Parts of this chapter have been reproduced with permission from Featherstone et al.106 © Queen’s Printer and Controller of HMSO 2019. This work was produced by Featherstone et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Data collection (in situ observations and interviews) and analysis was informed by the analytical tradition of grounded theory,132 which is a flexible approach for ethnographic research.126 This approach utilises theoretical sampling and the constant comparative method, in which data collection and analysis are inter-related134,135 and conducted concurrently.134,136 The flexibility and responsiveness of this approach were of particular significance, enabling us to increase the ‘analytic incisiveness’126 of the study. Preliminary analysis of data continued in parallel with data collection at later sites, informing the focus of further stages of data collection and subsequent concurrent analysis. The constant comparative method means that the coding of data into categories was a recurrent process. Data were examined in the context of previous fieldwork and analysis, which informed further strategies of data collection in subsequent sites, producing more focused stages of analysis.126 The analytical concepts emerging were then further tested and refined to develop robust analytical concepts that transcend the local contexts of individual wards and sites, and identify broader structural conditions137 that influence continence care for PLWD in the acute setting.
Findings from our mixed-methods review informed the ethnography in various ways, with a focus on initiating the process of early thinking and theorising during data collection and analysis. The review aimed to increase our theoretical sensitivity to key areas of importance to explore during data collection, including communication, language and the importance of non-verbal cues. The review was conducted alongside data collection at the first site, with data at this site analysed as they were collected. The review and its findings were used to stimulate questions during the ongoing iterative analytical process. This affirmed our focus on issues of continence-related communication, language, privacy and dignity, combined with known routines and strategies of bedside care.
Corbin and Strauss135 caution that, in grounded theory, literature should not impede ‘discovery’, emphasising the importance of using it actively to identify potential areas to inform theoretical sampling. Therefore, we explicitly sought opportunities to identify examples of individualised care, planning and assessments, with the goal of improving the continence of PLWD during an acute admission and the use of promoted strategies, such as ‘prompting’ and other continence routines and schedules, identified in the review.
Grounded theory strengthens the ethnographic aims of achieving theoretical interpretation of data, whereas the ethnographic approach prevents a mechanistic and rigid application of grounded theory.126 Ethnography can treat everything in a setting as data, leading to the ethnographer collecting large numbers of unconnected data and a heavily descriptive analysis.129 Our approach provides a middle ground in which the ethnographer uses grounded theory to provide a systematic approach to data collection, with the analytic goal of developing theory to address the interpretive realities of the range of actors in these ward settings.126 Data collection strategies explicitly supported ‘theoretical saturation’132 (i.e. where further data collection was no longer adding to the development of analytic concepts).
Analysis involved the development and testing of analytic concepts and categories. The strategies we used for the development of concepts and categories included careful reading of the data; looking for patterns and relationships; and noting surprises, inconsistencies and contradictions across the range of perspectives gathered. Line-by-line coding is inappropriate for field notes and, therefore, coding was selective, involving whole events or scenarios.117 Initially, this produced a collection of ‘sensitizing concepts’138 and analytic memos that informed the later development of more refined and stable analytic concepts. At this stage, Katie Featherstone and Andy Northcott re-examined the raw data informed by the subsequent phases of analysis (re-coding where necessary), looking for examples and events to test the analysis. Emerging analytic concepts were tested and refined to develop (in collaboration with the wider research team) stable concepts that identified broader structural conditions135 influencing continence care.
Throughout this process, we drew on multiple perspectives (e.g. sociological, policy, clinical, patient and carer) to inform our analysis. This included the use of our mixed-methods systematic review, with the narrative syntheses generated (see Chapter 6) informing data collection strategies and the analysis. Credibility checks included presenting emergent analysis to ward staff (in participating sites) and to PLWD and carers (see Chapter 9) for discussion throughout this process.
Field notes of observation and near-verbatim text were hand-written and then transferred into Microsoft Word files (Microsoft Corporation, Redmond, WA, USA) following data collection.139,140 All audio-recordings of observations and interviews (i.e. ethnographic and in-depth) were written up in Word files or transcribed verbatim by a professional transcription service. All sites and individuals, and the data collected, were anonymised and sorted in line with the UK General Data Protection Regulations as part of the Data Protection Act 2018.141 Storage of the data was managed by the Information Security Framework of Cardiff University (Cardiff, UK).