Welcome to the new academic year! To launch it in style we have two guest blogs, contributed by attendees at a Workshop held at Warwick University in June. The Workshop introduced researchers of different disciplines within Health Sciences to the theory and use of pluralistic qualitative research. The first provides a perspective on the value of pluralism from Andrew Morris, a Specialist Renal Dietician, and the second from the perspective of a Senior Fellow of Nursing Research, Stephanie Tierney. (See Stephanie’s comment about the Workshop at the end of her blog).
Andrew’s blog reflects on how the flexibility of pluralistic approaches can be used in research to both improve healthcare service delivery and to enable better understanding of how patient engagement changes with personal, social and medical circumstances. He highlights the importance of this in aiming to meet the Department of Health’s guidelines that include patient experiences of engagement as an evaluation measure for clinicians (DoH, 2011). Drawing on his own research, Andrew identifies points at which the introduction of an additional qualitative method can enable greater understanding of the different types of patient engagement, and the impact of these on the medical outcomes of their treatments.
Stephanie’s blog brings a sombre note by reminding us that the use of pluralism requires a range of resources, from the practical – more time and support, to the psychological- the ability to tolerate ‘messiness’ in research. Pluralistic research trajectories often twist and turn as they seek to follow and find meanings in data from different perspectives. Frequently pluralistic studies raise as many questions as answers as the research progresses. Pluralistic researchers are challenged to make decisions about which avenues of inquiry to follow, selecting the most appropriate methods, and how best to stay close to the research focus when employing them. Just as pluralistic research studies require a range of resources, so do pluralistic researchers: the resource to determine how to conduct the study meaningfully, the resource to consider ‘If it means this then how can it also mean that?’, and the resource to write up the research effectively.
Do take a look also at the Events page which Deborah as recently updated, and as ever, do get in touch with any ideas for a Guest Blog or Blogger, books to review, and suggestions for new research or events that you think pluralistic researchers will be interested in.
I hope you enjoy Andrew’s and Stephanie’s blogs.
Nollaig
Dietetic Qualitative Research: Is it time to add a pinch of pluralism to the recipe?
Reflections on a pluralism workshop
As a clinical dietitian and dietetics researcher interested in qualitative approaches, my invitation to Deborah Biggerstaff’s Warwick Medical School pluralism workshop certainly stirred my appetite. A review of current knowledge suggested pluralism in dietetics was an underutilised ingredient. Guidance on using qualitative methods in nutritional research emphasises the complexity and need to consider epistemology, ontology and methodology (Swift & Taylor, 2010). Guidance on the practical issues born from these recommendations is however still lacking for novice researchers. For example, after considering the epistemological/ontological approach and justifying this to funders, what do I do with the parallel analyses I can see emerging from data when my particular philosophical perspective does not accommodate the alternatives? What Nollaig Frost and Deborah Rodriguez (guest presenters) offered was a shift in the way we, as clinicians, could formally research and represent clinical service delivery.
Clinical dietetic research takes place in the context of the structural policies of UK health service delivery, which remains inadequate in delivering effective care (Francis, 2010). This has clear implications for dietetic research proposals, requiring relevant methodology to answer clinically related questions. For example, ‘How do patients experience renal dietetics?’ and ‘What implications does this have for delivery?’ The introduction of patient experiences of engagement as an evaluation measure was welcomed by clinicians as a way to understand patients’ experiences of engaging with and receiving care (DH, 2011). However these tools may not result in practical service delivery solutions that are meaningful to service users and their families. Likert tools with free text ‘qualitative’ boxes may not allow enough insight into a person’s experience, and it is this experience which is pivotal in understanding and providing an effective patient centred service (Ritchie et al, 2013). Other ways of exploring service delivery need to be explored.
Rejecting a likert statistical analysis approach, my thematic framework analysis uncovered two types of engagement style within the dietitian–patient relationship: sham and genuine engagement. Genuine engagement seemed to facilitate positive patient outcomes whereas sham engagement (merely a masquerade) left patients less pleased with their clinical outcomes (Morris et al., 2013). I performed an in-depth evaluation which went beyond statistical outcome measures, revealing levels of service satisfaction with implications for the way in which future services are delivered. However, the transcripts also told another story, a story of both types of engagement at different transition points within an individual’s health journey, and within changing social, personal and medical journeys. The reality seemed to be less clear cut than it had first appeared – which left me with two dilemmas. Firstly, should I re-analyse to take into account these emerging perspectives using a different methodology? Secondly – what would the funders say when they peer-reviewed my output against evidence-based checklists for methodological quality.
Incorporating pluralism would have accommodated a change halfway through this analysis to better represent people’s changing social and medical situations (dietary recommendations and medical plans can change with declining renal function). A narrative analysis might have captured finely nuanced events and might have offered further insight into these engagement experiences. It appears that the conflict created by promoting evaluation of patient engagement, while using methods that clinicians feel obliged to use to satisfy funders (reconciled as a ‘best fit’), may present challenges to clinicians who are familiar with the evidence-based research pathway (Sackett et al., 2003).
I would argue, after fully digesting the information in the workshop, that an alternative pathway is one worth venturing down. Challenging my own perceptions, and offering the flexibility to do what is required to understand service delivery, may not only facilitate an improvement in patient services, but, importantly, may also demonstrate best practice to fellow clinicians and begin to build the (much needed in my opinion) pluralism evidence base in dietetics. I feel there is a need to keep up-to-date with qualitative techniques that are not part of the mainstream research agenda and perhaps this begins by adding a new section to the dietetic research recipe book – the smorgasbord approach that pluralism brings to the table.
Andrew Morris
Specialist Renal Dietitian, University Hospital Coventry, UK
References
Department of Health (DH) (2011). ‘What matters to patients?’ Developing the evidence base for measuring and improving patient experience. London: Department of Health.
Francis, R. (2010). Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009. Volume 1. London: Department of Health.
Morris, A., Liles, C., and Roskell, C. (2014). Why are patients disappearing from dietetic services? British Journal of Renal Medicine. 19: 30–31.
Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., et al. (2003). Evidence-based medicine: what it is and what it isn’t. British Medical Journal, 312: 169–171.
Swift, J. A., and Victoria, T. (2010). Qualitative research in nutrition and dietetics: getting started. Journal of Human Nutrition and Dietetics, 23: 559-566.
Taking a leap into the multiple and (potentially) messy: Reflections on an introductory pluralism workshop
Embarking upon an introductory workshop on pluralism at the end of June, I was prompted to reflect upon a feeling I often have when completing a study – is there something more here that has not been captured, even though a rigorous analysis has been conducted? Pluralism, it seems, could serve a role in addressing such disquiet and, by applying more than one qualitative method to data, help overcome any assumptions held about a topic and what can be known about it. Pluralism acknowledges that lived experience and the social world are complex and highlights how phenomena being studied are not detached and self-contained, but are shaped or constructed by socio-historical and cultural factors. It emphasises that the lens through which one considers a dataset will constrain what comes out. This brought to mind, whilst in the workshop, the idea of hearing a song and, at a certain time, listening mainly to the lyrics, whereas on another occasion, focusing on the baseline; this would bring something new to how the song is perceived and allow for a fuller appreciation of it.
As someone relatively new to pluralism, this broader approach to engaging with data was enlightening and thought provoking. However, although pluralism may surmount the limits of using a single method, and overcome that sense of not telling the whole story, opening data up to other approaches can require extra time and skills to ensure it is done in a rigorous manner. So, at a practical level, we learnt that it is essential to have the right team (or support if doing this for a PhD). Given the extra investment pluralism may entail, it is essential to be transparent about the value of what is planned. It calls for a degree of reflexivity, being clear why specific methods have been selected and how they will be used in relation to the research question. Another challenge raised in the workshop was being able to tolerate messiness. Pluralism does not strive towards triangulation, but to interpret data from different angles. It allows for contradictions because it explores multiple perspectives. Therefore, there may be no neat ending. This is something that I will have to manage when I conduct my first pluralistic study – a possible theme for another blog post, once I have undertaken this task?
“I really enjoyed this thought-provoking session. It introduced me to the basics of pluralism and allowed me to take some time to reflect on how it might apply to my own research. I have several references that I intend to follow-up and read to consolidate my learning.”
Stephanie Tierney
Royal College of Nursing Research Institute, University of Warwick
Guest blogger biographies
Andrew Morris is a clinical dietitian at University Hospital Coventry and Warwickshire NHS Trust. His research interests focus on clinical nutrition and the nutritional related consequences of kidney disease from a nutritional anthropological perspective. His current study explores the cultural-environmental influences on food choice in kidney disease by utilising qualitative methodology; specifically photo-elicitation.
Andrew has a first class degree in dietetics, a Masters in Research and received numerous grants from the National Institute of Health Research, UK.
Stephanie Tierney works as a Senior Research Fellow in Compassionate Care at the Royal College of Nursing Research Institute (University of Warwick). She has an interest in understanding people’s experiences of receiving and delivering treatment and services, focusing particularly on long-term conditions. She has run several studies using a range of methods: questionnaires with people who have diabetes, focus groups with health professionals, qualitative interviews with people who have cystic fibrosis, heart failure or an eating disorder, creative techniques with children who have a cleft palate. She has also conducted several systematic reviews/meta-syntheses.
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