase of research, I ensured that I had organisational buy-in and support which positively impacted the project’s success in recruitment.
To reciprocate the good-faith interactions which benefited my project, I maintained communication with health service leadership so that my project findings were immediately available to them (within the constraints of my ethics approval). This mutually beneficial relationship had a double-outcome; research impact, and organisational endorsement which encouraged more participants to volunteer for the project.
What I found
While not commonly recommended in journal articles or textbooks on qualitative research design, I followed my instinct and engaged with stakeholders during the early stages of project development. I followed this instinct, after reading in various articles with a clinical-based sample, that non-clinical researchers often experience difficulty generating interest and participants for their study for unknown reasons. I knew that, on occasion, academics can sometimes ‘miss’ important factors and variables in their study due to the isolated nature of non-clinical research design.
To bridge the gap – or, in management terms, ‘break down the communication silo’ – I sought out clinicians after work so that I might ask for their opinion on topics I was considering for my study. By tailoring my research project to the direct needs of members of my community, I ensured that the questions written for the interview schedule were appropriate, and addressed gaps in knowledge which would provide a real benefit to hospital staff. When clinicians heard about the way I approached the project, by incorporating their feedback into my design and responding to their requests for change, they began seeking me out to participate in the project before I had formally begun recruiting. To me, this was a positive sign that my unconventional approach to qualitative research was working.
What I learned
An article which provided a huge foundation for my understanding of the interactions between clinicians and management practitioners was Stephen Ackroyd’s article, ‘Organisation Contra Organisations; Professions and Organisational Change in the United Kingdom’. I had always been curious to see how Ackroyd’s theory would play out in real-time, as few studies have followed up Ackroyd’s work with empirical data displaying the interactions between two different professional cultures in the same workplace.
In my case, this was the employee cultures of clinicians, and management-trained professionals. To summarise Ackroyd’s writings on the topic; management and medicine produce two very different cultures which often result in workplace conflicts as the two professional groups attempt to work together to achieve different aims. Authors such as Sue Llewellyn identify that this conflict has a potential mitigator in the form of hybrid-managers; or, clinicians cross-trained in management, but the implementation of this concept has wide individual variation for success. In relation to my project, Ackroyd and Lewellyn’s work provided a scaffold for a management-trained researcher such as myself to communicate across the disciplines and seek a mutual understanding despite our different professional backgrounds. In understanding the culture and values of clinicians, such as ‘patients before profit’ and a general distrust of management due to their often obstructionist role in the hospital workplace, I was able to present myself in a way that earned the trust of the often-closed community of medical practitioners. The contrast between the trust I held with participants, and the trust fostered by health service management, is briefly illustrated in my results section, where participants complained that management made the very same mistakes I worked to avoid in my research. To me, this reinforced a useful benefit of my research approach, not just to academics, but also to practitioners.
The trust I gained was aided by mirroring clinical research practices, such as structuring my ethics application and research protocol in the style of a clinical trial, and seeking clinical supervision for my work while I was at the hospital site. These elements of research design, while unnecessary for qualitative projects, gave my research the legitimacy it needed to be trusted as robust, valid, and appropriately confidential; just like clinical research projects routinely conducted in hospitals. Thus, I was perceived by my clinical sample as adhering to their social standards of research competence and confidence; conducting myself in the familiar manner of a clinical researcher despite receiving no formal clinical training. As you may be able to tell, this was an extremely positive outcome that has yet to be fully demonstrated in traditional management research literature, making my experience a unique contribution to the academy.
Closing
Based on my experiences in the Australian health care environment, understanding and participating in the working culture of your target sample (a method commonly used in participative collaborative ethnography), can better prepare researchers for organisational endorsement and support. What I found was that participants received my efforts well, volunteering in higher numbers than anticipated. Additionally, interview transcripts returned the finding that management practitioners often do not take the time to engage with front-line staff as thoroughly as my research project did. Management practitioners in hospitals are perceived with greater respect and collegiality by clinicians when clinical staff feel that management ‘understands’ their role, and profession’s values, in the workplace. Now I have the chance to open the floor to questions, I’d like to ask a question of the audience; in my position, what would you have done differently? What would you do next?
Thank you, and I will now answer as many questions as I can.”
Prepared Responses to Potential Questions:
What was the difference between designing the project along clinical trial headings, as opposed to the ‘normal’ ethics application?
In a hospital setting, all research projects are required to have their protocol and proposal reviewed under the guidelines of the state health department’s guidelines. These guidelines cover headings and points of information usually relevant for clinical work, such as managing data collection from those unable to provide consent (such as children, those with mental illness, and someone who is unconscious) and strict protocols for protecting privacy. While not all headings in the clinical trial protocol template was relevant for my study, such as the handling of biological samples (i.e., blood), the ability to answer each and every question usually posed to a clinician allowed my ethics application to be thorough and comprehensive enough to earn approval without amendment.
I could, feasibly, have designed my study as a non-clinical study and submitted that protocol to the research governance service for my target health system, however this would have likely been delayed due to scrutiny and requests to elaborate on points not usually required by academic ethics applications, so logically it made more sense to put in the detail at the start.
How did you factor in potential bias from participants?
There was potential for my sample to have 70 disaffected staff members, who would be more inclined to participate due to their unhappiness with the workplace. To combat this, I approached participants individually, encouraging complete patient-care teams to participate. By aiming for a complete patient-care team, I hoped to get a range of responses including those who were satisfied with their working conditions, and those who were not, so I could understand the reasons behind staff satisfaction and dissatisfaction.
By including a range of clinical specialties, professions, and two separate hospital sites in the data collection, I wanted a large enough spread to offer a broad range of opinions, while still identifying patterns and trends. This was the main reason that the study sample was around 70 individuals, as this number afforded a handful of doctors, nurses, dieticians, physiotherapists, administration, management, and cross-trained clinical leadership from three different clinical specialties. Thus, while the paper submitted to this conference only contained preliminary information from the first five participants, the scope of the full project is much larger.
Perhaps more relevant is the design of the study. Since my study was more looking at the ‘why’ and the ‘how’ of management influence of staff well-being, levels of participant satisfaction was perhaps not as important as why they discussed they were unhappy. For example, had all of my participants discussed that they were unhappy at work, I may have suspected bias. However, if all of my participants independently reported, from a wide range of specialties and professions, that the reason they were unhappy was the same factor, I could deduce that response to be a project finding.
Research & Beyond 