IMCI – A CHILD SURVIVAL STRATEGY

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CHAPTER 3 METHODOLOGY

INTRODUCTION

This chapter presents the research methodology and design upon which this study is based. In a study of this nature, it is imperative that an appropriate research strategy is chosen to elicit rich and generalizable data. Thus, the chapter describes the scope of the study, research paradigm, research approach and design and the methods that were used to conduct this study. The chapter further describes the study populations, sampling and sampling techniques, and research instruments that were used in the three phases of this study. The ethical considerations adhered to during this research study are also discussed.

SCOPE OF THE STUDY

South Africa is divided into nine provinces. Nurse training is conducted in both public and private nursing education institutions in all nine provinces of the country. In the province of KwaZulu-Natal there is only one public nursing education institution, the KwaZulu-Natal College of Nursing. It is aligned to the KwaZulu-Natal Department of Health and two public higher education institutions of learning, the University of KwaZulu-Natal and the University of Zululand. This single nursing education institution addresses the needs of the province in respect of nurse training output and therefore has 11 campuses and 12 sub-campuses geographically dispersed in nine districts of KwaZulu-Natal. Each nursing campus has a campus principal, a deputy principal and nurse educators whose core function is nursing education and training. The KwaZulu-Natal College of Nursing is authorised by the Department of Health and accredited by the South African Nursing Council to conduct the R425 nurse training programme for learners at selected campuses. In addition, pre-service training for the IMCI case management strategy has been included in the R425 curriculum. The scope of this study is limited to the KwaZulu-Natal College of Nursing, and the ten nursing campuses that offer the R425 nurse training programme. The scope of this study is further limited to the campus principals, nurse educators and learners based at the ten (10) nursing campuses which conduct IMCI case management training for learners in the R425 programme.

RESEARCH PARADIGM

Researchers should be guided by a framework that incorporates and aligns philosophical worldview assumptions to the research methodology and research methods when commencing research (Creswell 2009:5). The term worldview and paradigm are interchangeable (Creswell 2009:6). The academic literature sources refer to the term worldview or paradigm as “a basic set of beliefs that guide action (Creswell 2009:6).” Morgan (2007) cited in Shannon-Baker (2015:[1]) argues that the original “Kuhnian perspective” of the term paradigm as “a way to summarise researchers’ beliefs about their efforts to create knowledge” has evolved. According to Biesta (2010) cited in Shannon-Baker (2015:[1]), paradigms should be viewed as “tools” that guide the research process
The components of a paradigm consist of the following assumptions: ontology, epistemology, methodology (including methods) and axiology (Scotland 2012:9; Mertens 2010:10). Ontological assumptions are concerned with the nature of reality (Crotty 1998:10). Ontological questions focus on the nature of reality, and researchers therefore often pose the question, “What is reality?” (Guba & Lincoln 1994:108). The epistemological assumptions are concerned with what can be known and epistemological questions ask, “How can I know reality?” (Guba & Lincoln 1994:108). Methodological assumptions are concerned about the process of achieving reality, and thus researchers frequently ask the question, “How do you go about finding out about reality?” (Guba & Lincoln 1994:108), and methods are the techniques used to collect and analyse data (Crotty 1998:3). Axiological assumptions are beliefs about the nature of ethical behaviour. The focus of the axiological question is on the ethical behaviour and the nature of ethics (Mertens 2010:10). In this context, researchers often pose the question: “What is the nature of ethics?” (Mertens 2010:10). Every paradigm is based on its own ontological, axioological and epistemological assumptions, which are ultimately reflected in the methodology (methods) of research studies (Scotland 2012:9).
The researcher adopted pragmatism as the research paradigm in this study. The pragmatic perspective of “what works” and the fact that the research question should direct the research study guided the researcher in accepting and using this paradigm in this study (Riazi & Candlin 2014:142; Polit & Beck 2012:604). Additionally, the fact that pragmatism supports integrating perspectives and approaches, and provides justification and logical explanations for mixing approaches and methods, strengthened the argument for the researcher to accept this worldview (Johnson, Onwuegbuzie & Turner 2007:125). According to Polit and Beck (2012:604), pragmatism, as a paradigm, is associated with mixed methods research.
The ontological, epistemological, methodological and axiological assumptions are interrelated and therefore explained from a position of pragmatism.

Ontological assumptions

According to Terre Blanche et al (2006:6), ontologic assumptions are specific regarding the nature of reality that is to be studied. Pragmatists assert that although there is a single reality, all individuals view this reality differently and therefore have their own unique interpretation of reality (Mertens 2010:36). The researcher has adopted the pragmatic worldview of not committing to a singular reality in this study (Creswell 2009:10). The researcher’s view of reality regarding IMCI case management training and ICATT use and implementation at nursing campuses is that it be examined from the perspectives of campus principals, nurse educators and learners, as different perceptions or realities will emerge. Pragmatists further view the measurable world or ‘existential reality” as having different layers or elements, of which some layers or elements are subjective whilst others may be objective or may even be a mixture of the two (Feilzer 2009:3). The researcher is in agreement with the view that the perceptions of the research participants may differ that is be either objective or subjective, which is influenced by the way they view the world. Proponents of pragmatism also hold the view that research should not only aim to provide an accurate account of reality but should also aim to be useful (Feilzer 2009:3). The researcher acknowledges this and therefore aimed to not only provide data on the readiness of nursing campuses for ICATT use and implementation, but also to develop guidelines and a model for nursing campuses for ICATT use and implementation.

Epistemological assumptions

Crotty (1998:3) defines epistemology as “the theory of knowledge that is embedded in theoretical perspective.” Epistemology is about “what it means to know” and is concerned with how knowledge can be created, acquired and communicated (Scotland 2012:9). Guba and Lincoln (1994:108) further state that epistemology concerns whether there is a relationship between the enquirer (researcher) and the social world (research participants). The basic beliefs of pragmatists are that the formation of relationships in research are determined by what the researcher deems as appropriate to that particular study (Mertens 2010:11). Pragmatists further argue that the methods that are used are not as important as is the knowledge that is gained (Feilzer 2009:9). Bearing this in mind the researcher visited the research sites, established relationships with the research participants and collected data through individual and focus group interviews. The findings of this study are as a result of a meaningful interaction between the researcher and the research participants in this study. Pragmatism is characterised by an emphasis on communication and shared meaning-making (Shannon-Baker 2015:[4]). Thus, the researcher does not position herself as a casual observer, but as part of the research process, gathering information and making sense of the phenomenon of interest together with the research participants (Mertens 2010:38). In the data collection phases of this study, the researcher interacts with the campus principals, nurse educators and learners at the nursing campuses in KwaZulu-Natal to explore their understanding of ICATT use and implementation. It was the researcher’s intention to determine the state of readiness of the principals, nurse educators and learners regarding ICATT use and implementation.

Methodological assumptions

According to Crotty (1998:3), methodological assumptions are concerned with the “how” of research. It provides guidelines for conducting research using methods that are scientifically acceptable. From a pragmatic perspective, methods should be aligned to the specific questions and purpose of the research study (Mertens 2010:11). Additionally, the use of mixed methods allows the researcher to move back and forth between the qualitative and quantitative components (Mertens 2010:11). The methodological assumptions related to the mixed methods research approach is when the researcher integrates: (1) qualitative and quantitative research questions, (2) qualitative and quantitative research methods, (3) techniques for collecting and analysing qualitative and quantitative data and (4) qualitative findings and quantitative results (Pluye & Hong 2014:30). Proponents of mixed methods research are cognisant of the value of both quantitative and qualitative worldviews to develop a deep understanding of the phenomenon of interest (Venkatesh et al 2013:24). Qualitative and quantitative research methods were used sequentially to answer the research questions and to understand the phenomenon of interest i.e. ICATT implementation and use at nursing campuses. In this study the researcher used interviews and focus group interviews (qualitative data collection approaches) and surveys (quantitative data collection approach) to collect data about ICATT implementation and use at the nursing campuses. Individual interviews and focus group interviews were conducted to understand individuals’ perceptions regarding ICATT implementation and use at the nursing campuses. An exploratory approach was necessary as there was no extant literature regarding ICATT implementation at nursing campuses in South Africa. Self-administered questionnaires were used to collect additional data on the readiness of campus principals, nurse educators and learners for ICATT implementation and use at nursing campuses. Both open- and closed- ended questions were included in the data gathering tools. Open-ended questions allowed research participants to communicate their experiences or opinions in their own words. Closed-ended questions yielded standardised “yes” or “no” responses or “agree” or “disagree” responses that allowed for comparative data analysis in quantitative studies. Quantitative data analysis was done using both descriptive and inferential statistics. In the qualitative components of this study, interviews were recorded and the participants’ perceptions about ICATT implementation and use emerged during the transcription and the interpretative phenomenological analysis (IPA) step-by-step analytical process. The integration of the qualitative findings and the quantitative results facilitated the development of the guidelines and a model for ICATT use at nursing campuses.

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Axiological assumptions

The philosophical concept of axiology relates to morals, values and right actions (Beatty, Leigh & Dean 2009:104). Proponents of the pragmatic paradigm emphasise the importance of the researchers’ values and adherence to a code of ethics during the research process (Mertens 2010:36). The assumption within this paradigm is that the ethical goal of research is to gain knowledge (Mertens 2010:36). In the context of this study the aim of the researcher was to understand the perceptions of the research participants regarding ICATT use and implementation and, add to the body of knowledge without compromising ethical standards. The researcher thus adhered to the ethical principles of respect for the privacy, anonymity and confidentiality of the research participants in this study.

 MIXED METHODS RESEARCH APPROACH: A RATIONALE

This study utilises a mixed methods approach. Mixed methods refer to an “emergent methodology” that uses quantitative and qualitative data in a single study so as to address a wide variety of research questions (Wisdom & Cresswell 2013:1). Tashakkorri and Creswell (2007) cited in Polit and Beck (2012:603) define mixed methods research as “research in which the investigator collects and analyses data, integrates the findings, and draws inferences using both qualitative and quantitative approaches in a single study or programme of inquiry.” According to Venkatesh et al (2013:21) mixed methods research combines qualitative and quantitative research methods in a single research enquiry so as to have a better understanding of a phenomenon of interest. Thus, the core characteristics of a mixed methods study as identified by Wisdom and Creswell (2013:1) include the following: 1) collecting and analysing both quantitative and qualitative data, 2) applying rigorous procedures when collecting and analysing the quantitative and qualitative data, 3) mixing the data during data collection, data analysis or during the discussion of the results and 4) combining both kinds of data either sequentially or concurrently.
Grove et al (2013:208) present a strong argument for adopting a mixed methods approach which is that neither the quantitative nor the qualitative data alone, is capable of capturing the essence or addressing the complexity of research problems. The researcher’s understanding that the study was complex, and the use of a single method would not adequately address the research question motivated the researcher to depart from using a single research approach to using the mixed methods approach. This allowed the researcher to obtain a full picture regarding IMCI case management training and ICATT implementation at the nursing campuses. Combining quantitative and qualitative methods allows researchers to utilise the strengths of both approaches in a single study (Grove et al 2013:208). In a mixed methods study, the strength of one approach alleviates or minimises the weaknesses of the other approach (Creswell 2009:14). Combining quantitative and qualitative methods also adds depth and breadth to the study during data collection and allows for accuracy when making inferences (Venkatesh et al 2013:25). It is for this reason that the researcher used both interviews and surveys for data collection, in this study. The interviews (qualitative) provided depth to the study from the rich narratives provided by the participants regarding ICATT implementation at the nursing campuses. The surveys (quantitative) added breadth to the study by gathering data about different aspects related to ICATT implementation from many participants. In addition, the researcher mixed the quantitative data and the qualitative data during the analysis of the results and in the discussion of the results to strengthen and validate the findings of this study.
The advantages of the mixed methods approach highlighted by Polit & Beck (2012:604) and relevant to this study includes: complementarity, enhanced validity and practicality. Complementarity allows for the use of text and numbers in a study to avoid or reduce the limitations of a single approach. Practicality allows for a “what works” approach when addressing research questions whilst enhanced validity allows for the outcomes of a study to be supported by multiple and complementary types of data. Wisdom and Creswell (2013:3) further identify additional advantages of the mixed method approach which are:
1) researchers are better able to understand the incongruity between the quantitative results and the qualitative findings in a study, 2) the experiences and “voices” of the research participants are reflected in the research findings and 3) mixing of the qualitative and quantitative data allows for rich and comprehensive data to be presented in the findings.
In summary, proponents of mixed methods research have provided a rationale and advantages for mixing the approaches in a single study. The rationale and advantages were motivating factors for the researcher to adopt the mixed methods approach in this study. An important aspect which should not be overlooked is whether the mixed mixed methods approach addresses the research questions which are asked in a study (Polit & Beck 2012:613). The researcher’s understanding that the use of a qualitative and quantitative approach would answer the research questions strengthened the argument for the researcher to adopt the mixed methods approach. Additionally, the researcher considered that the emerging findings from combining the quantitative and qualitative methods will provide a better understanding of the complexity and nuances of the phenomenon that is the implementation of ICATT at nursing campuses in KwaZulu-Natal.

RESEARCH DESIGN

In order to explore these dynamics, the research design of a study needs to be appropriate and ethical. The research design is a plan that guides data collection in a research study (Brink et al 2012:217). Similarly, Polit and Beck (2012:740) agree that a research design is a plan for data collection that should effectively address the research question thus strengthening the study’s integrity. Grove et al (2013:693) state that the research design provides researchers with a plan for conducting a study together with full control over factors which could negatively impact the validity of the study findings. Creswell (2009:5) is in agreement that a research design is a plan or proposal to conduct research. However, Creswell strongly argues that the research design or framework should clearly show the interconnectedness between philosophical worldviews, strategies of inquiry and specific methods of data collection and analysis (Creswell 2009:5). Creswell (2009:206) further identifies four main aspects that should influence researchers when selecting the design procedures for a mixed methods approach namely: timing, weighting, mixing and theorizing.Timing addresses how data collection will take place (sequentially or concurrently), weighting addresses the priority that is given to qualitative or quantitative research, mixing address the how and when of mixing data and theorizing addresses whether the research design will be underpinned by a theoretical framework (Creswell 2009:206). The researcher considered this, together with the research problem, the researcher’s experiences and the target population (Creswell 2009:19) when choosing the research design which is further discussed below.
Creswell (2009:224) broadly identifies six designs which guide how data collection occurs when using the mixed methods approach namely: sequentially (explanatory and exploratory), concurrently (triangulation and nested) or transformatively (sequential or concurrent). Creswell and Clark (2007) cited in Venkatesh et al (2013:24) suggests four major types of mixed methods designs: triangulation, embedded, explanatory and exploratory. Grove et al (2013:208) narrows the focus to three main research designs which are associated with the mixed methods research approach. These include the sequential design, the concurrent design and the transformative design. In the sequential design, the researcher seeks to enhance the findings of one research methodology with another research methodology, so that the results can be generalised to a population (Grove et al 2013:208; Creswell 2009:14). An example of the sequential design is when the qualitative method is used first to explore a phenomenon, followed by a quantitative method using a large sample to generalise the findings of the study. Similarly, a quantitative method can be used first to test a theory followed by a qualitative method where the researcher conducts interviews which allows participants add to theory development (Grove et al 2013:208). In the concurrent design, the researcher collects both quantitative and qualitative data at the same time, allowing for the data to be triangulated or merged to provide a comprehensive analysis of the research problem. This design also allows for the researcher to embed one form of data within another in order to analyse different types of questions (Grove et al 2013:208; Venkatesh et al 2013: 24; Creswell 2009:14). The transformative design makes use of a “theoretical lens” or perspective within a design that guides the study, contains both quantitative and qualitative data, and usually addresses issues pertaining to minority or marginalised groups (Grove et al 2013:209; Creswell 2009:15).
It was not the intention of the researcher to embed one form of data with another to analyse different types of questions or to collect both quantitative data and qualitative data at the same time. Similarly, the researcher was not using a theoretical framework that provides methods for data collection and anticipated outcomes from the study. It was however, the researcher’s intention to conduct a two-phase study where data will be collected in sequence in phases one and two. This means one set of data (either qualitative or quantitative data) will be collected first, followed by the collection of a second set of data (either qualitative or quantitative data). It therefore made sense for the researcher to use the “sequential design” to investigate the readiness of nursing campuses for implementation of ICATT in KwaZulu-Natal.
The two main approaches of the sequential design are: the sequential explanatory design and the sequential exploratory design (Grove et al 2013: 209; Venkatesh et al 2013:24). The difference between the sequential explanatory design and the sequential exploratory design lies in the sequence of data collection and data analysis. In a sequential explanatory design, the collection of and analysis of quantitative data occurs first, followed by the collection and analysis of qualitative data (Grove et al 2013:209). In a sequential exploratory design, the qualitative data collection and analysis occurs first, followed by the quantitative data collection and analysis (Grove et al 2013:209). In this study the sequential exploratory design was adopted because qualitative data collection and data analysis occurred first. This was followed by quantitative data collection and analysis. The sequence of data collection was the same in phases one and two of this study. In phase one the researcher used individual interviews to collect data from the campus principals which was analysed. This was followed by the use of the survey method to collect quantitative data from the campus principals which was analysed. In phase two of the study the researcher used focus group interviews to collect data from the nurse educators and learners which was analysed. This was followed by using the survey method to collect quantitative data from the nurse educators and learners which was analysed.
A sequential exploratory design can be used if the focus is on exploring a phenomenon rather than explaining and interpreting relationships (Creswell 2009:211). Researchers can adopt the sequential exploratory design when the aim of the study is to use the quantitative data and results to assist with the interpretation of qualitative findings (Creswell 2009:211). According to Grove et al (2013:210) integration of the qualitative and quantitative data can occur in the interpretation phase. Morgan (1998) cited in Creswell (2009:211) states that the sequential exploratory design can also be used in a research study if it is the researcher’s intention to generalise qualitative findings to different samples. The researcher adopted the sequential exploratory design as this study sought to explore a phenomenon rather than explain relationships between variables. The focus of this study is to explore the readiness of campus principals, nurse educators and learners for ICATT implementation at the nursing campuses. The focus of this study is to further explore the readiness of nurse educators and learners for ICATT use for IMCI case management training. In this study separate qualitative and quantitative data collection and analyses are carried out. The mixing of the data from the two methodologies was done in an attempt to integrate the information and develop guidelines and a model. In this study there is mixing in the research design and the results.
Creswell (2009:212) has identified that there are advantages to adopting the sequential exploratory design. Firstly, the sequence of data collection that is qualitative methods followed by quantitative methods is easy for researchers to implement (Creswell 2009:212). Secondly it is easy for the researcher to report on the phases in the write up stage of the research study. Lastly, the sequential exploratory design allows the researcher to explore a phenomenon and expand on the qualitative findings (Creswell 2009:212). The disadvantages of using the sequential exploratory design is that it can be time consuming as data must be collected in sequence that is qualitative data collection and analysis followed by quantitative data collection and analysis. Additionally, the researcher has to decide which aspects of the qualitative data will be used during the integration of the results Creswell 2009:212).
As already stated this study utilises the sequential exploratory mixed methods design which is shown in Figure 3.1. There are three phases in this design. Phases 1 and 2 have two components i.e. a qualitative component and a quantitative component. The qualitative component is usually the dominant component in the sequential exploratory design (Creswell 2009:211). The capitalisation in the QUAL/quan notation denotes that the qualitative data collection, analysis and results are dominant. The directional arrows in phase 1 and phase 2, with the arrowhead pointing to the right indicate that the qualitative component occurred first and was followed by the quantitative component. On completion of phase 1 and phase 2, mixing of the results occurred. The results from the qualitative and the quantitative component of phase 1 which have lain side by side are mixed together with the results from the qualitative and the quantitative component of phase 2. These results, as indicated by the two arrows pointing downwards, were used in the development of guidelines and model for ICATT implementation at nursing campuses. The broken line indicates that the development of guidelines did not occur immediately following the mixing of the results from phases 1 and 2. The guidelines and model were developed over a period of time following an in depth reading of the results and literature sources. Phase 3 followed the guideline development. Phase 3 was refinement of the guidelines through the use of the Delphi method. The model however was not tested or refined.

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TABLE OF CONTENTS
CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 THE RESEARCH PROBLEM
1.3 RATIONALE
1.4 AIM AND OBJECTIVES OF THE STUDY
1.5 Contribution OF THE STUDY
1.6 DEFINITION OF THE KEY CONCEPTS
1.7 FOUNDATIONS OF THE STUDY
1.8 RESEARCH METHODOLOGY and RESEARCH DESIGN
1.9 ETHICAL CONSIDERATIONS
1.10 LIMITATIONS OF THE STUDY
1.11 LAYOUT OF THE THESIS
1.12 SUMMARY
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 THE THEORETICAL FRAMEWORK OF THE STUDY: A DETAILED DISCUSSION
2.3 IMCI – A CHILD SURVIVAL STRATEGY
2.4 IMPLEMENTING THE IMCI STRATEGY
2.5 IMCI case management training
2.6 ELECTRONIC LEARNING
2.7 IMCI Computerised Adaptation and Training Tool
2.8 THE READINESS FOR ELECTRONIC LEARNING
2.9 SUMMARY
CHAPTER 3 METHODOLOGY
3.1 INTRODUCTION
3.2 SCOPE OF THE STUDY
3.3 RESEARCH PARADIGM
3.4 MIXED METHODS RESEARCH APPROACH: A RATIONALE
3.5 RESEARCH DESIGN
3.6 ETHICAL CONSIDERATIONS
3.7 SUMMARY
CHAPTER 4  THE RESULTS OF THE QUALITATIVE AND QUANTITATIVE COMPONENTS OF THE STUDY (PHASES 1 AND 2)
4.1 INTRODUCTION
4.2 PHASE 1:
4.3 PHASE 2
4.4 PHASE 2
4.5 MIXING OF THE RESULTS
4.6 SUMMARY
CHAPTER 5  THE DEVELOPMENT OF GUIDELINES AND A MODEL FOR THE IMPLEMENTATION OF ICATT AT NURSING CAMPUSES OF THE KWAZULU-NATAL COLLEGE OF NURSING (PHASE 3)
5.1 INTRODUCTION
5.2 THE FOUNDATION FOR GUIDELINE AND MODEL DEVELOPMENT
5.3 GUIDELINE DEVELOPMENT
5.4 MODEL DEVELOPMENT
5.5 SUMMARY
CHAPTER 6 DISCUSSION, LIMITATIONS, RECOMMENDATIONS AND CONCLUSION
6.1 INTRODUCTION
6.2 DISCUSSION OF THE FINDINGS
6.3 SUMMARY OF THE RESULTS
6.4 SCOPE AND LIMITATIONS OF THE STUDY
6.5 RECOMMENDATIONS
6.6 SCIENTIFIC RIGOUR
6.7 CONCLUSION
LIST OF REFERENCES
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