Nurse Researcher
mixed methods
Mixing methodology, nursing theory and research design for a practice model of district nursing advocacy Cite this article as: Reed FM, Fitzgerald L, Bish MR (2016) Mixing methodology, nursing theory and research design for a practice model of district nursing advocacy. Nurse Researcher. 23, 3, 37-41. Date of submission: October 10 2014. Date of acceptance: May 22 2015. Correspondence [email protected] Frances M Reed RN, BN(Hons), HC H (G Nurs), HC HP PC is a higher degree research student Les Fitzgerald RN, RM, Dip Teach Nurs, BEd, MNursStud, PhD is head of department Melanie Rae Bish RN, BN(Hons), BCN MN, PhD is senior lecturer and academic manager All at the Rural Health School, La Trobe University, Bendigo, Victoria, Australia 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 Aim To highlight philosophical and theoretical considerations for planning a mixed methods research design that can inform a practice model to guide rural district nursing end of life care. Background Conceptual models of nursing in the community are general and lack guidance for rural district nursing care. A combination of pragmatism and nurse agency theory can provide a framework for ethical considerations in mixed methods research in the private world of rural district end of life care. Discussion Reflection on experience gathered in a two-stage qualitative research phase, involving rural district nurses who use advocacy successfully, can inform a quantitative phase for testing and complementing the data. Ongoing data analysis and
Introduction If nursing is to be guided by contemporary healthcare knowledge, the elements of philosophy, theory and research design that support the generation of findings to inform practice must be considered (Flemming 2007). There is a need for research on advocacy that is specific to community nursing (Community Health Nurse Special Interest Group 2010). In many parts of rural Australia, community end of life care is provided at home by general nurses as part of a broad scope of practice called district nursing. The increasing demand internationally for support to live and die at home is affected by rural resources and constraints to access, affecting nurses’ ability to offer good care and choice (Reed et al 2015). Research into how district nurses can use advocacy © RCNi / NURSE RESEARCHER
integration result in generalisable inferences to achieve the research objective. Conclusion Mixed methods research that creatively combines philosophical and theoretical elements to guide design in the particular ethical situation of community end of life care can be used to explore an emerging field of interest and test the findings for evidence to guide quality nursing practice. Implications for practice Combining philosophy and nursing theory to guide mixed methods research design increases the opportunity for sound research outcomes that can inform a nursing model of care. Keywords mixed methods, research design, nurse agency theory, pragmatism, reflection for choice in end of life care can inform a practice model for rural health organisations offering this service and may improve care. If philosophy and practice theory can be applied to this research, a design with methods most suited to answering research questions and generating knowledge useful for practice can be crafted (Johnson et al 2007, Brannen and Halcomb 2009). This paper discusses how the elements of pragmatism, nurse agency theory and a mixed‑methods design can be combined to inform a practice model for rural, end of life, district nursing advocacy.
Pragmatism and nursing research Pragmatism emerged as a philosophy more than a century ago, in response to the dualism of subjective and objective views of the world January 2016 | Volume 23 | Number 3 37
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Art & science Nurse Researcher | acute care (Johnson and Onwuegbuzie 2004). Referred to as the ‘third paradigm’, it sits between positivism and constructivism, and combines the beneficial features of each (Johnson and Onwuegbuzie 2004). In the pragmatist’s view, reality exists in the daily happenings of people striving to achieve the best life possible (Dewey 2011b). Consequently, pragmatic knowledge is naturally occurring and constructed from people’s perspectives, and a mix of research methods is needed to understand the fullness of reality (Teddlie and Tashakkori 2009, Creswell and Plano Clark 2011). Pragmatic research involves mixed methods, collecting and analysing intentional combinations of qualitative and quantitative data for a broader, deeper understanding of complex phenomena and confirmed results (Johnson et al 2007). These can include multifaceted health concerns, such as the quality of end of life care, through mixing methods that combine the narratives of the people involved with measurements of causative variables, generating greater knowledge than single methods can produce (Teddlie and Tashakkori 2009). The pragmatic framework can also improve rigour by selecting suitable mixed methods designs that are practical and relevant to complex nursing questions (Flemming 2007). Pragmatism promotes intelligent action as an ethical platform for mixed methods research. The seminal concept of intelligence proposed by Dewey (2011a) continues to influence pragmatic research action intended to solve problems in society and professional practice (Talisse and Aikin 2011). Dewey (2011a) conceived of intelligence as a greater force than intellect, encompassing ‘the sum-total of impulses, habits, emotions, records and discoveries’ that lead to doing good. This concept of intelligence can guide action to establish a more ‘humane’ existence for everyone (Dewey 2011b). Thus intelligent action enables causes, character and conditions to be understood using the most suitable information sources, while being sensitive and respectful of the diverse perceptions of people involved in research (Dewey and Tufts 1932, Hall 2013). Intelligent mixes of information sources and knowledge can lend understanding to nursing practice relevant to the prevailing situation, interests and purposes that benefit humanity (Dewey 2001b). The pragmatic knowledge gained by creative, purposeful use of mixed methods is valid and meaningful if the end results are satisfactory and have beneficial consequences (Dewey 2011a). Pragmatism complements nursing in the search for practical knowledge focused on the achievement of the best health and wellbeing possible (Banfield 2011). Pragmatic and nursing world views hold that 38 January 2016 | Volume 23 | Number 3
knowledge is expanded by people learning from experience. Pragmatic understanding of reality is developed through the intelligent action of reflection on experiences and the subsequent reactions (Dewey 2011b). In nursing, reflecting on experiences and consequences leads to useable knowledge and a higher degree of autonomous practice (Ghaye and Lillyman 2000). People act with agency when they imagine the future with concern and hope, and experiment with ideas that might improve the situation (Dewey 2011a). Nurses may use intelligent action in their professional caring role. Agency enables changes in habits, such as care routines, through reflection on experiences, relationships and consequences that can project knowledge for future success (Dewey 2011b).
Using nurse agency theory in research In 1971, the Nursing Development Conference Group became the first organisation to use ‘agency’ to name the nursing process designed and used for the wellbeing of others (Orem 1985). Orem (1995) used it to describe the reflection and action fundamental in planning systems for effective nursing care. Personal attributes and learned abilities advance care and expertise based on the power to reflect, analyse and use knowledge to guide action in unique situations (Orem 1995). These abilities vary between individuals according to personality, education, experience and the ability to choose ethical actions that deliver on nursing goals (Orem 1995). Benner et al (2011) expanded the view of nurses as agents by focusing on the emotional work of nursing relationships. Nurse agency develops through commitment to caring relationships enhanced by the experience and knowledge of expert nurses who help patients to make plans and choices to achieve their health goals (Benner et al 2011). Nurse agency involves the perception, understanding and use of emotions to provide therapeutic nursing relationships (Theodosius 2008). Reflective nursing practice is required to apply these emotional abilities for the wellbeing of those involved in the caring relationship (McQueen 2004). While Orem (1995) warned against crossing the boundaries between personal and professional relationships, the emotionally intelligent action of nurse agency may benefit nurses and others with flexible boundaries that are responsive to need. The qualities of emotional intelligence relevant to interpersonal care and teamwork are the recognition and understanding of, and cooperative provision for, emotional need (McQueen 2004). Through reflection on caring relationships, nurses can understand, interpret and value their own and other people’s emotions, competently provide holistic care, and sustain themselves (Codier et al 2010). © RCNi / NURSE RESEARCHER
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mixed methods Developing knowledge about end of life care for people in their homes requires an understanding of emotional work. The sense of control at home and the comfort of prolonged relationships can free people to express emotion to their nurses, creating the opportunity for emotionally intelligent care (Davies et al 2010). However, the combination of increasing demand, professional isolation, medicalisation of the role and time constraints increases the burden of care and affects the setting of personal and professional boundaries in district nursing practice (Reed et al 2015). The gaps in knowledge of this situation call for exploration to develop understanding and confirm applicability to practice. Knowledge of how nurses manage boundaries in the provision of emotional end of life care and advocate for people in their rural homes can be derived from reflection on experience. Incorporating their agency in a research design may increase understanding of the personal and structural influences on care. A pragmatic mixed methods design provides the opportunity to capture the essence of agency in nursing advocacy and explore how it evolves in rural district care. The pragmatic choice of qualitative and quantitative phases is based on efficacy to address the complexity of the research question using a common sense combination of methods created to fit considerations and achieve the research objectives (Johnson and Onwuegbuzie 2004, Sandelowski 2014). Pragmatic intelligence can guide ethical considerations in designing mixed methods research into rural end of life care. Intelligent action requires concern for the effect the research will have on others while collecting data, and after its findings have been revealed (Hall 2013). Considerations include the personal comfort of participants, and the levels of burden and vulnerability they may experience by being involved in research into an emotive topic (Halcomb and Andrew 2009, Pepper and Wildy 2009). The potential for vulnerability is also likely to increase the time needed and the difficulty of obtaining ethical approval from multiple rural health services to collect two sets of data (Tan et al 2012). Respect for privacy in both phases is also essential in rural settings, where there is a high risk that ‘everybody knows everybody else’s business’ (Perkins 2013). This includes collecting, interpreting and conveying participants’ meanings faithfully while acting as the instrument in the qualitative phase and the developer of the instrument in the quantitative phase (Giddings and Grant 2009, Hall 2013). Thus, having appreciation for the time, effort and resources involved in conducting mixed methods research will assist with success and ensure good © RCNi / NURSE RESEARCHER
outcomes (Halcomb and Andrew 2009). Maximising reflection in end of life advocacy respects the agency of participants in a pragmatic design (Dewey 2011a) and may expedite the procedure to produce results that can be confidently applied to achieve good care.
Using reflection Reflection is vital to informing pragmatic knowledge of the complex concepts inherent in how district nurses successfully advocate for rural end of life goals. Reflection can challenge the meaning of personal responses to ethical decision-making, experiences and outcomes to enable deeper understanding. Reflection helps to release people from routine and misdirection through thinking about the meanings of experience (Dewey 2011a). Interactions between people can inspire change to bring about balance and cooperation (Dewey 2011a). Reflection on experience promotes self-acknowledgment, the valuing of others and engagement in close relationships (Peterson 2013). Emotional participation in relationships is guided by intuition and reflection in expert nurses, who sense what constitutes quality care (Ghaye and Lillyman 2000). Reflection by district nurses can reveal deeper meanings of quality care through advocacy and promote understanding of nursing relationships. For rural district nurses, reflection may help to resolve ethical decisions and enable delivery of safe, effective care to a relatively isolated community. Nurses self-regulate to varying extents, guided by codes of ethics and conduct, and the norms of practice in their situation (Johns 2005). District nurses reflect on their actions and subsequent outcomes to elicit personal satisfaction in the emotional labour of caring relationships (Rose and Glass 2010). These perceptions of experience are needed to develop knowledge and theory (Orem 1995), and ‘the outcomes of research should be tested in the realities of practising nurses’ to confirm findings (Wuest 2002). Respecting these different representations of truth avoids simplifying perceptions of people’s behaviour (Dewey and Tufts 1932).
The design procedure Planning to gain the most in-depth understanding possible from rural district nurses in distant locations, and then testing the results quantitatively by surveying a larger sample, can maximise strengths and reduce weaknesses (Creswell 2014, Sandelowski 2014). Considering this in the design adds ‘rigor, breadth, complexity, richness and depth’ to research (Denzin and Lincoln 2008). The research question calls for pragmatism and nurse agency theory to create a mixed methods January 2016 | Volume 23 | Number 3 39
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Art & science Nurse Researcher | acute care Figure 1 A mix of research elements to inform rural district nursing end of life care Complex research question To explore gaps in knowledge of advocacy in rural end-of-life home nursing Pragmatism Intelligent action: flexible, ethical, reflects on consequences of experience to benefit humanity
Nurse agency theory Uses intelligent action to reflect and manage emotional/relational care
Mixed methods sequential exploratory design Qualitative phase Reflection on experience of integrated narrative stages to develop a model
Quantitative phase Testing and refining the informed practice model development
Final integration and inferences To answer the question and to meet research objectives with a model of care
design that promotes reflection and explores experience as a basis for collecting and analysing data and the development of a model (Figure 1). The exploratory nature of the study requires the selection of people who can inform knowledge by reflecting on experiences. In Australia, rural district nurses often work in relatively autonomous roles; their work contact details are available so they can be sent invitations to participate in research. Rural district nurses who can share knowledge of success in end of life advocacy are experts because they can provide understanding and they can indicate this by responding to an invitation to participate (Minichiello et al 1990). Purposive sampling of experts on a topic can be used to gain in-depth knowledge (Holloway and Freshwater 2007). Vogt et al (2012) recommended using a small sample to provide a depth of information that surprises the researcher with new understandings. Participants’ in-depth reflections and analysis of outcomes can be collected through narratives. 40 January 2016 | Volume 23 | Number 3
Narrative offers a strategy that provides room for thought and calls on personal attributes applied to nursing in the telling of experiences, thoughts and reactions (Holloway and Freshwater 2007). It provides a rich source of different and deeper meanings and new insights (Frost and Cliff 2004). Using different methods to collect data increases the opportunity for reflection on practice to build pragmatic knowledge iteratively (Dewey 2011b). Using two stages of narrative collection can increase the quality and depth of knowledge available. The first stage asks informants for a written account of an experience of successful advocacy. Interpreting and sharing personal understanding of influences through writing these experiences invites more evaluation and emotional analysis than verbal narrative (Özyıldırım 2009), and can increase understanding of relationships (Foster and McKenzie 2012). The second stage of narrative collection makes use of the written data to inform the follow-up interview and access deeper meanings. The changing nature of reality and the shaping of data collection as understandings occur are recognised as beneficial in pragmatic intelligent action (Hall 2013). Minichiello et al (1990) proposed using in-depth interviews as an effective way to gather data in different settings in a short time, but added that repeat exposure to the world views of informants helps researchers to understand them. The time between the two narrative stages can promote continuing reflection by nurses and help the researcher to consider the written data. This may inspire questions and increase the opportunity for deeper understanding of successful advocacy through a visit to each rural location. In a pragmatic approach, ongoing transcription and analysis of reflections drives sequential data collection (Hall 2013). Categorising meaningful data can help in recognising the essence of relationships and themes identified participants (Silverman 2010). The flexibility of intelligent action enables each new insight from emerging themes and any differences in understandings to influence the procedure (Dewey 2011b). Themes significant to a district nursing practice model can be clarified and confirmed by exploring meanings in subsequent interviews. The quantitative research phase is used to test the developing model’s ability to meet the research objectives. Emergent themes indicate variables for exploration (Creswell and Plano Clark 2011), providing the framework for a survey of a larger, varied sample of rural district nurses. Representative samples increase confidence that findings are generalisable to the target © RCNi / NURSE RESEARCHER
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mixed methods population, strengthening the model by clarifying and confirming findings to be included in data integration (Lee and Smith 2012). In a pragmatic design, integration of the data is planned and occurs throughout the research, with critical review leading to practical inferences (Teddlie and Tashakkori 2009, Hall 2013). Enabling agency to influence the mixed methods data collection in sequential analysis can increase validity and help to unravel the complexities of the research question (Brannen and Halcomb 2009). Results that confirm or complement the emerging themes and the exploration of discrepancies can lead to knowledge that gives the whole picture of successful district nurse end-of-life advocacy (Tashakkori and Teddlie 2008). This broad scope of evidence can generate inferences about best practice that support a tentative practice model (Andrew and Halcomb 2006/7). The most convincing evidence that consistently fits
with theory and peer agreement is suitable to inform practice (Tashakkori and Teddlie 2008). The future quality of rural end-of-life nursing care may be usefully informed by the combination of the complementary elements of pragmatism and nurse agency theory in the mixed methods design, conduct and outcomes of research.
Conclusion Consideration of how philosophical, theoretical and design elements can be mixed to respect the ethical responsibilities inherit in conducting rural end of life nursing research improves the likelihood of obtaining good findings that can inform practice. Pragmatism and nurse agency theory provide a valid framework for understanding how rural district nurses apply successful end of life advocacy. This can be used to create a usable theoretical practice model that promotes quality of life through choice.
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Conflict of interest None declared
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January 2016 | Volume 23 | Number 3 41
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mixed methods
Mixing methodology, nursing theory and research design for a practice model of district nursing advocacy Cite this article as: Reed FM, Fitzgerald L, Bish MR (2016) Mixing methodology, nursing theory and research design for a practice model of district nursing advocacy. Nurse Researcher. 23, 3, 37-41. Date of submission: October 10 2014. Date of acceptance: May 22 2015. Correspondence [email protected] Frances M Reed RN, BN(Hons), HC H (G Nurs), HC HP PC is a higher degree research student Les Fitzgerald RN, RM, Dip Teach Nurs, BEd, MNursStud, PhD is head of department Melanie Rae Bish RN, BN(Hons), BCN MN, PhD is senior lecturer and academic manager All at the Rural Health School, La Trobe University, Bendigo, Victoria, Australia 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 Aim To highlight philosophical and theoretical considerations for planning a mixed methods research design that can inform a practice model to guide rural district nursing end of life care. Background Conceptual models of nursing in the community are general and lack guidance for rural district nursing care. A combination of pragmatism and nurse agency theory can provide a framework for ethical considerations in mixed methods research in the private world of rural district end of life care. Discussion Reflection on experience gathered in a two-stage qualitative research phase, involving rural district nurses who use advocacy successfully, can inform a quantitative phase for testing and complementing the data. Ongoing data analysis and
Introduction If nursing is to be guided by contemporary healthcare knowledge, the elements of philosophy, theory and research design that support the generation of findings to inform practice must be considered (Flemming 2007). There is a need for research on advocacy that is specific to community nursing (Community Health Nurse Special Interest Group 2010). In many parts of rural Australia, community end of life care is provided at home by general nurses as part of a broad scope of practice called district nursing. The increasing demand internationally for support to live and die at home is affected by rural resources and constraints to access, affecting nurses’ ability to offer good care and choice (Reed et al 2015). Research into how district nurses can use advocacy © RCNi / NURSE RESEARCHER
integration result in generalisable inferences to achieve the research objective. Conclusion Mixed methods research that creatively combines philosophical and theoretical elements to guide design in the particular ethical situation of community end of life care can be used to explore an emerging field of interest and test the findings for evidence to guide quality nursing practice. Implications for practice Combining philosophy and nursing theory to guide mixed methods research design increases the opportunity for sound research outcomes that can inform a nursing model of care. Keywords mixed methods, research design, nurse agency theory, pragmatism, reflection for choice in end of life care can inform a practice model for rural health organisations offering this service and may improve care. If philosophy and practice theory can be applied to this research, a design with methods most suited to answering research questions and generating knowledge useful for practice can be crafted (Johnson et al 2007, Brannen and Halcomb 2009). This paper discusses how the elements of pragmatism, nurse agency theory and a mixed‑methods design can be combined to inform a practice model for rural, end of life, district nursing advocacy.
Pragmatism and nursing research Pragmatism emerged as a philosophy more than a century ago, in response to the dualism of subjective and objective views of the world January 2016 | Volume 23 | Number 3 37
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Art & science Nurse Researcher | acute care (Johnson and Onwuegbuzie 2004). Referred to as the ‘third paradigm’, it sits between positivism and constructivism, and combines the beneficial features of each (Johnson and Onwuegbuzie 2004). In the pragmatist’s view, reality exists in the daily happenings of people striving to achieve the best life possible (Dewey 2011b). Consequently, pragmatic knowledge is naturally occurring and constructed from people’s perspectives, and a mix of research methods is needed to understand the fullness of reality (Teddlie and Tashakkori 2009, Creswell and Plano Clark 2011). Pragmatic research involves mixed methods, collecting and analysing intentional combinations of qualitative and quantitative data for a broader, deeper understanding of complex phenomena and confirmed results (Johnson et al 2007). These can include multifaceted health concerns, such as the quality of end of life care, through mixing methods that combine the narratives of the people involved with measurements of causative variables, generating greater knowledge than single methods can produce (Teddlie and Tashakkori 2009). The pragmatic framework can also improve rigour by selecting suitable mixed methods designs that are practical and relevant to complex nursing questions (Flemming 2007). Pragmatism promotes intelligent action as an ethical platform for mixed methods research. The seminal concept of intelligence proposed by Dewey (2011a) continues to influence pragmatic research action intended to solve problems in society and professional practice (Talisse and Aikin 2011). Dewey (2011a) conceived of intelligence as a greater force than intellect, encompassing ‘the sum-total of impulses, habits, emotions, records and discoveries’ that lead to doing good. This concept of intelligence can guide action to establish a more ‘humane’ existence for everyone (Dewey 2011b). Thus intelligent action enables causes, character and conditions to be understood using the most suitable information sources, while being sensitive and respectful of the diverse perceptions of people involved in research (Dewey and Tufts 1932, Hall 2013). Intelligent mixes of information sources and knowledge can lend understanding to nursing practice relevant to the prevailing situation, interests and purposes that benefit humanity (Dewey 2001b). The pragmatic knowledge gained by creative, purposeful use of mixed methods is valid and meaningful if the end results are satisfactory and have beneficial consequences (Dewey 2011a). Pragmatism complements nursing in the search for practical knowledge focused on the achievement of the best health and wellbeing possible (Banfield 2011). Pragmatic and nursing world views hold that 38 January 2016 | Volume 23 | Number 3
knowledge is expanded by people learning from experience. Pragmatic understanding of reality is developed through the intelligent action of reflection on experiences and the subsequent reactions (Dewey 2011b). In nursing, reflecting on experiences and consequences leads to useable knowledge and a higher degree of autonomous practice (Ghaye and Lillyman 2000). People act with agency when they imagine the future with concern and hope, and experiment with ideas that might improve the situation (Dewey 2011a). Nurses may use intelligent action in their professional caring role. Agency enables changes in habits, such as care routines, through reflection on experiences, relationships and consequences that can project knowledge for future success (Dewey 2011b).
Using nurse agency theory in research In 1971, the Nursing Development Conference Group became the first organisation to use ‘agency’ to name the nursing process designed and used for the wellbeing of others (Orem 1985). Orem (1995) used it to describe the reflection and action fundamental in planning systems for effective nursing care. Personal attributes and learned abilities advance care and expertise based on the power to reflect, analyse and use knowledge to guide action in unique situations (Orem 1995). These abilities vary between individuals according to personality, education, experience and the ability to choose ethical actions that deliver on nursing goals (Orem 1995). Benner et al (2011) expanded the view of nurses as agents by focusing on the emotional work of nursing relationships. Nurse agency develops through commitment to caring relationships enhanced by the experience and knowledge of expert nurses who help patients to make plans and choices to achieve their health goals (Benner et al 2011). Nurse agency involves the perception, understanding and use of emotions to provide therapeutic nursing relationships (Theodosius 2008). Reflective nursing practice is required to apply these emotional abilities for the wellbeing of those involved in the caring relationship (McQueen 2004). While Orem (1995) warned against crossing the boundaries between personal and professional relationships, the emotionally intelligent action of nurse agency may benefit nurses and others with flexible boundaries that are responsive to need. The qualities of emotional intelligence relevant to interpersonal care and teamwork are the recognition and understanding of, and cooperative provision for, emotional need (McQueen 2004). Through reflection on caring relationships, nurses can understand, interpret and value their own and other people’s emotions, competently provide holistic care, and sustain themselves (Codier et al 2010). © RCNi / NURSE RESEARCHER
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mixed methods Developing knowledge about end of life care for people in their homes requires an understanding of emotional work. The sense of control at home and the comfort of prolonged relationships can free people to express emotion to their nurses, creating the opportunity for emotionally intelligent care (Davies et al 2010). However, the combination of increasing demand, professional isolation, medicalisation of the role and time constraints increases the burden of care and affects the setting of personal and professional boundaries in district nursing practice (Reed et al 2015). The gaps in knowledge of this situation call for exploration to develop understanding and confirm applicability to practice. Knowledge of how nurses manage boundaries in the provision of emotional end of life care and advocate for people in their rural homes can be derived from reflection on experience. Incorporating their agency in a research design may increase understanding of the personal and structural influences on care. A pragmatic mixed methods design provides the opportunity to capture the essence of agency in nursing advocacy and explore how it evolves in rural district care. The pragmatic choice of qualitative and quantitative phases is based on efficacy to address the complexity of the research question using a common sense combination of methods created to fit considerations and achieve the research objectives (Johnson and Onwuegbuzie 2004, Sandelowski 2014). Pragmatic intelligence can guide ethical considerations in designing mixed methods research into rural end of life care. Intelligent action requires concern for the effect the research will have on others while collecting data, and after its findings have been revealed (Hall 2013). Considerations include the personal comfort of participants, and the levels of burden and vulnerability they may experience by being involved in research into an emotive topic (Halcomb and Andrew 2009, Pepper and Wildy 2009). The potential for vulnerability is also likely to increase the time needed and the difficulty of obtaining ethical approval from multiple rural health services to collect two sets of data (Tan et al 2012). Respect for privacy in both phases is also essential in rural settings, where there is a high risk that ‘everybody knows everybody else’s business’ (Perkins 2013). This includes collecting, interpreting and conveying participants’ meanings faithfully while acting as the instrument in the qualitative phase and the developer of the instrument in the quantitative phase (Giddings and Grant 2009, Hall 2013). Thus, having appreciation for the time, effort and resources involved in conducting mixed methods research will assist with success and ensure good © RCNi / NURSE RESEARCHER
outcomes (Halcomb and Andrew 2009). Maximising reflection in end of life advocacy respects the agency of participants in a pragmatic design (Dewey 2011a) and may expedite the procedure to produce results that can be confidently applied to achieve good care.
Using reflection Reflection is vital to informing pragmatic knowledge of the complex concepts inherent in how district nurses successfully advocate for rural end of life goals. Reflection can challenge the meaning of personal responses to ethical decision-making, experiences and outcomes to enable deeper understanding. Reflection helps to release people from routine and misdirection through thinking about the meanings of experience (Dewey 2011a). Interactions between people can inspire change to bring about balance and cooperation (Dewey 2011a). Reflection on experience promotes self-acknowledgment, the valuing of others and engagement in close relationships (Peterson 2013). Emotional participation in relationships is guided by intuition and reflection in expert nurses, who sense what constitutes quality care (Ghaye and Lillyman 2000). Reflection by district nurses can reveal deeper meanings of quality care through advocacy and promote understanding of nursing relationships. For rural district nurses, reflection may help to resolve ethical decisions and enable delivery of safe, effective care to a relatively isolated community. Nurses self-regulate to varying extents, guided by codes of ethics and conduct, and the norms of practice in their situation (Johns 2005). District nurses reflect on their actions and subsequent outcomes to elicit personal satisfaction in the emotional labour of caring relationships (Rose and Glass 2010). These perceptions of experience are needed to develop knowledge and theory (Orem 1995), and ‘the outcomes of research should be tested in the realities of practising nurses’ to confirm findings (Wuest 2002). Respecting these different representations of truth avoids simplifying perceptions of people’s behaviour (Dewey and Tufts 1932).
The design procedure Planning to gain the most in-depth understanding possible from rural district nurses in distant locations, and then testing the results quantitatively by surveying a larger sample, can maximise strengths and reduce weaknesses (Creswell 2014, Sandelowski 2014). Considering this in the design adds ‘rigor, breadth, complexity, richness and depth’ to research (Denzin and Lincoln 2008). The research question calls for pragmatism and nurse agency theory to create a mixed methods January 2016 | Volume 23 | Number 3 39
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Art & science Nurse Researcher | acute care Figure 1 A mix of research elements to inform rural district nursing end of life care Complex research question To explore gaps in knowledge of advocacy in rural end-of-life home nursing Pragmatism Intelligent action: flexible, ethical, reflects on consequences of experience to benefit humanity
Nurse agency theory Uses intelligent action to reflect and manage emotional/relational care
Mixed methods sequential exploratory design Qualitative phase Reflection on experience of integrated narrative stages to develop a model
Quantitative phase Testing and refining the informed practice model development
Final integration and inferences To answer the question and to meet research objectives with a model of care
design that promotes reflection and explores experience as a basis for collecting and analysing data and the development of a model (Figure 1). The exploratory nature of the study requires the selection of people who can inform knowledge by reflecting on experiences. In Australia, rural district nurses often work in relatively autonomous roles; their work contact details are available so they can be sent invitations to participate in research. Rural district nurses who can share knowledge of success in end of life advocacy are experts because they can provide understanding and they can indicate this by responding to an invitation to participate (Minichiello et al 1990). Purposive sampling of experts on a topic can be used to gain in-depth knowledge (Holloway and Freshwater 2007). Vogt et al (2012) recommended using a small sample to provide a depth of information that surprises the researcher with new understandings. Participants’ in-depth reflections and analysis of outcomes can be collected through narratives. 40 January 2016 | Volume 23 | Number 3
Narrative offers a strategy that provides room for thought and calls on personal attributes applied to nursing in the telling of experiences, thoughts and reactions (Holloway and Freshwater 2007). It provides a rich source of different and deeper meanings and new insights (Frost and Cliff 2004). Using different methods to collect data increases the opportunity for reflection on practice to build pragmatic knowledge iteratively (Dewey 2011b). Using two stages of narrative collection can increase the quality and depth of knowledge available. The first stage asks informants for a written account of an experience of successful advocacy. Interpreting and sharing personal understanding of influences through writing these experiences invites more evaluation and emotional analysis than verbal narrative (Özyıldırım 2009), and can increase understanding of relationships (Foster and McKenzie 2012). The second stage of narrative collection makes use of the written data to inform the follow-up interview and access deeper meanings. The changing nature of reality and the shaping of data collection as understandings occur are recognised as beneficial in pragmatic intelligent action (Hall 2013). Minichiello et al (1990) proposed using in-depth interviews as an effective way to gather data in different settings in a short time, but added that repeat exposure to the world views of informants helps researchers to understand them. The time between the two narrative stages can promote continuing reflection by nurses and help the researcher to consider the written data. This may inspire questions and increase the opportunity for deeper understanding of successful advocacy through a visit to each rural location. In a pragmatic approach, ongoing transcription and analysis of reflections drives sequential data collection (Hall 2013). Categorising meaningful data can help in recognising the essence of relationships and themes identified participants (Silverman 2010). The flexibility of intelligent action enables each new insight from emerging themes and any differences in understandings to influence the procedure (Dewey 2011b). Themes significant to a district nursing practice model can be clarified and confirmed by exploring meanings in subsequent interviews. The quantitative research phase is used to test the developing model’s ability to meet the research objectives. Emergent themes indicate variables for exploration (Creswell and Plano Clark 2011), providing the framework for a survey of a larger, varied sample of rural district nurses. Representative samples increase confidence that findings are generalisable to the target © RCNi / NURSE RESEARCHER
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mixed methods population, strengthening the model by clarifying and confirming findings to be included in data integration (Lee and Smith 2012). In a pragmatic design, integration of the data is planned and occurs throughout the research, with critical review leading to practical inferences (Teddlie and Tashakkori 2009, Hall 2013). Enabling agency to influence the mixed methods data collection in sequential analysis can increase validity and help to unravel the complexities of the research question (Brannen and Halcomb 2009). Results that confirm or complement the emerging themes and the exploration of discrepancies can lead to knowledge that gives the whole picture of successful district nurse end-of-life advocacy (Tashakkori and Teddlie 2008). This broad scope of evidence can generate inferences about best practice that support a tentative practice model (Andrew and Halcomb 2006/7). The most convincing evidence that consistently fits
with theory and peer agreement is suitable to inform practice (Tashakkori and Teddlie 2008). The future quality of rural end-of-life nursing care may be usefully informed by the combination of the complementary elements of pragmatism and nurse agency theory in the mixed methods design, conduct and outcomes of research.
Conclusion Consideration of how philosophical, theoretical and design elements can be mixed to respect the ethical responsibilities inherit in conducting rural end of life nursing research improves the likelihood of obtaining good findings that can inform practice. Pragmatism and nurse agency theory provide a valid framework for understanding how rural district nurses apply successful end of life advocacy. This can be used to create a usable theoretical practice model that promotes quality of life through choice.
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Conflict of interest None declared
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