Application of summative content analysis to a postal questionnaire.

Nurse Researcher

Application of summative content analysis to a postal questionnaire Cite this article as: Griffiths TH (2016) Application of summative content analysis to a postal questionnaire. Nurse Researcher. 23, 3, 30-36. Date of submission: September 15 2014. Date of acceptance: May 19 2015. Correspondence [email protected] Thomas Howard Griffiths MSc, BSc, PGCE, DipCart, RNT, RN is a senior lecturer at Swansea University, Swansea, UK Peer review This article has been subject to double-blind review and checked using antiplagiarism software Author guidelines journals.rcni.com/r/ nr-author-guidelines

Abstract Background Content analysis of replies to closed questions in questionnaires can be undertaken to understand remarks that may explain the responses, provide illustrative examples of issues raised in the questionnaire, define new issues or issues of importance that were not covered in the questionnaire and inform the design of new questions in future surveys. Aim To discuss the usefulness of summative content analysis to free text in postal questionnaires. Discussion Content analysis provides useful comparative insights between two respondent groups in the case example provided. Five themes emerged: poor understanding of the concept of ‘patient lateral transfer work technique’ and the direct instrument nursing observation (DINO) instrument’s key directions; outcomes of patient transfer; positive responses;

Introduction In this paper, a case example illustrates the methodological usefulness of undertaking summative content analysis. The example involves the use of a postal questionnaire to determine the validity of a Swedish instrument, direct instrument nursing observation (DINO), in the UK. DINO measures the effects of a work technique in manual handling (Johnsson et al 2004, Johnsson 2005). The postal questionnaire was sent to NHS Wales back care advisors and university college nursing staff who taught a standardised training package to nursing students. Comparison of respondent sub-groups enabled the internal validity of DINO to be scrutinised.

Content analysis In contrast to grounded theory or hermeneutic phenomenology, in which a high level of interpretive complexity is required, the qualitative descriptive 30 January 2016 | Volume 23 | Number 3

manual handling risk; and poor translation into English of DINO. Conclusion Respondents need an opportunity to clarify their responses to questionnaires using free text, to provide insight into their understanding of the question being asked, understanding of the concept or construct being discussed, and data triangulation through the confirmation of item responses and free-text comments. Implications for practice Responses to questions in a postal questionnaire and the opportunity for free-text commentary by respondents enable the identification of hidden meanings behind tickbox responses to questions. Keywords translational validity, questionnaire, postal questionnaire, summative content analysis, free text commentary, narrative data, data analysis. approaches ‘descriptive phenomenology’, content analysis and thematic analysis are suitable for researchers who need a relatively low level of interpretation (Vaismoradi et al 2013). Content analysis may be suitable for simple reporting of common issues mentioned in data (Green and Thorogood 2004). It is a term for a number of different strategies for analysing the content of narrative data to identify prominent themes and patterns amongst themes (Powers and Knapp 2006). It requires systematic coding and categorising of text to determine trends and patterns of words through their frequency, relationships, and structures and discourses of communication (Grbich 2006, Pope et al 2006). By using content analysis, it is possible to analyse data qualitatively and quantitatively (Grbich 2006). There are two approaches to content analysis: inductive and deductive. Inductive analysis is used © RCNi / NURSE RESEARCHER

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Content analysis when there are no previous studies dealing with a phenomenon and so coded categories are derived directly from the text (Hseih and Shannon 2005, Vaismoradi et al 2013); deductive analysis aims to test a previous theory in a different situation or to compare categories at different periods (Hseih and Shannon 2005). Every analysis requires a context in which the available texts are examined (Krippendorff 2004). With content analysis, if only the frequencies of codes are counted to find significant meanings in the text, there is a danger of missing the context (Morgan 1993). Data analysis is recursive, with frequent reviews. The aim of content analysis is to describe the phenomenon conceptually (Elo and Kyngäs 2008). Researchers who have a broad understanding of the contexts influencing the stories of their studies’ participants may develop wider understandings of what is going on, in addition to understandings that they can share with the participants (Downe-Wamboldt 1992). ‘Credibility’, ‘dependability’, ‘conformability’ and ‘transferability’ are common measures of rigour in qualitative studies (Lincoln and Guba 1985).

Postal questionnaires Free text can be analysed in a variety of ways. Thematic analysis of data can enable themes, rather than preconceived ideas, to emerge from the data (Glaser and Strauss 1967). Replies to closed questions can be examined for remarks that might explain the replies (as illustrated in the case example, below). Another use of content analysis is to provide illustrative examples of issues raised in a questionnaire. Free text can define new issues or issues of importance to respondents that were not covered in the questionnaire. It can also be used to obtain feedback on the research process. Comments can inform the design of new questions for future surveys. Verbatim quotes from free text can illustrate respondents’ answers to any closed questions in a postal questionnaire (Garcia et al 2004). Although individual commentary from a single respondent is unrepresentative, the aggregated comments from a survey may be representative of the findings. It is common practice to include in questionnaires that respondents complete themselves an invitation to add issues not covered in the main part of the questionnaire or expand on terms in the questionnaire (Garcia et al 2004). This may be useful when determining the ‘translational validity’, or translation of a construct from one context to another,) of an instrument using a questionnaire. ‘Latent’ and ‘manifest’ content analysis, or visible components of text and interpretation of its © RCNi / NURSE RESEARCHER

underlying meaning, provide an opportunity to interpret the translation of subtle conceptual meanings from one culture to another. Because of the un-representativeness and self-selected nature of free-text comments, any findings emerging from them are not generalisable to the study population (Garcia et al 2004).

Case example Content analysis was an important step in ascertaining whether respondents understood DINO or whether there were cultural and translational issues that needed addressing before it could be used in another setting. A postal survey avoids interviewer bias and reaches a widely dispersed audience (Oppenheim 1992, Edwards et al 2002). The questionnaire enabled the calculation of DINO’s ‘content validity’ indices (Polit and Tatano Table 1 Example of summative content analysis manifest coding undertaken for direct instrument nursing observation face validity DINO face validity: manifest code derived from content analysis

Total (f)

(f) NHS

NCl = Not clear

2

1

CI = Clear instructions

3

1

PG = Poor grammar

4

1

2

17

2

2

NCl = Not clear

2

2

1

3

PG = Poor grammar

4

2

1

3

17

4

5

3

3

3

PPH = Poor phraseology

PPH = Poor phraseology RW = Reads well, no problems

4


(f) UKT

Q 1

2

2

17

1

5

BA = Should it refer to brakes being applied?

1

1

6

RW = Reads well, no problems

4

1

6


17

1

6


17

1

2

7

IS = Incorrect sequencing

4

1

3

4

FUNCT = The word functional is confusing; better to use in an appropriate position

1

1

8


17

1

8


17

1

10

1

NCl = Not clear

2

1

10

LO = Too long to read

4

1

3

Note: UKT = university key trainers in manual handling; NHS = back care advisers in NHS Wales

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Art & science | acute care Nurse Researcher Beck 2008). Misunderstanding of DINO was a threat to the study’s validity, and an attempt to counteract this was undertaken with an explanation and free-text questions in the postal questionnaire.

Content analysis The author designed and collected the data for the pilot study himself and so was immersed in all aspects of the research. The free text was analysed using manifest and latent content analysis (Green and Thorogood 2004) and with simple frequency counts of the codes that emerged from the data. ‘Summative content analysis’ involves counting and comparing keywords or content, followed by interpreting the underlying context (Hsieh and

Shannon 2005). This goes beyond frequency counts of words to include latent content analysis (Hseih and Shannon 2005). The qualitative commentary received from the returned postal questionnaires was transcribed into Microsoft Word tables; the author analysed the data and an academic colleague checked it for emerging themes. Three rounds of text analysis were undertaken: coding text, then formulating sub-categories and categories, which eventually were organised into themes (Tables 1 and 2). This was achieved by cutting and pasting the text in the Word document. Categories were formulated partly from frequency counts of codes derived from free text. Initial coding

Table 2 Coding, subthemes and content themes from free-text commentary in the postal questionnaire DINO content validity – codes derived from content analysis

Content subthemes

Content themes

DUC = does not understand the concept (latent) + DUB = does not understand biomechanics (latent) + DUPO = does not understand purpose of observation (latent) Training needs of user of DINO + DUP = difficult to use preparation phase in practice (latent) + TOE = has the handler had any training/experience of using the equipment or transferring aid CD = clinical decision

Does not understand concept of observing and measuring patient lateral transfer work technique

KDR = key directions need reading + HRI = has not read instructions fully + PP = profiling bed inserted in the transferring aid section + IBH = nothing about the interaction between handlers + NH = not sure of relevance of nurse height to patient

Key direction needs reading

1. Further training required for respondents, in understanding the concept of ‘work technique’ and DINO’s key directions

APF = not obvious to the observer whether pain or fear has been experienced by the patient + VIP = very important phase + COM = concept of comfort for the patient not covered + MIR = more information required for result phase

Patient outcomes

PN = no question about whether transfer caused any pain to the nurse + TEN = no assessment of the transfer effects upon the nurse

Nurse outcomes

2. Outcomes of patient transfer

RE = relevant + = Comprehensive in its ability to measure manual handling work technique + CI = clear interpretation of what is required to be observed + = Comprehensive in its ability to measure manual handling work technique + NPE = considers nurse and patient environment

4. Positive responses

WR = risk assessment + IC = does not consider individual capacity of the staff + PAP = is the patient adequately prepared for the transfer? + MPD = more patient details are required + BCO = information about background of co-worker and interaction between handlers + HP = handling plan + = does not take account of the current manual handling education of handler + TILE = background description could follow TILE format + PR = patient risk assessment + SAF = could include whether the patient is safe + PCCA = patient capability and cognition + PL = posture and load + COMM = communication unreliable due to the patient’s condition + MPD = more patient details are required (Latent) + AHA = appropriateness of the handling aid + ER = no reference to appropriate equipment

5. Manual handling risk

DINO face validity code derived from content analysis

Face subthemes

Face validity themes

PG = Poor grammar

Poor grammar

1. Poor translation

PPH = Poor phraseology + BA = should it refer to brakes being applied? + NCl = not clear + FUNCT = the word functional is confusing better to use in an appropriate position. IS = incorrect sequencing

Poor phraseology

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Content analysis Table 3 Author’s reflexive commentary of free-text commentary in the postal questionnaire Postal questionnaire questions

Reflexive notes on NHS respondents

Reflexive notes on university respondents

Rate the DINO instrument’s ability to measure manual handling work technique

Back care advisers seem to regard ‘work technique’ as the method used when moving and handling the patient, rather than the concept defined by Johnsson (2005)

This does not appear to be an issue with university trainers, which may reflect the predominance of risk reduction prevalent in the NHS

Rate the DINO key directions for its use

NHS back care advisers had problems with the grammar and phraseology of the directions; a variety of issues which are different to individuals as above. Conclusion: thorough training of concept of ‘work technique’, as well as definitions used in directions, required before use of DINO

Some of the university trainers have similar issues as with back care advisers. Some however found no problem with the direction. Conclusion: thorough training of concept of ‘work technique’, as well as definitions used in directions, required before use of DINO

Rate the translation of DINO from Swedish to English

NHS back care advisers struggle in places with the Swedish translation into English

Trainers noticed some typographical errors with some improvements in the phraseology

Rate the sequencing of the questions in DINO

NHS back care advisers seem to focus more on risk reduction. Most of the respondents agree that DINO’s questions are in a logical order

University trainers seem to focus on patient assessment as the first priority

Rate the relevance of the background description in the DINO instrument

NHS back care advisers see the background section as more of a handling plan to reduce the risk of injury to the handler

Most trainers agree that this is useful but some comments suggest that the weight of the patient should be recorded or that this is difficult to complete when used for training purposes as opposed to being used in practice setting

Rate the relevance of the performance phase in the DINO instrument

The NHS back care advisers seem to focus on the risk component of this part of the DINO tool rather than the biomechanical aspect of transferring patients by handlers. Some acknowledgement that guidance is required in using the directions of the tool

University manual handling trainers appear to be struggling with the items under the performance section. This may be partly explained by the lack of experience and depth of training of university trainers compared with back care NHS advisers

Rate the relevance of the result phase in the DINO instrument

Concern among NHS staff with regard to whether pain can be accurately observed without asking the patient whether they are experiencing any pain. Directions provide guidance on this point but yet most respondents seem not to have read or referred to instruments of direction for guidance

University trainers agree that this result phase is important and relevant but some have not read the instructions of the tool. Discrimination of concepts between comfort and pain is valid. Issues with some of the phraseology used in the instrument such as position instead of function

Are there any items within the domains that require adding to the instrument?

Comments by back care advisers focused more on risk, preparation details and equipment used

University trainers focus is more on patient outcomes or result phase in DINO

Are there any items within the domains that require deletion from the instrument?

All respondents agree that DINO does not require any removal of items from its content

All respondents agree that DINO does not require any removal of items from its content

How appropriate are items within DINO?

NHS may focus more on risk. University trainers focus more on patient outcomes. This may reflect the mind-set of two different roles of registered nurses: one reducing risk in practice, the other focusing more on holistic care and the patient’s perspective in back care

University trainers focus more on patient outcomes. This may reflect the mind-set of two different roles of registered nurses: one reducing risk in practice, the other focusing more on holistic care and the patient’s perspective in back care

How representative are items within DINO?

NHS respondent has fair comment about capacity of handler. NHS respondent focus is very much on concept of risk of back injury

University trainers have misunderstood the question in the questionnaire




Art & science | acute care Nurse Researcher was descriptive and a priori – that is, it used some pre-existing theories, such as the manual handling technique sought to be measured using DINO. An analytical approach to coding aimed to determine the causes of what was happening with the data. Throughout this process, a continually reflexive commentary was undertaken to make sense of the free text (Table 3). This was particularly useful in determining latent coding and providing an insight into issues associated with the cultural validity of DINO.

Results Theme 1: further training in the use of DINO is required This may be attributed to respondents’ insufficient understanding of Johnsson’s (2005) theoretical concept of work technique, but also partly to cultural differences in viewing the lateral transfer of patients by nurses. This is because, in the UK, there is an emphasis on occupational health and clinical risk management rather than ergonomic and biomechanical efficiency of nurses who are moving patients. For example, one respondent said: ‘It has the ability to measure the work technique, but you feel you need to look at the whole technique, not the risky aspects, which is difficult to do.’ The findings suggest a need for adequate training in the use of DINO before implementing it in the UK. DINO has three aspects of measuring the moving and handling patients: preparation, performance and result. The university’s trainers found the performance domain, or phase, of DINO conceptually challenging. For example, ‘I found this section clumsy – quite difficult to understand and assess.’ This may be explained by university trainers’ lack of experience and depth of training in back care compared to that of NHS back care advisers. There was concern among NHS staff with regard to whether pain can be accurately observed without asking the patient, such as ‘very concerned about possible misrepresentation of pain, if only a record of expression observed.’ DINO provides guidance on this point, but most respondents seemed not to have read or referred to this. Theme 2: outcomes of patient transfer Most respondents agreed that outcomes or evaluations of the lateral transfer of patients are important. DINO has a result phase that seeks to measure a limited aspect of patient outcomes, during and after manual handling. Further indicators could be added to this, such as patient discomfort, but this would require conceptual discrimination between 34 January 2016 | Volume 23 | Number 3

pain and discomfort: ‘Concept of patient “comfort” not covered explicitly as this differs from fear or pain.’ Further training in and clarification of DINO’s result phase would be required for observers. Theme 3: positive text responses The positive comments received seemed to confirm the validity of DINO in UK contexts. To measures of content validity are the item content validity index (ICVI) and scalar content validity index (SCVI) (Table 4). Polit and Tatano Beck (2008) suggested an average ICVI of 0.78 and a SCVI of 0.90 should be the standards for establishing excellent content validity. In this study, most DINO items achieved an excellent ICVI and a SCVI score of 0.91, which indicates excellent content validity (Table 4). This ties in with the triangulated summative content analysis theme of positive text responses regarding DINO, such as: ‘Very comprehensive, covering different aspects. Preparation phase particularly important.’ The positive responses obtained through the analysis suggest that there seems to be a broad consensus regarding the validity of DINO in the UK. Theme 4: manual handling risk Documenting and incorporating risk is more important for NHS back care advisers than for university trainers, who emphasise patient outcomes more. This may partially be a reflection of the risk-adverse culture in the UK’s largest public sector organisation, or the NHS’s staff training, which is driven by a need to reduce litigation claims for occupational injury, rather than by the more educative, holistic view of university trainers. In the responses, the NHS back care advisers seemed to focus more on reducing risk, while university trainers seemed to focus on assessing patients as the first priority. Theme 5: poor translation Johnsson et al (2004) did not publish any SCVI or ICVI for DINO. The findings from the pilot study suggest DINO has a satisfactory standard of content validity for most items (0.78), with the exception of its translation from Swedish to English and its ease of use (Table 4). This triangulates with the content analysis of the free text. One respondent said: ‘Difficult to understand the terminology used. Should be translated into user-friendly terms.’ Some of the issues arising are minor alterations needed to correct typographical errors, grammar and phraseology; slight amendments to the technical phraseology to be more in keeping with current manual handling technical wording; and slight amendments to its layout and presentation to make it more presentable for the user. © RCNi / NURSE RESEARCHER


Content analysis Table 4 DINO Item and Scalar Content Validity Indices derived from postal questionnaire Questions or items in postal questionnaire

Respondents ICV1 (3+4)

Respondents SCVI 3+4)

NHS Back Care Advisers ICVI (3+4)

University Trainers ICVI(3+4)

Difference ICVI (3+4) Univ-NHS

Q1 Rate the DINO instrument’s ability to measure the manual handling work technique

0.93

0.93

0.93

0.00

Q2 Rate the DINO key direction for use

0.87

Total ICVI/ No of items =11.82/13 =Average approach 0.91

0.75

0.93

+0.18

Q3 Rate the translation of DINO from Swedish to English

0.74

0.81

0.71

-0.10

Q4 Rate the sequencing of the questions in DINO

0.97

0.81

1.0

+0.19

Q5 Rate the relevancy of the background description in the DINO instrument

0.90

0.88

0.93

+0.05

Q6 Rate the relevance of the preparation phase in the DINO instrument

0.93

0.88

1.0

+0.12

Q7 Rate the relevance of the performance phase in the DINO instrument

0.87

0.94

0.80

-0.14

Q8 Rate the relevance of the result phase in the DINO instrument

0.87

0.81

0.80

-0.01

Q9 Does DINO incorporate all the required domains (background description, preparation phase, implementation phase, result phase) in measuring the concept of manual handling work technique?

1.0

1.0

1.0

0.00

Q10 Open question

n/a

n/a

n/a

n/a

Q11 Open question

n/a

n/a

n/a

n/a

Q12 How appropriate would you rate the items within DINO?

1.0

1.0

1.0

0.00

Q13 How representative are the items within DINO?

1.0

1.0

1.0

0.00

Q14 How clear are the items within DINO?

0.97

1.0

0.93

-0.07

Q15 How easy would you rate the use of the DINO instrument?

0.77

0.88

0.67

-0.21

Total

11.82

11.69

11.7

+0.01


NHS Back Care Advisers SCVI (3+4)

University Trainers SCVI (3+4)

Total ICVI/ Total ICVI/ No of items No of items = 11.69/13 =11.7/13 = Average = Average approach 0.90 approach 0.90

Difference SCVI(3+4) Univ-NHS Average approach 0.900.90 = 0



Nurse Researcher Discussion Insights Undertaking content analysis in this pilot case study provided useful comparative insights between NHS back care advisers and university trainers. Subtle cultural differences in emphasis were found between NHS Wales and university organisations. NHS back care advisers seem to regard ‘work technique’ as the method used to move and handle a patient, rather than the concept defined by Johnsson (2005), which combines ergonomic consideration with safe biomechanical principles and considerations of whether a transfer has been satisfactorily achieved. This appears to be subtler with university trainers, which may reflect the emphasis in the NHS on reducing risk. Limitations The main limitations of this analysis were the lack of time and resources available, which caused several issues. Without the study’s time limitations, the sampling of one university college’s manual handling trainers could be extended to other universities, to give more geographically diverse opinions of DINO. Findings from analysis of the free text cannot be generalised, but provide insight into possible cultural and training differences between the two respondent sub-groups in this example. Time restraints also meant that not all types of validity testing of DINO were undertaken, and the limited training time given to the respondents meant it is difficult to know whether respondents fully understood the construct of ‘manual handling work technique’ (Johnsson et al 2004). Some did not take enough time to read and follow DINO’s instructions before responding to the questionnaire about its translational validity. Determining the credibility of the study involved establishing whether participants found its results believable. Unfortunately, the NHS respondents were distributed throughout Wales and, due to a lack of resources and time, there was no feedback.

Implications The results of the study may be cautiously applied across the rest of the UK, as the context of the study was fairly narrow (translational validity of DINO), and may be applied specifically to those involved with educating and training staff and students in manual handling of patients. Summative, low-level, descriptive content analysis provided the researcher with additional ways of gaining insight into responses to questions and concepts pertinent to the investigation. A mixed approach of item responses to questions and free-text commentary by respondents enabled the identification of hidden meanings behind tickbox responses to questions, for example, the understanding of the construct ‘work technique’ had been misunderstood by some university trainers and NHS back care advisers. This suggests that issues of translation and emphasis on measurement are partly determined by cultural background. Content analysis can provide an opportunity to address the training needs of observers when using a new observational instrument.

Conclusion Summative content analysis of free text has provided a deeper insight into how two groups of respondents have common and different organisational emphases in moving and handling patients. There are many advantages to providing respondents with an opportunity to clarify their responses through free text, such as an insight into understanding of the question being asked, understanding of the concept or construct being discussed, and data triangulation through confirmation of item responses and free-text comments. Subtler results can be found through latent and manifest coding of data, such as the emphasis placed in the NHS on the risk of health and safety litigation versus the emphasis when training nursing students in higher education on outcomes when moving and handling patients.

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Conflict of interest None declared

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Polit DF, Tatano Beck C (2008) Nursing Research: Generating and Assessing Evidence for Nursing Practice. Eighth edition. Lippincott Williams & Wilkins, Philadelphia PA. Pope C, Ziebland S, Mays N (2006) Analysing qualitative data. In Pope C, Mays N (Eds) Qualitative Research in Health Care. Third edition. Blackwell, Oxford. Powers BA, Knapp TR (2006) Dictionary of Nursing Theory and Research. Third edition. Springer Publishing Company, New York NY. Vaismoradi M, Turenen H, Bondas T (2013) Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nursing and Health Sciences. 15, 3, 398-405.



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