Qualitative design

NPT can help inform, guide or structure your initial research design, sampling and data collection.  You could think of it in a similar way to one of Glaser and Strauss' (1) middle-range theories like 'Awareness Contexts', in that NPT may inform the range of situations or people you may want collect data from.

Introduction

Good qualitative research should be both flexible and adaptable. When you initially start a project you will spend time clarifying your research question, aims and objectives.  These may or may not have been influenced by NPT (see section - research focus and questions).  You may have quite a refined set of research question or you may start with more general, generic, questions - that you just want to map a specific implementation issue.  As with all qualitative research, whilst conducting your research you should remain open to new avenues of understanding, to explore new, albeit related questions and issues.

NPT can help with the development of a design for your research in terms of your decisions about sampling, sites and data collection methods.  NPT does not tell you, in advance, everyone who you will need to talk to, everyone you will need to observe or everywhere you will need to go. In keeping with the iterative nature of qualitative research such information will emerge from your time in the field.  However, NPT can help you think through some potentially fruitful issues to research at the outset and as things progress

In relation to sampling, NPT encourages you to think about a large range of potential actors.  Following NPT, you should be thinking about all those whose day-to-day routines, work or life is in someway impacted upon by the new technology or way of working that your research is exploring.

  • By 'work', you could be referring to the work of conducting, analysing, reviewing or delivering the results of a specific diagnostic test as well as the work of being a patient in a consultation room, living with a specific diagnosis, or being a partner of someone who is ill.
  • Centrally, NPT encourages you to focus beyond the 'usual suspects' of healthcare research, for example beyond the health professional or patient.  You may want to focus on others who are vital to the normalisation of a new technology or way of working those that are less visible and often omitted from implementation studies. For example receptionists, secretaries and managers often coordinate specific administrative and research tasks and actions that impact on clinical encounters between health professionals and patients. Clinical and organisational support staff, from lab technicians, to hospital porters and IT technicians, often have to accommodate and realise aspects of new technology or way of working.

You may not always be able to get direct access to all these people, situations or places but at least you will be aware that they are very relevant to the implementation work and will be alert to the need to ask other participant groups questions about them, to begin to think of the distributed work involved in any technology or way of working.

In relation to sampling sites, NPT encourages you to focus on, a large range of potential situations, sites and contexts.  Most implementation work does not occur at a single point in time or at a single location.  Most implementation work is distributed across times and places.

  • Again, NPT encourages you to focus beyond the usual situations, times and contexts of health care research.   You may need to focus on the more 'frontstage' of clinical work, where patients, carers and health practitioners interact, as well as the 'backstage' of healthcare, the home, the office, the laboratory or even the staff coffee room.  You may need to focus on the diffuse situations where the process is discussed or enacted.  From the management meetings where ideas are first raised, to the corridors where these ideas are complained about or praised, to the office where people attempt to work with the new processes.
  • It is important to note that the same technology or way of working will not always normalize in all the settings and situations that it is introduced in.  This is an ideal research situation - a natural experiment - that enables you to begin to understand the specific conditions normalization can occur in, by comparing different sites.

When thinking about which people and sites to sample, it may be useful at the start of the project to list all the potential actors, situations, sites and contexts that might involved in enacting the process.  Just brainstorm the potential trajectory of the technology or way of working, either through developing lists or diagrams. As the project unfolds, and you gain new findings and insights, regularly adjust you list or diagram.  Given the iterative nature of qualitative research, it is good practice to return to this again and again, to both inform your analysis (generally and using the NPT) and to develop new ideas and avenues of thought [1].

  • It is important to note that NPT does not direct you about which type of sampling frame you should employ (e.g. typical case, maximum variation, criterion, opportunistic etcetera) or tell you when you have collected enough data.  Clearly, as with all qualitative research, you will be relying on some type of purposive sampling or some combination of them.

When it comes to sampling, be as creative as you can be.  As noted above, don't just interview the usual suspects or observe the usual situations. Your only constraints are based on what is practical and feasible given the time, funding and access you have, alongside what is ethically appropriate.

In relation to methods of data collection, clearly you have a range of typical qualitative methods to draw on, ranging from face-to-face or telephone interviews, focus groups and non-participant observation.

  • Given NPTs focus on process and action, you may also want to consider other methods, like collecting audio or video-recordings of key, process-rich interactions and situations. Or you may want to consider collecting key documents, screen-shots of computer programmes or photographs of objects, processes or technologies that are central to the implementation work  Given the increasing prevalence of the media and the internet in healthcare, often as source of knowledge for patients and their significant others, you may also want to focus on that.
  • NPT does not direct the specific methods or methodology you should employ.  Above all, you need to focus on what goes on, so focus questions on practice, not ideals. If you get the chance, consider life beyond the qualitative interview.  Clearly they are relatively time-effective but they can offer you a rather generalised gloss of the work.  If you get the chance to observe, even fleetingly, how people enact aspects of the specific technology or way or working, this will often offer you new important insights.

Once you have decided on your data collection methods, NPT can also inform the development of questions for interviews or focus groups and direct specific aspects of your observation.

  • NPT is not prescriptive - for example it does not write your interview questions but it can help guide some of the specific, practical, choices you make.
  • When it comes to developing your topic guide or specific questions for interviews, you need to make sure you tailor the specific ideas in the theory - be they the four constructs or specific components you are interested in exploring - to the specific phenomena you are studying. This means you may generate a series of questions about coherence and another series of questions about cognitive participation and so on.

Do not expect your participants to speak in the language of the theory. For example, do not expect them to understand an interview question that asks uses theoretical terms like 'differentiation' or 'internalization'. You will need to translate the intended meaning of each construct or component into clear and simple language that is relevant to the technology or way of working that is the focus of your implementation research. If your interested in coherence, it may be enough to simply ask them to describe what they thought when they first heard about it or used it, how they felt it related to current work practices and what the was the view of the unit they are working in.

  • Your questions should not be straight translation from the language of NPT. Instead you need to 'make NPT at home' within your specific study context.  For example, don't ask people questions like "Can you tell me what you know about the contextual integration for the implementation of language interpreters in your general practice surgery?"  You might want to discuss things like 'local and national policy' or 'government document, decisions or guidelines'.  It will take time to tailor your questions to make them fit within your research needs, alongside the language of participant, both when you initially develop your topic guide and questions, and when you come to review it after each interview or period of coding and analysis.

If you are collecting data through observation, do not expect to be able to witness specific constructs or components of NPT unfolding before your eyes.  At the start, as is typical with most observation, you will see far too much and not be that sure what to focus on, how to deal with the complexity of what you are witnessing, just take notes.  Again, you need to tailor the ideas of NPT to the emerging findings from your observation.  Being aware of the four constructs or components of NPT may encourage you to observe specific actions or ask you to ask specific questions of the actions you observe

However, as with the use of any middle range theory, NPT can only suggest specific issues that you might want to focus on.  In keeping with the principles of good quality qualitative research you need to remember to follow the phenomena you are studying and to be directed by your ongoing analysis.  For example, it might transpire, during your research that certain NPT constructs are not relevant to the data you are collecting or, indeed, that your data is indicative of important issues that are not covered by NPT.

Things to consider

  • NPT encourages you to design a project that enables you to follow the process, to focus on a range of people, situations, times and places that are involved in all aspects of enacting that process.
  • NPT asks you to be ambitious.  However, do not overstretch yourself, either practically or analytically.  You can never capture everything.
  • NPT does not tell you, in advance, who to talk to, what to observe or where to go. This is in part, emergent, this should emerge from your time in the field.
  • You always need to tailor and adapt the ideas of NPT to your specific research project.  It does not aim to be a theory that will help you make sense of everything you and hear and see in the field.
  • NPT is not about individuals intentions and perceptions, it is focused on helping you to making sense of collective, distributed, patterns of work.

References

  1. Glaser, B.G. & Strauss, A.L. (1965) Awareness of dying. Chicago: Aldine.  
  2. Clarke, A. (2005) Situational Analysis: Grounded Theory After The Postmodern Turn Thousand Oaks, CA: Sage

Notes

[1] See Clarke's (2) discussion of 'situational maps'.  Although she advocates them as an outcome of research, it can be helpful to attempt them at the beginning of a project.