by Jody Crombie
BScN, Vancouver Island University, 2004 A Thesis Submitted in Partial Fulfillment
of the Requirements for the Degree of Master of Nursing
in
The Faculty of Graduate Studies
Jody Crombie, 2011 University of Victoria
All rights reserved. This thesis may not be reproduced in whole or in part, by photocopy or other means, without the permission of the author.
ii Supervisory Committee
Exploring Experiences of People Accessing Addictions Facility Beds by
Jody Crombie
BScN, Vancouver Island University, 2004
Supervisory Committee
Dr. Bernie Pauly, Department of Nursing Supervisor
Dr. Joan MacNeil, Department of Nursing Departmental Member
Dr. Cecilia Benoit, Department of Sociology Outside Member
iii Abstract
Supervisory Committee
Dr. Bernie Pauly, Department of Nursing Supervisor
Dr. Joan MacNeil, Department of Nursing Departmental Member
Dr. Cecilia Benoit, Department of Sociology Outside Member
Many people seek out supports for addiction treatment and recovery. Communities are committed to providing addictions facility beds to individuals struggling with substance use. However, there is limited understanding of the
experiences of people who move through these beds. The purpose of this research is to explore the experiences of individuals accessing addictions facility beds, including the process of coming to a facility, being in the facility, windows and doors to recovery, discharge, and follow up care. Interpretive descriptive methodology was used to guide this study. Eight qualitative interviews were completed with people who self-identified as having problematic substance use and were admitted to any addictions facility in the past six months. The interviews were analyzed using the grounded theory method of constant comparative methods of analysis. The five themes generated in this research were understanding individuals as the experts of their care; challenges in gaining access to supports; systemic issues, including knowing what to expect and flexibility; gaining insight into personal challenges and successes; and present experiences and expectations affecting future encounters. Understanding individual experiences of the process of accessing supports can be of great value in future planning and development, and making the available resources as effective as possible. The findings of this research may be useful in five ways. First, this research is directly useful to those working with individuals who have problematic substance use through helping them understand the experiences of their clients. Second, this research is useful for planning the delivery of services to individuals who have problematic substance use. Third, this research is indirectly useful to anyone negatively affected by problematic substance use, through the potential to improve supports. Fourth, this research contributes to the profession of nursing by building on and strengthening nursing care offered to individuals. Fifth, and last, this research contributes to the wider base of literature regarding what is known about caring for individuals with substance use.
iv Table of Contents
Supervisory Committee ... ii
Abstract... iii
Table of Contents ... iv
List of Tables ... vi
Acknowledgements ... vii
Dedication ... viii
Chapter 1 ... 1
Problem Statement... 1
Aims and Objectives of the Research... 3
Importance and Significance of Topic ... 3
Terminology Used in this Research... 4
Research Questions... 6
Locating Myself as the Primary Researcher ... 6
Chapter 2: Literature Review... 8
Need for Supports for Individuals with Problematic Substance Use... 8
Supports for Problematic Substance Use ... 9
Experiences of Individuals Accessing Supports... 12
Challenges Experienced by Individuals Accessing Supports... 13
Chapter Summary ... 15
Chapter 3: Methodology... 16
Interpretive Description ... 16
Grounded Theory ... 17
Paradigms, Epistemology, and Ontology... 18
Methods... 20
Ethical Considerations ... 39
Limitations... 42
Chapter 4: Findings ... 44
Experts of Care ... 44
Windows and Doors to Recovery ... 47
Balancing Consistency with Flexibility ... 51
Gaining Insight... 55
Anticipating Future Experiences... 61
Summary... 65
Chapter 5: Discussion of Findings... 66
Findings in Relation to the Literature ... 66
Chapter 6: Conclusions ... 76
Summary of the Main Aims of the Research... 76
Summary of the Research Design and Methods ... 76
Summary of the Findings ... 76
Reflexivity ... 76
Summary of the Limitations ... 78
Future Research Recommendations ... 78
Policy Suggestions ... 79
v Appendix A... 95 Appendix B ... 96 Appendix C... 97 Appendix D... 98 Appendix E ... 102
vi List of Tables
Table 1 ... 22 Table 2 ... 45
vii Acknowledgements
I would like to acknowledge the great work of my committee members, and especially my supervisor for always prompting me to look a little harder, and revise a little more. I would like to acknowledge the support and enthusiasm I received from the research participants, and thank them for sharing their stories Further, I would like to acknowledge the support of the agencies for providing space for interviews, and for expressing their enthusiasm for the project.
viii Dedication
I want to dedicate this work to my family. Thank you for your never ending support and love.
Chapter 1
There is little known about the experiences of individuals who use licit, or legal, and illicit, or illegal, substances, as well as their access to addictions facility beds, services, and resources. In addition, little attention is paid to the unique experiences of individuals to inform the planning and delivery of supports in addictions care. This research explores the experiences of individuals accessing facility beds for problematic substance use, specific to those admitted in the last six months to an addictions facility, including social detox, medical detox, and crisis stabilization beds. In this chapter, I discuss the problem statement, the aims and objectives of the research, the importance and significance of the topic, an overview of the terminology used, the research questions and locating myself as the primary researcher. In the subsequent chapters, I will provide a review of the relevant literature, describe the research methodology, and present and discuss my findings.
Problem Statement
The prevalence of substance use is to be explored here, along with the harms and costs of substance use exacted on individuals, communities and families. Illicit drug use increased in Canada from 1994 to 2004 (Canadian Centre on Substance Abuse, 2004). The Canadian Alcohol and Drug Use Monitoring Survey (Health Canada, 2009) shows that in 2009 British Columbians reported a higher use of the illicit drugs of “cannabis, cocaine/crack, meth/crystal meth, ecstasy, hallucinogens, salvia, inhalants, heroin, pain relievers, stimulants, or sedatives to get high” in the past year than any of the other provinces in Canada. BC also had the highest lifetime illicit drug use of any province in
2 Canada, with 48.6% of British Columbians having used an illicit drug in their lifetime compared to the national average of 43.9% (Health Canada, 2009).
Substance use plays a prevalent role in many people’s lives and for some is associated with harms to families and children. The Canadian Centre on Substance Abuse (2004) says that almost 33% of adult individuals taking part in their survey relayed they had been harmed by someone else’s drinking within the past year. There are many struggles and burdens in families where problematic substance use is prevalent (Conry, 1997). In family members of the using individual, the challenges can exacerbate stresses related to “anxiety, depression or psychosomatic complaints” (Copello, Orford,
Velleman, Templeton & Krishnan, 2000, p. 330).
Substance use can affect children both before they are born and after, with fetal alcohol syndrome effects being found in children and in adults. These effects include damaged social skills, cognition, learning, memory and attention span (Conry, 1997). Increased risk of harm to children of untreated or ineffectively treated substance using parents (O’Connor, Morgenstern, Gibson & Nakashian, 2005) can include admission to care homes (Litzke & Glazer, 2004), “developmental consequences,” and increased risk of “over-dependence, low self-esteem, withdrawal and even suicide” (Conry, 1997, p. 419).
There are many costs associated with problematic substance use. Communities bear huge financial costs, especially in areas of health care that increase each year (Rehm et al., 2006). Rehm et al. (2006) explored the costs of substance abuse in Canada in 2002 and found that substance abuse cost $39.8 billion, with 61 percent of that in productivity losses, 22% in health care costs, 14% in law enforcement costs, and the rest in other
3 costs. The authors state, “substance abuse represents a significant drain on Canada’s economy in terms of both its direct and indirect impact” (p. 4). Morell (1996) emphasizes that while much is spent on problematic substance use, both problematic using and its negative effects continue to expand and are “a personal and social tragedy” (p. 311).
Not much is known about how people seek out supports, what their process is of accessing supports, and what difficulties and challenges they experience along the way. These details help us understand how supports can make a difference in decreasing the prevalence as well as the costs and harms of substance use.
Aims and Objectives of the Research
Facility beds are often used by individuals with problematic substance use for detox, supportive recovery and treatment. There is little known about the experiences of these individuals from their own perspective. The aims of the research are to contribute toward gaining a better understanding of the experiences of individuals accessing supports and services for problematic substance use and to better understand the connections between these supports and services.
Importance and Significance of Topic
Improving the effectiveness and responsiveness of addictions care is paramount in assisting individuals to overcome the challenges associated with problematic substance use. As more is understood about individual experiences, insights can be provided to facilities and other services on how they are perceived by those who use them. Further, this research can contribute to the development and refinement of supports provided, encourage improvement in the delivery of these supports, and help care providers
4 understand the challenges people have in accessing supports. This research also
contributes to the literature base regarding individuals with substance use and their experiences.
Terminology Used in this Research
Individuals may use many types of substances, which may or may not be harmful to them, physically, psychologically, and socially. In this section, I will discuss the use of terms including substance use, problematic substance use, and addiction. I will also discuss the terms for preferred use in this thesis. Within this research, problematic substance use may refer to substances that are legal or illegal. For example, marijuana, cocaine, crack and heroin are commonly used illegal drugs. Alcohol and morphine are examples of legally sanctioned and regulated drugs.
According to the British Columbia Ministry of Health Services (2004), the term substance use
refers to the use of any substance that is psychoactive (i.e. alters consciousness). Psychoactive substances include alcohol, tobacco, caffeine, illegal drugs, some medications and some kinds of solvents and glues. The use of psychoactive substances is an almost universal human cultural behaviour and has been engaged in since the beginning of human history. Substance use may range from beneficial to problematic, depending on the quantity, frequency, method or context of use. The British Columbia Ministry of Health Services (2004) defines problematic substance use as
instances or patterns of substance use associated with physical, psychological, economic or social problems or use that constitutes a risk to health, security or
5 well-being of individuals, families or communities. Some forms of problematic substance use involve potentially harmful types of use that may not constitute clinical disorders, such as impaired driving, using a substance while pregnant, binge consumption and routes of administration (i.e. ways of taking a substance into one’s body) that increase harm. Problematic substance use also includes “substance use disorders” (i.e. clinical conditions defined by the DSM-IV,
including dependence or “addiction”). Problematic substance use is not related to the legal status of the substance used, but to the amount used, the pattern of use, the context in which it is used and, ultimately, the potential for harm.
The term addiction can be difficult to define and has many meanings (Roberts & Koob, 1997). Achieving consistent use and meaning of terms can be challenging, but is integral to ensuring the terms are consistent with what they are meant to represent. The term addiction can be used to refer to problematic chemical use, gambling (Andres & Hawkeye, 1997), sex (Roller, 2004), food (Driscoll, 1995), or even computer use (Wieland, 2005). Given that this research is concerned with the experiences of
individuals in addictions facility beds, the focus of the research is on chemical substance use only, without distinguishing between licit, or regulated, and illicit, or unregulated use, as some licit substances are used in an illicit manner. For example, prescription drugs may be bought or sold on the street. The Canadian Society of Addiction Medicine (2008) defines addiction as
a primary, chronic disease, characterized by impaired control over the use of a psychoactive substance and/or behaviour. Clinically, the manifestations occur along biological, psychological, sociological and spiritual dimensions. Common
6 features are change in mood, relief from negative emotions, provision of pleasure, pre-occupation with the use of substance(s) or ritualistic behaviour(s); and
continued use of the substance(s) and/or engagement in behaviour(s) despite adverse physical, psychological and/or social consequences. Like other chronic diseases, it can be progressive, relapsing and fatal.
Although meanings of the word have varied over the years, addiction is often associated with value laden judgements regarding the substances used and the people using them (Heise, 2003; Hyman, 2004; Ogborne, 1997). This is especially true in the case of illicit drug use. Individuals participating in this research can be labelled as an addict, a user, a substance user, a problematic substance user, a patient, a client, an individual, a consumer and a research participant. Some of these labels can be
stigmatizing for individuals. In an attempt to avoid the use of stigmatizing language, the terms individual with problematic substance use, individual, and research participant will be predominantly used throughout this thesis.
Research Questions
The primary research purpose is: To explore the experiences of individuals accessing and using addictions supports. Research questions to be addressed include: What are people’s experiences of accessing addictions facility beds? What are people’s experiences of being in an addictions facility bed? What are people’s experiences of the links between facility beds and other related supports and agencies?
Locating Myself as the Primary Researcher
I have been educated as a Registered Nurse, with my Baccalaureate of Science in Nursing. I have also completed much of my Master’s of Nursing Degree with the
7 University of Victoria in Advanced Practice Leadership, focussing on individuals with problematic substance use. I have been employed over the last seven years with a small private not-for-profit hospital, working in a psychiatric unit as well as working as an addictions nurse with both clients in the community and clients in the hospital. I also work in a community mental health and addictions office in one BC local health authority.
Life experiences of knowing people in need of care for problematic substance use, as well as work experiences have made me curious about addictions clients and how they are served by the health care system. Often clients with problematic substance use present challenges for nurses and other health care professionals in their work. While working in this field, I have frequently come to notice gaps in knowledge and leadership surrounding care, as well as gaps in evidence to support decision making regarding the care that is offered and the funding that is allocated.
8 Chapter 2: Literature Review
In this chapter, I review literature on the need for supports for individuals with problematic substance use, substance use supports, and experiences of individuals accessing treatment supports. I also explore the current research on challenges
experienced by persons accessing or trying to access supports for problematic substance use.
Need for Supports for Individuals with Problematic Substance Use
Problematic substance use can be a chronic challenge for individuals, spanning much of their lifetime. Both inpatient and outpatient supports, as explored below, can be effective in ending or reducing harms of use. One challenge in looking at the
effectiveness of supports lies in defining success. Successes can be distinguished by improved health, decreased use, abstinence, improved living conditions, improved relationships with others, et cetera. Some emphasize the importance of “improvement rather than cure” (O’Brien & McLellan, 1996, p. 238) when working with individuals with problematic substance use. Others emphasize learning to “measure clients’ success in degrees, the small steps they take to improve their lives” (Konrad, 2004, p. 9).
There is evidence that both inpatient and outpatient supports are effective for treatment of problematic alcohol and other drug use (National Institute on Alcohol Abuse and Alcoholism, 1998; Raistrick, Heather & Godfrey, 2006), with money spent on
problematic substance use being an effective investment (O’Brien & McLellan, 1996; Raistrick, Heather & Godfrey, 2006; Roberts, Ogborne, Leigh & Adam, 1999). Between 40 to 60% of individuals with drug addiction relapse, and “individual treatment outcomes depend on the extent and nature of the patient's problems, the appropriateness of
9 treatment and related services used to address those problems, and the quality of
interaction between the patient and his or her treatment providers” (National Institute on Drug Abuse, 2009, p. 11).
Treatment supports are especially effective in areas of reduced crime and reduced health spending, increased employment wages and money not spent on use (McCollister & French, 2003). However, treatment can be frustrating with much of the work
culminating in only “respites” from using (White, Boyle, & Loveland, 2003, p. 40). Leshner (2003) notes that understanding “addiction as a chronic, relapsing disorder means that a good treatment outcome, and the most reasonable expectation, is a significant decrease in drug use and long periods of abstinence” (p. 192).
There is evidence that the relationship developed between the clinician and the client can be a strong predictor of positive treatment outcomes (Fiorentine, Nakashima & Anglin, 1999; Najavits &Weiss, 1994). A clinician with “strong interpersonal skills” (Najavits &Weiss, 1994, p. 2) who offers a service that the client finds to be useful or helpful (Fiorentine, Nakashima & Anglin, 1999, p. 204) is associated with higher rates of effectiveness for treatment of problematic substance use. Raistrick, Heather, and
Godfrey (2006) state that “more effective therapists are characterised as empathic, supportive, goal-directed, helping and understanding, encouraging service user
autonomy, and are effective at using external resources” (p. 47), while emphasizing that treatment effectiveness is varied, different for each clinician and each facility.
Supports for Problematic Substance Use
Institutional supports for alleviating problematic substance use consist of both inpatient and outpatient supports, as explored below. In this research the focus is on
10 inpatient supports and the experiences of individuals in addictions residential facilities, including social detox, medical detox, and crisis stabilization beds.
Both medical and social detox admissions tend to be for a few days up to a week (Centre for Substance Abuse Treatment, 2006). Medical detox employs the regular use of medications to help people off their substances (Centre for Substance Abuse
Treatment, 2006, p. 7). Medical detox may be in hospital, in a specified unit for medical detox, or as a home detox with close monitoring (Centre for Substance Abuse Treatment, p. 7). Individuals are admitted to medical detox when they have been determined to need medical management of their withdrawal, including situations where an individual has had severe and life threatening withdrawal from alcohol in the past, and situations where an individual using opiates is pregnant and needs to be stabilized. Crisis stabilization beds are facility beds that are often used for social detox, but can be accessed for other types of need as well. Social detox centres often do not use medications and have staff present to assess and work with individuals in an ongoing manner (Centre for Substance Abuse Treatment, 2006). Individuals are admitted to social detox when they have been assessed as needing increased support to stop their problematic substance use but they are not in need of medical management. For example, this may include situations where an individual is living in a home where they are constantly surrounded by using, making it very difficult to stop using and connect with supports. This may also include situations where an individual has tried to quit using many times on their own at home and is simply unable to abstain from using without further assistance.
The Center for Substance Abuse Treatment (2006) notes that “regardless of setting or level of care, the goals of detox are to provide safe and humane withdrawal
11 from substances and to foster the patient’s entry into long-term treatment and recovery” (p. 23). Mark, Dilonardo, Chalk and Coffey (2003) found in their research that less than half of the clients who went through detox connected with subsequent substance use services, “missing opportunities for sustaining treatment gains and sobriety” (p. 303). They state that additional “research and efforts are required in order [to] ensure that detoxification is followed by treatment” (p. 304). Thus, the transition between services and follow up supports is not seamless.
Outpatient supports include counseling, self-help groups, and professional led groups for purposes of trying to achieve recovery, treatment, and relapse prevention. Self-help groups can arise out of a system that many individuals find disempowering and hierarchical, and can work to complement other supports already in place (Baldacchino & Rassool, 2006), even providing “a sense of belonging and empowerment” (McCall, 1999, p. 19) to individuals with problematic substance use. Many individuals also find supports in the community in the form of their physician, pastoral care, family, friends, and others. The research has had difficulty distinguishing the differences in effectiveness of the various inpatient and outpatient supports (Morgenstern & McKay, 2007; National
Institute on Alcohol Abuse and Alcoholism, 1998; Saxe, Dougherty, Esty & Fine, 1983). As well as treatment supports, harm reduction initiatives have positive effects for many individuals. Harm Reduction International (2011) defines harm reduction as being “policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption.” Harm reduction can include many actions and programs aimed at making using safer, such as teaching techniques for safer
12 use, supervised injection sites, needle exchanges and methadone programs. Harm
reduction “neither condones nor condemns drug use, but respects it as a choice” (Hilton, Thompson, Moore-Dempsey & Janzen, 2001, p. 358), taking a “value-neutral and humanistic view” (Cheung, 2000, p. 1697). Harm reduction frames care in terms of health rather than in terms of legal repercussions (Prakesh & Taylor, 2001). While harm reduction is not the focus of this research, harm reduction is understood to be
complementary to treatment supports. This is especially important if we view addiction, as described above, as a chronic and relapsing condition.
Experiences of Individuals Accessing Supports
Both Young (1994) and Wilkinson, Mistral and Golding (2008) have explored the experiences of individuals accessing a supports for problematic substance use. Young looked at pregnant addicted women and their experiences. In her study, she identified paternalism, and punitive ways of working with the clients. This included strict and hard to follow rules, power imbalances reinforced and strengthened, and surveillance of clients by staff being encouraged in drug treatment facilities. Wilkinson, Mistral and Golding looked at residential treatment from both the client and the staff perspective, noting what they found to be the “most and least useful aspects” (p. 404). Their research found that “understanding, commitment, and continuity on the part of key workers was deemed of considerable importance by both clients and staff” (p. 412). They also found counselling, group therapy and the therapeutic milieu of the unit to be important. They emphasized the importance of holistic care including such things as child care and housing, starting even before the client is admitted to the facility. They also emphasized that clients who have a history of different substances used may do well with different types of a unit
13 milieu. Each of the above studies highlight the experiences of individuals accessing services.
Challenges Experienced by Individuals Accessing Supports
Individuals can experience many barriers in accessing or trying to access supports for substance use. The Center for Substance Abuse Treatment (2006) recognizes many barriers to accessing services for problematic substance use. These include
“transportation, child care during treatment, the potential for relapse between
detoxification discharge and treatment admission, housing needs, and safety issues such as possible domestic violence” (p. 42). They see these barriers as also including wait lists, concerns about Child Protective Service involvement for those with children,
“hostile or unfriendly practitioners,” (p. 43) “resistance from family, partners, or friends,” (p. 43) “physical or cognitive disability,” (p. 44) and “language, cultural, and financial factors” (p. 44). Additional barriers identified by Hser, Maglione, Polinsky and Anglin (1998) include not being eligible for services, not being able to afford services,
scheduling difficulties, illness, legal challenges, and having a difficult time setting up supports (p. 218).
The literature on compliance and power shows how labels also can become
significant barriers. Labelling a client as non-compliant can serve to devalue the client’s ability to make their own decisions (Hobden, 2006, p. 257). Labels can identify people as “deviant, irrational and problematic” (Playle & Keeley, 1998, p. 309). Labelling clients as non-compliant also “emphasizes professional power” (Playle & Keeley, 1998, p. 309), reinforcing the health care professional as being the one in control and
14 why they are choosing differently than recommended.
Marland (1999) states that “patient self-determination is essentially a moral and legal right” (p. 620), cautioning that professionals need to respect the decision making capacity of clients, even when they are making decisions that are challenging to witness. It is important to recognize that a client can be pushed into accepting supports for their problematic substance use by health care professionals, by outside pressures, by the legal system, and by family, friends, or work (Wild, 2006). Professionals need to be aware of these pressures, and the importance of “balancing the public importance for [feelings of] safety against the individual importance of the addicted user” (Dike van de Mheen, 2003, p. 123). Balancing what other people think is best for an individual against what that individual wants for him or her self can be a significant challenge.
Many authors recognize a gap between the needs of people with problematic substance use and the care offered. Milloy et al. (2009) and Hadland et al. (2008) both identify waitlists for accessing services as gaps in care. Hadland et al. state that “a substantial increase in the provision of addiction treatment services may be required to mitigate the harms of drug use” (p. 6). Care needs to be a better match to the needs of individuals with problematic substance use (Raistrick, Heather & Godfrey, 2006).
There is also a notable gap in applying what is known about best practices to working with substance using individuals (Chiauzzi & Liljegren, 1993; Hser, Maglione, Polinsky & Anglin, 1998; Leshner, 2003). Leshner (2003) sees this lack as propagated by stigma and a moralistic view of substance use. Hser, Maglione, Polinsky and Anglin (1998) state, “methods to improve treatment access may prove to be useful at relatively low cost for increased accessibility and utilization among drug abusers, leading to
longer-15 term return at both individual and societal levels” (p. 219-220).
As much of the research has been done regarding barriers to general health care services, it is difficult to know whether the same barriers apply to both homeless individuals and individuals with problematic substance use. Barriers identified for homeless individuals trying to access care include lack of a health card (Butters & Erickson, 2003; Turnbull, Muckle & Masters, 2007), negative attitudes of health care professionals, both actual and anticipated (Butters & Erickson, 2003; Plumb, 2000; Turnbull, Muckle & Masters, 2007), fear of coming forward with obvious evidence of violence (Butters & Erickson, 2003), lack of transportation (Turnbull, Muckle & Masters, 2007), and lack of ability to navigate the system (Hatton, 2001; Turnbull, Muckle & Masters, 2007). Another barrier is individuals perceiving their other needs, including food and housing, as a higher priority than health care (Hatton, 2001; Plumb, 2000).
Two significant gaps in the knowledge base regarding the population of individuals with problematic substance use are noticeable in the literature review. The first gap is the lack of knowledge regarding substance use clients and their experiences in addictions specific facilities. The second gap is the lack of knowledge surrounding the client experience of accessing any type of substance use supports.
Chapter Summary
In this chapter I reviewed literature on the need for supports for individuals with problematic substance use, substance use supports, and experiences of individuals accessing treatment supports. I also explored the current research on challenges
experienced by persons accessing or trying to access supports for problematic substance use.
16 Chapter 3: Methodology
In this chapter, I will discuss interpretive description informed by grounded theory as the overall methodological approach used to guide my research. I will discuss
interpretive, constructivist, and naturalistic paradigms as well as the epistemological and ontological underpinnings of the research approach I have chosen. Lastly, I will describe the methods used in this study, including the sample, recruitment, setting, data collection, analysis, and attention to rigor. This research underwent a University of Victoria and Vancouver Island Health Authority joint ethics approval process. Ethical considerations and limitations of this research will be explored last in this chapter.
Interpretive Description
Interpretive description is a qualitative research methodology developed by Thorne, Reimer Kirkham, and MacDonald-Emes (1997). As a methodology, importance is placed on the need for researchers to exercise self-exploration and understanding of where they stand in relation to the phenomenon of interest, and to find themselves within their “theoretical allegiances,” their “discipline,” and their “personal relationship to the ideas” held (Thorne, 2008, p. 64). Interpretive description can be used by researchers to describe and interpret a phenomenon for clinical use, while recognizing the larger context within which their focus of interest is located (Thorne, 2008).
Interpretive description has been used with narrative inquiry (Irwin, Thorne, & Varcoe, 2002) and grounded theory (Thorne, McGuinness, McPherson, Con,
Cunningham & Harris, 2004), as well as on its own (Thorne, Con, McGuinness, McPherson & Harris, 2004; Thorne, Hislop, Armstrong & Oglov, 2008; Thorne, Kuo, Armstrong, McPherson, Harris & Hislop, 2005). In interpretive descriptive research,
17 findings reflect an interpretive maneuver within which the researcher considers what the pieces of data might mean, individually and in relation to one another, what various processes, structures, or schemes might illuminate about those relationships, and what order and sequence of presentation might most effectively lead the eventual reader toward a kind of knowing that was not possible prior to your study. (Thorne, 2008, p. 163)
Within a framework of interpretive description, a researcher has the space to use a variety of methods to collect and analyze data (Thorne, 2008). In this research project, I used interpretive description informed by grounded theory. I chose interpretive
description and grounded theory because they were a good match to my research questions and would help me explore the experiences of people while still keeping their stories in context.
Grounded Theory
Grounded theory is a research methodology primarily used when doing qualitative research (Moore, 2009). It was developed in the 1950’s by Glaser and Strauss (Licqurish & Siebold, 2011). The purpose of grounded theory is to inductively generate theory from data. There are some variations on how to do grounded theory, including classic
grounded theory, Straussian grounded theory, and constructivist grounded theory (Hunter, Murphy, Grealish, Casey, & Keady, 2011). In my research the method of data analysis, constant comparative analysis, was borrowed from grounded theory
methodology.
Constant comparative analysis is a method of analysing data to develop and pull out themes of what is happening with the phenomena of interest. It originally arose out
18 of work by Glaser and Strauss and has been further developed by Lincoln and Guba (1985). In using constant comparative analysis the researcher compares all bits of data with all other bits of data during the process of data collection. This allows the
researcher to delve into differences, similarities, patterns and themes, while the process of data collection is underway.
Paradigms, Epistemology, and Ontology
The paradigm or worldview underlying a research project influences the development of the research plan, from the research questions asked and the
methodologies chosen, to views about the research participants themselves. Weaver and Olson (2006) see paradigms as being “sets of philosophical underpinnings from which specific research approaches . . . flow” (p. 460). They write “paradigms are patterns of beliefs and practices that regulate inquiry within a discipline by providing lenses, frames and processes through which investigation is accomplished” (Weaver & Olson, 2006, p. 460). There are many different classifications of paradigms. As explained below, the methodology of interpretive description is informed by interpretive, constructivist, and naturalistic paradigms. Different paradigms have different ontologies and
epistemologies, which affect how they view phenomena.
Ontology can be said to be “concerned with the nature and relations of being” (Cohen & Omery, 1994, p. 140) while epistemology is “concerned with the nature and grounds of knowledge” (Cohen & Omery, 1994, p. 140). The epistemology and ontology of any research methodology affects the understanding of being and knowing within that study. Being upfront and open with the ontology and epistemology of a study allows the reader to know what angle the study comes from and to recognize how that angle could
19 affect the study results (Pesut & Johnson, 2008).
Weaver and Olson (2006) recognize paradigms of “positivist, postpositivist, interpretive and critical social theory” (p. 460) as being relevant to what is being done in areas of nursing research. Interpretive description fits into the interpretive paradigm within this framework, which “emphasizes understanding of the meaning individuals ascribe to their actions and the reactions of others” (Weaver & Olson, p. 460).
Denzin and Lincoln (1998) distinguish between paradigms of positivist/
postpostivist, constructivist, feminist, ethnic, Marxist, and cultural studies. Within this classification, interpretive description fits into the constructivist paradigm as this methodology aims “to understand meaning not ‘truth’” (Bailey, 1997, p. 21), consistent with the constructivist paradigm.
Interpretive description can also be placed within the natural inquiry paradigm. Bailey (1997) states that,
the term ‘natural inquiry’ reflects the initial work done by qualitative researchers. It implies the acquisition of knowledge in a manner other than empirical research. Interpretive or hermeneutical research, terms used interchangeably with natural inquiry, simply refer to the basic nature of qualitative work, that of interpreting meanings within the context of the natural environment. (pp. 19-20)
Lincoln and Guba (1985) state that “design in the naturalistic sense . . . means planning for certain broad contingencies without, however, indicating exactly what will be done in relation to each” (p. 226). They state that the research design of a naturalistic inquiry “must emerge, develop, unfold” (p. 225) as part of the process. The ontology, or beliefs of being and existence, affects the understanding of this research as it assumes that there
20 are many unique experiences of people to be explored and observed. Denzin and Lincoln (1998) recognize that naturalist inquiry “assumes a relativist ontology (there are multiple realities)” (p. 35) and “a subjectivist epistemology (knower and subject create
understandings)” (p. 35).
The epistemology, or beliefs of knowing and coming to know, is important to understanding the assumptions behind the research design of this project. These assumptions include that individuals with problematic substance use are important
sources of knowledge, and that the research methodologies of interpretive description and grounded theory are valuable ways to explore this knowledge.
Methods
In this section I will discuss sample, recruitment, setting, data collection methods, analysis, and attention to rigor.
Sample. The population of interest for this research was individuals having been admitted in the last six months, from the time of the first interview, to an addictions facility, including but not limited to social detox, medical detox, or crisis stabilization beds, as defined above on page 10. When deciding on sampling it is imperative to be thoughtful about the research participants, whom they represent, and what perspective they represent (Thorne, 2008). Thorne (2008) warns that it is important for researchers to be able to reasonably understand what their sample is “privileging or silencing” (Thorne, 2008, p. 88) and that the researcher needs to use this understanding when drawing meanings from the research results. Keeping in mind what the sample does and does not reflect helps the researcher to draw their findings from the data, and better understand the applicability of those findings to various individuals and situations.
21 Convenience sampling was used when recruiting participants for this research. Polit and Beck (2004) define convenience sampling as a type of non-probability sampling. They state that it “entails using the most conveniently available people as study participants” (p. 292). Statistics Canada identifies both pros and cons of using convenience sampling. Pros include that it “can be useful when descriptive comments about the sample itself are desired,” that it is “quick, inexpensive and convenient,” and that it can be more feasible in some studies than other sampling methods (Statistics Canada). Cons include difficulty to measure reliability, potential bias as there is no randomization of who is included in the study, and a lack of representativeness of the population (Statistics Canada). Polit and Beck (2004) reinforce that a sample gathered through convenience sampling “might be atypical of the population of interest with regard to critical variables” (p. 292).
There are many reasons why convenience sampling was used in this research project. These include that convenience sampling is convenient, fast, and easy to do. Limitations as a consequence of this sampling method are that the research reflects a homogenous sample, limited in representing different age groups, socioeconomic status groups, and ethnicities.
Eight research participants were interviewed in total. The table below demonstrates further data on these participants, including gender, ethnicity by
appearance, and age. Average age of the participants was 41, with the omission of one participant who did not give her age.
22
Table 1
Research Participant Characteristics
Participant # Gender Ethnicity Age
1 Female First Nations 32
2 Female Caucasian Data Unavailable
3 Female Caucasian 41 4 Female Caucasian 52 5 Male Caucasian 42 6 Male Caucasian 33 7 Male Caucasian 42 8 Male Caucasian 47
The above sample of eight participants included experiences accessing a range of services including social detox, medical detox, supportive recovery, treatment facilities, crisis stabilization beds, recovery housing and second stage housing.
Recruitment. Recruitment posters (Appendix B) were placed in many areas frequented by individuals with problematic substance use, both in Campbell River and in communities in the Comox Valley. In many of the locations where the posters were located there was a free courtesy phone near by. The poster indicated a cell phone number for potential research participants to use to contact the researcher, and that potential research participants would need to have been in a facility bed within the last six months, including social detox, medical detox, and crisis stabilization beds. As well, potential research participants needed to identify themselves as being over age eighteen to be involved in the research. They were included in the research regardless of whether they were abstaining from substance use or actively using substances.
Participants were given an honorarium of $15.00 each to recognize and value their time and effort. Eight interviews were completed in total. Originally seven to
23 fifteen interviews had been planned. Flexibility in this number allowed the content of the interviews themselves to be used as a guide. The possibility of a second interview with research participants was built into the method, with the potential to do the subsequent interview by telephone. Research participants were asked to provide one or two phone numbers to the researcher if they consented to being contacted for a second interview. I stopped at eight interviews and did not do any second interviews as there was a large amount of rich data already gathered, and no significant gaps were found while doing the analysis.
Setting. I approached seven agencies in the communities of Campbell River and the Comox Valley and asked if I could use a space in their office to interview research participants. Most of the agencies said yes. However, one did not respond to my phone calls and one had space limitations and stated that using their space was not practical. When potential research participants called they were given their choice of locations for conducting the interviews to maximize their comfort.
Data collection. The methods of data collection I used in this research were unstructured qualitative interviews and observational field notes. Donalek (2005) notes that interview “questions should be brief and unambiguous and, and the same time, sensitive to the feelings of participants” (p. 124). Unstructured interviews are meant to be participant driven rather than researcher driven with discussion topics left up to the participant (Morse, 1994; Polit & Beck, 2008). The interviews are “conversational and interactive” (Polit & Beck, 2008, p. 392). In unstructured interviews, “researchers let participants tell their stories, with little interruption” (Polit & Beck, 2008, p. 392). If the participant asks questions during the process, the responses and subsequent discussions
24 are to be saved until the end or until another interview (Morse, 1994).
A rough plan, however, was needed to guide the conversations to avoid having copious amounts of information not relevant to the research questions. The initial trigger questions used with research participants to prompt conversation surrounding their facility stay and use of resources were as follows.
1. Tell me about your substance use.
2. What supports have you accessed for your using? Tell me about these supports.
3. What type of facility or facilities for addressing substance use have you been in?
What was your experience with getting access to these resources? What resources did you get connected to while in this facility? How did you hear about and access this facility?
4. How did you hear about and access each of the supports you are connected with?
The interview questions were refined after the first couple of interviews to
include new questions, to change questions, and to drop questions. This helped focus the inquiry more on the areas of interest. For example, the refined list of questions asked more specifically about experiences in the last facility the participant had been in to give more direct information about their most previous experience. The interview questions became as follows.
1. What type of facility or facilities for addressing substance use have you been in?
25 What is the last facility you have been in?
What type of place is that?
How did you first hear about that facility? How did you get into there?
What was the process for getting in? 2. What did you do in that facility?
What did a typical day look like? 3. What was your discharge like?
Where did you go afterwards?
4. What resources did you get connected to while there? How did you stay connected to those resources? Tell me about your substance use.
What supports have you accessed for your using? What supports are you accessing now?
Pick one support. Tell me about this support. How did you access this support?
What does this support do?
What would improve this support?
5. Tell me about your experiences with health care.
6. Is there anything you would like nurses to know about working in an addictions facility? What would improve your experience?
There are both negatives and positives to doing unstructured interviews with individuals. Drawbacks to unstructured qualitative interviews are that they can be time
26 consuming, they produce large amounts of data, and that they rely heavily on interviewer skills (Patton, 2002). In addition, transcribing interviews can be time consuming and the transcriptions themselves “often include much data that ultimately are not used” (Wuest, 2007, p. 250). I audio taped the interviews and transcribed them myself. Positives of unstructured qualitative interviews include that they are unique to each participant and their situation. They allow for “effective interpersonal skills and the willingness to reword questions as necessary” for participants (Appleton, 1995, p. 994). The interview is noted to be “a shared journey. . . . A co-created work emerging from the interaction of researcher and participant” (Donalek, 2005, p. 124).
Throughout each interview, areas of interest were explored and probed as they came up. Research participants were encouraged to take the conversation where they wanted it to go in regards to their facility stay and the resources they had accessed or were currently accessing. Once there was a large amount of data without any significant new information emerging in the interviews, no more interviews were scheduled. Thorne (2008) recommends the use of the second interview “so that your evolving interpretations can be informed by an increasing depth of clarifying questioning” (p. 130). All
interviews took less than two hours each, and no second interviews were done because, as noted above, there was no significant new information emerging and no significant gaps noted in the analysis.
Field notes can give context to the interview transcription. Emphasis is placed on the importance of “descriptions of the participants’ demeanor and behaviors during the interactions” (Polit & Beck, 2008, p. 543). Wolf (2007) writes that the field notes “begin with extensive detailed description with little evaluation or summary; they note language
27 events, situations, leadership roles (formal and informal), and informants of importance” (p. 305). Throughout the interviews, field notes were written for all the interviews and kept. The majority of the field notes were written after the interviews, with the exception being if an interview was interrupted and I had time to record some observations at that time. This gave context to the interviews and recognized and recorded the unspoken details. For example, the field notes captured details of what the participants looked like, their body language, and the impact of the environment on the interviews.
Data analysis. Both interpretive description and constant comparative analysis, borrowed from grounded theory, guided data analysis. The analysis “requires that nurse researchers come to know individual cases intimately, abstract relevant common themes from within these individual cases, and produce a species of knowledge that will itself be applied back to individual cases” (Thorne, Reimer Kirkham & MacDonald-Emes, 1997, p. 175). Thorne (2008) states that
what you are aiming for is a series of technical and/or intellectual operations that will allow you to know your data intimately, to consider similarities and
differences with respect to a wide range of dimensions among the various cases you have included in your sample, and to follow a logical line of inquiry in
relation to individual cases as they illuminate those aspects that might legitimately be considered patterns and themes within the data set overall. (p. 150)
Knafl and Webster (1988) call this process constructionistic as the focus is on
“rebuilding and presenting the processed data set in a thematic or conceptually relevant whole” (p. 196). Thorne, Reimer Kirkham and O’Flynn-Magee (2004) note that
28 interpretive description uses a “a rigorous analytic process” (p. 9) to “illuminate the phenomenon under investigation in a new and meaningful manner” (p. 9).
Constant comparative analysis. In this research I drew on constant comparative
analysis to inductively develop themes regarding the experiences of participants in addiction facilities. Lincoln and Guba (1985) extrapolate from Glaser and Strauss’ development of the constant comparative method of data analysis, adapting it to match the naturalistic paradigm and for the purpose of data analysis. Constant comparative analysis involves “comparing incidents applicable to each category,” (p. 340) “integrating categories and their properties,” (p. 342) “delimiting the theory,” (p. 343) and “writing the theory” (p. 344).
Comparing incidents applicable to each category. In the first step the bits of information are put into groups “on a ‘feels right’ or ‘looks right’ basis” (Lincoln & Guba, 1985, p. 340), comparing them with each of the pieces of data in that and the other groups to ensure the fit. The units of information should be “aimed at some
understanding or some action that the inquirer needs to have or to take” and should be “the smallest piece of information” that can stand alone (Lincoln & Guba, 1985, p. 345). These units can derive from any part of the interview, including the field notes and should “err on the side of overinclusion” (Lincoln & Guba, 1985, p. 346). Lincoln and Guba (1985) emphasize the importance of writing memos at this stage as the collection of memos over time can help to delve into “the properties of the category. Knowledge of properties make it possible to write a rule for the assignment of incidents to categories” (p. 342).
29 I read and re-read my interview transcripts, with notes of the smallest bits of the interview with their meanings written in the margins. Index cards from the notes in the margins were begun after the second interview, with groupings being arranged, and rearranged as they were being developed and explored, and as more data came in. Relationships between the groupings were also arranged and rearranged. As each index card came into the data it was compared with all the groups to determine the best fit, or, if there was no fit with any of the established groupings, to start its own. While the index cards were the primary source of developing groupings, I often referred back to the original transcripts so that the context of the conversations was not lost.
In speaking of coding, Thorne (2008) states “a good coding scheme is one that steers you toward gathering together data bits with similar properties and considering them in contrast to other groupings that have different properties” (p. 145). She emphasizes the use of coding for seeing new relationships, angles, and patterns in the data. While working with the data in my research study I used many processes to assist in the coding, and in the organizing and analyzing the data. I asked myself many questions about the data, to develop new insights and ideas about the data as I went through it. I did not use a preset coding scheme, but allowed one to emerge from the data as I progressed, and continually worked at finding the best fits for the pieces of data.
In interpretive description the researcher is warned against too much breaking down of the data, especially early in the research process, encouraging limited use of coding until later in the process (Thorne, Reimer Kirkham & MacDonald-Emes, 1997) so that the researcher is able to see the broad picture and not get caught up in the details. Thorne, Reimer Kirkham, and O’Flynn-Magee (2004) emphasize the “process of
30 intellectual inquiry” (p. 13) used in data analysis and warn against over-reliance on coding and sorting.
Integrating categories and their properties. The second step of constant comparative analysis includes a “shift from comparing incidents with other incidents classified into the same category to comparing incidents to the primitive versions of the rules (properties) describing the category,” (Lincoln & Guba, 1985, p. 342) and
“exposing both incident and category to searching criticism” (Lincoln & Guba, 1985, p. 342). This stage helps to make the categories more explicit and distinct, helps to start defining relationships between categories, and helps guide further data collection efforts to address gaps, weaknesses, and inconsistencies in the data so far (Lincoln & Guba, 1985).
Within my data analysis I used my coding and my writings to note and further develop patterns discernible in the stories of the research participants. Through that process I became much more aware of typical and atypical situations, and variations from the usual.
Jacelon and O’Dell (2005) prompt the researcher to explore such questions in the data as change, degrees, themes, and patterns. They encourage the use of creativity in analyzing data and mention the use of graphs, charts, memos to self, metaphors, and analogies, stating that the “more ways the researcher can explore the data creatively, the richer the findings will be” (p. 219). Thorne, Reimer Kirkham & MacDonald-Emes, (1997) emphasize that when analyzing the data “struggling to apprehend the overall picture with questions such as ‘what is happening here?’ and ‘what am I learning about this?’” (p. 174) will be more useful to the research than focussing all the attention on
31 coding and sorting. I asked myself these questions, using my journaling and
brainstorming to look for what was happening with the individuals in the transcripts. I used mind mapping, charts, graphs, memos, and drawings and looked for themes, and patterns across the various experiences of the research participants.
Thorne, Reimer Kirkham and O’Flynn-Magee (2004) note that within this methodology the “researcher constantly explores such questions as: Why is this here? Why not something else? And what does it mean?” (p. 13) and emphasize the need to “remember to move in and out of the detail in an iterative manner, asking repeatedly, ‘what is happening here?’ ” (p. 14). This includes the researcher challenging themselves to see the data in increasingly new and creative ways throughout the research process, keeping in mind the importance of being open and creative in the process (Thorne, Reimer Kirkham, & O’Flynn-Magee, 2004). Within my analysis of the research I asked myself the questions above, while writing and being thoughtful of the data as it was being gathered and processed. These questions allowed me to delve more deeply into what the data meant.
Thorne (2008) notes the usefulness of “marginal memos” (p. 147), highlighting, categorizing like data together, and keeping a “quotable quotes” (p. 148) file. Knafl and Webster (1988) note the use of index cards with transcript excerpts attached to assist in organizing and reorganizing the information to come to a better understand of the data collected and possible relationships between bits of data collected. They also note the usefulness of descriptive grids to place bits of data into, as well as putting together a conceptual model to illustrate data and relationships between data. Thorne (2008)
32 recommends the use of “analytic notes” (p. 153), a written account of thoughts, patterns, ideas, inquiries, questions, and so on, throughout the analysis of the researcher.
While working with the data I used memos, highlighting, and categories as they developed. I also kept a quotable quotes file and I kept analytical notes. I wrote large amounts regarding what I was seeing and thinking throughout the process of analyzing the data. In addition, I wrote about patterns and relationships I was seeing in the data, and what each might mean.
Delimiting the theory. The third step of constant comparative analysis, delimiting the theory, comes together through further processing the data as categories reach saturation and definition and “both parsimony and scope” of the data is discerned (Lincoln & Guba, 1985, p. 342). In my research as themes began to emerge, they were continually
considered in relation to each other, and in relation to this writer’s previously held beliefs and knowledge base to challenge preconceived expectations and bias. Themes were also explored with experts in the fields of addictions care and mental health to continue to develop and articulate the meaning of the material.
Themes were separated and distinguished from one another through the development of inclusion and exclusion criteria, and subthemes were developed. A quotable quotes file was kept; however, in many situations the original transcripts were used to pull quotes out of to ensure the quotes were kept in context. Morse states that while coding “look for and note signs that may reveal implied meanings, cultural values, and linkages to other concepts or contexts” (p. 29). While Morse looks to data saturation as being a sign of comprehension being achieved, Thorne (2008) indicates a mismatch between the idea of saturation and the method of interpretive description, she states “in
33 the disciplinary context of health research, the idea that one can claim that no new
variation could emerge seems antithetical to the epistemological foundations of practice knowledge” (p. 98). In my research I stopped booking interviews once there were no more significant ideas relevant to my area of interest being generated, and there were no notable gaps in the data collected and analyzed.
In qualitative analysis special attention is paid to outliers, or cases that do not fit within the research done so far (McPherson & Thorne, 2006). McPherson and Thorne (2006) see outliers as being a healthy challenge to the analysis of the data, pushing researchers to expand and strengthen their work to be inclusive of all data. They also see the inclusion of outliers as strengthening the credibility of qualitative research and decry the pattern they identify of researchers disregarding that which does not fit. They write, observations that appear to us as exceptions might prompt new avenues of thinking, push our analyses toward more complex and sophisticated conceptualizations of the phenomena in question, or even prompt us to uncover assumptions that might revise our core understandings of that which we are investigating. (p. 3) They further emphasize that it is “imperative that we attend carefully to subtlety, variation, and depth as essential qualitative quality criteria” (p. 9). Outliers in research can be a healthy challenge to find and include that which remains unknown. I did not disregard outliers in my research. I included the transcripts of all the individuals who were interested in participating, as long as they met the criteria for involvement.
Rigor. There are a variety of criteria that can be used to assess the quality of research (Denzin & Lincoln, 1998; Polit & Beck, 2008). The criteria as described by Lincoln and Guba (1985) were used to enhance the rigor of this research project. These
34 criteria include “trustworthiness” in delving into the “credibility, transferability,
dependability, and confirmability” (Lincoln & Guba, 1985, p. 189) of the research. Each of these are discussed below in relation to this research project.
Credibility. Credibility was enhanced by recording field notes and confidence
building. Field notes are discussed above, in the section on data collection. Field notes enhance rigor by ensuring the context of the interviews is not lost in transcribing and analyzing the data. Credibility could have been further enhanced by taking transcripts and findings back to the original research participants and taking into consideration their responses in the data analysis process. While this would have enhanced findings, as a Masters thesis, this would have significantly expanded the scope of the research project.
Chenail and Maione (1997) see confidence building as an important element of increasing trustworthiness of the research, through seeking out opportunities to challenge the research and the emerging results of the research throughout the data collection and analysis. Chenail and Maione (1997) recognize challenges specific to researchers who have clinical experience in the field they are researching. Challenges include how to recognize the wealth of experience of the researcher, while not limiting the research through preconceived ideas, thoughts, and values surrounding the research phenomenon. Chanail and Maione see the need for researchers to “bring forth their own ideas, hunches, biases, blind spots, and questions, examine them closely, and challenge them at the same time” (para. 15). They call this continuous challenging a “construction-deconstruction-reconstruction process” (para. 17) leading into “confidence building” (para. 17). Chenail and Maione (1997) state “in this fashion, qualitative research becomes an unfolding dialectic of building and shaking confidence until researchers reach a level of trust in
35 their sensemaking of the phenomenon in question that they are able to produce a study” (para. 28). Through confidence building, the researcher gains credence that the research results have been explored and challenged sufficiently to be credible.
In this research, confidence building was done through talking to others about my research during the process of data collection, analysis, and writing results. I spoke with hospital nurses who worked for many years case managing social detox beds in the Comox Valley. We discussed the results of my ongoing analysis and talked about how this matched or did not match what their opinions would be regarding client experiences. This was a great way to validate what I was finding to be themes and patterns in the data I was working through. I also spoke with clinicians who had many years of experience working with clients in the community, including working with individuals admitted to crisis stabilization beds and supportive recovery beds. These clinicians as well were also able to validate my findings so far. In addition, I often spoke to people not involved in caring for individuals with problematic substance use about the research I was working on and the findings as they were coming about and being written up. This helped me to organize my thoughts and ideas and to present them in a way that makes sense to the general public. It also helped me to become more comfortable with answering questions about the research, the process, and the findings.
Transferability. Transferability can be enhanced through thick description of the
research findings. Thick description is providing enough information about the research participants, and the research design that readers can decide how it applies, or is
transferable to other individuals and their situation (Polit & Beck, 2010). Polit and Beck (2010) state that researchers need to provide “basic information about their participants,
36 contexts, and timeframes. Readers should know when data were collected, what type of community was involved, and who the participants were, in terms of their age, gender, race or ethnicity, and any clinical or social characteristics” (Polit & Beck, 2010, p. 1456). In my research findings and discussion I have provided much detail about the participants and the research design, so that the reader can determine transferability. For example, I spoke about the geographical location of the research and the services for individuals with problematic substance use in the area as well as how potential research participants were recruited.
Dependability. Shenton (2004) speaks of dependability being enhanced by
credibility as well as by ensuring adequate detail for someone to replicate the research study. I enhanced dependability in my research project by doing both of these things, I enhanced the credibility of this research, and I offered in great detail how the research was done throughout this thesis.
Confirmability. Confirmability was enhanced by taking field notes, again as
discussed in the section above on data collection. Confirmability was also enhanced by keeping an audit trail, by journaling, and through reflexivity. Throughout the process of doing this research I kept an audit trail. A documented audit trail allows the researcher and others to draw out and review decision-making processes. Polit and Beck (2008) recognize the importance of keeping a “log of decisions” (p. 543). They state that an audit trail is a “systematic collection of materials and documentation that would allow an independent auditor to come to conclusions about the data” (p. 545). The audit trail helps to “establish dependability” (Wolf, 2007, p. 318) of the researcher and the resulting research, and “helps readers and external reviewers to develop confidence in the data”
37 (Polit & Beck, 2008, p. 545).
In this research project, any decisions or changes from the original plan were written out with a discussion of what was happening and why. For example, when revising the research questions to be asked of the research participants, I kept my notes taken of conversations with my supervisor, as well as notes on my thoughts about the changes, what changes were made, and why. This allows myself and others to
understand when and why decisions were made. It also pushed me to be thoughtful and to articulate these decision making processes. In addition my supervisor reviewed and discussed decisions with me regarding the data collection, analysis, and results writing.
Personal journaling is used to enhance self awareness while doing research (Thorne, 2008). Journals can help to “enhance rigor” (Polit and Beck, 2008, p. 545), through prompting the researcher to challenge their previously held beliefs and knowledge, making room for new understandings of the phenomena being explored (Bergum, 1989, p. 49). Thorne (2008) emphasizes the need for the researcher to find ways to encourage oneself to “explore, question, seek, and tentatively interpret” (p. 139) the data and emerging results. She states that “documenting something of what is
happening to you subjectively and conceptually within the research engagement becomes a core element informing your inductive analytic process” (p. 109). She encourages the researcher to “record all of the thoughts, questions, and ideas. . . . Background
preconceptions (theoretical allegiances, your expert clinical opinion, other sources of prior knowledge) and. . . ongoing analytical notes (questions, inspirations, and evolving interpretations)” (p. 109) throughout the research process.
