Research Methods
In this qualitative research project, Lisa utilized three main techniques of data collection: (1) semi-structured interviews, (2) focus groups with nurses and nursing students, and nurse researchers, and (3) ethnographic observation combined with photography. To supplement these primary methods, she also made use of documents and quantitative data generated by the governments, multilateral agencies such as the Pan-American Health Organization, national news media, and nursing researchers and advocates in the two countries.
An initial research trip in May 2010 helped her decide on the overarching criteria by which to attempt to “recruit” participants for both focus groups and interviews: the sector of health-care in which the nurses worked (the main divisions being that of public, private, and the semi-public social insurance institutions), type of workplace (for example, hospital, community clinic, educational institution, and others), employment status (full-time vs. temporary contract), and the number of years in the profession (ranging from recently graduated, to 30 years or more). |
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For the focus groups, an additional category outside of any of these was that of nursing student. In El Salvador, there were 38 individual interviews and 32 focus group participants, the latter including 10 students. In Nicaragua, there were 20 and 31, respectively, with 8 students in the latter group. The focus groups and interviews were carried out during several weeks of research in August 2010, February 2011, and May 2011.
The questions Lisa used to guide focus group discussions corresponded to three broad themes: labour conditions; recognition of nurses’ contribution to health-care; and what can be done to improve the situation. These were also the overarching themes of the individual interviews, though these focused more on the nurses’ employment biography, and their experience of stresses, challenges, opportunities, and intrinsic rewards of the profession.
In ethnographic research the goal is to illuminate how things transpire, and how individuals perceive, experience, and cope with their situation, rather than to determine “the central tendency in a larger group”.[1] But even with qualitative research, causal analysis often appears as a background objective[2] or outcome. Both of these characteristics of qualitative research proved true in this project. The data from interviews and focus groups gradually painted a picture of causal links between policy shifts of the past 30 years and the situation of Salvadorean and Nicaraguan nurses today. They revealed how decisive processes and events including changes in education, labour law, crime levels, gender inequality, national electoral outcomes, and of course, health-care restructuring and reform, have deeply affected nurses.
The questions Lisa used to guide focus group discussions corresponded to three broad themes: labour conditions; recognition of nurses’ contribution to health-care; and what can be done to improve the situation. These were also the overarching themes of the individual interviews, though these focused more on the nurses’ employment biography, and their experience of stresses, challenges, opportunities, and intrinsic rewards of the profession.
In ethnographic research the goal is to illuminate how things transpire, and how individuals perceive, experience, and cope with their situation, rather than to determine “the central tendency in a larger group”.[1] But even with qualitative research, causal analysis often appears as a background objective[2] or outcome. Both of these characteristics of qualitative research proved true in this project. The data from interviews and focus groups gradually painted a picture of causal links between policy shifts of the past 30 years and the situation of Salvadorean and Nicaraguan nurses today. They revealed how decisive processes and events including changes in education, labour law, crime levels, gender inequality, national electoral outcomes, and of course, health-care restructuring and reform, have deeply affected nurses.
Participant observation and photography for the e-book: methods and logistics
To complement and deepen the data obtained through interviews and focus groups, Lisa carried out a final phase of field research in July 2013, in El Salvador only[3]. This entailed participant observation of a small number of nurses during the course of their daily and nightly shifts, in four different types of Health Ministry establishments in San Salvador. In addition, thanks to Jim Gronau, who specializes in “social landscape” photography, she also obtained photos of these nurses as they went about their activities. This final ethnographic phase of data collection was aimed at producing an e-book that, with the help of visual material, would document the daily and nightly work responsiblities of nurses across a variety of types of health-care settings. Lisa wanted to profile what nurses are routinely expected to do during a typical 10.5 to 13.5 hour shift, and what they are capable of achieving notwithstanding the strains from deficiencies in physical and human resources that one inevitably expects in the public health system of a developing country.
During the first two weeks of July, while in the process of seeking authorization from El Salvador’s Health Ministry to carry out the observation and photography, Lisa also received crucial advice and support from the Ministry’s Nursing Unit (Unidad de Enfermería). Several Nursing Unit officials, and members of the Unit’s Research Nucleus, helped in selecting hospitals and clinics that would represent a good cross-section of types of MINSAL establishments. They also acted as a crucial liason with the heads of nursing in these institutions, introducing her to them so that she could coordinate dates and, in the case of the hospitals, to decide on the particular units or wards that were feasible for both observation and photography.
The research sites that Lisa chose for this phase of the study were the Cancer Unit and Intensive Care Unit of a specialized or “third level” hospital (specifically, Hospital Benjamín Bloom, which is the National Children’s Hospital), the Internal Medicine ward at Hospital Saldaña, which is a second level hospital, a community clinic (Unidad Comunitaria de Salud Familiar), and a Community Health Team (Equipo Comunitario de Salud or ECOS). Launched in 2009/2010 as part of the expansive health-care reform of the FMLN-Funes government (2009-2014), the ECOS are intended to make health services – diagnosis, treatment, and education – available to the large proportion of Salvadoreans whose access to care had been curtailed for decades by a mix of poverty, neoliberal user-fees, geography, and governmental neglect. Observation and photography of the ECOS nurses took place as she conducted home visits with several community members in a rural region of the San Salvador department.
Participant-observation is called such because the researcher is not a mere passive observer, but rather, asks questions, converses with the people being observed, and records observations. Lisa's observation and interaction with the nurses who volunteered to participate in this phase of the study was geared to finding out what are their principle stresses and physical challenges during the shift; how they improvise to provide care; what their direct and indirect care actions consist of; the differences between the functions of professional or degree nurses and auxiliares[4] and how nurses are treated by patients, patients’ family members, and other members of the health-care team. Lisa conducted semi-structured interviews with several of the nurses who allowed her and Jim to observe and photograph them.
[1] Palys, Ted and Chris Atchison. 2014. Research Decisions: Quantitative, Qualitative and Mixed Methods Approaches. 5th edition. Toronto: Nelson Education.
[2]Alford, Robert. 1998. The Craft of Inquiry: Theory, Methods, Evidence. New York: Oxford University Press. Alford points out that historical analysis also typically makes its way into the interpretive mode of inquiry.
[3] Focusing on only one country reflected an insufficiency of time available to secure authorizations and carry out the research in two countries. The choice of El Salvador over Nicaragua mainly reflected a more well-developed set of contacts and supports for the e-book project there (owing in turn to the arbitrary decision to complete the preliminary report for El Salvador before that of Nicaragua). It also turned out that prioritizing El Salvador responded to greater urgency in completing the e-book in time to have a meaningful policy impact, given the electoral cycle; Presidential and legislative elections were scheduled for February 2014.
[4] The “auxiliar” job title corresponds roughly with Licensed Practial Nurse (LPN) in most of Canada and the U.S., and with Registered Practical Nurse (RPN) in Ontario.
To complement and deepen the data obtained through interviews and focus groups, Lisa carried out a final phase of field research in July 2013, in El Salvador only[3]. This entailed participant observation of a small number of nurses during the course of their daily and nightly shifts, in four different types of Health Ministry establishments in San Salvador. In addition, thanks to Jim Gronau, who specializes in “social landscape” photography, she also obtained photos of these nurses as they went about their activities. This final ethnographic phase of data collection was aimed at producing an e-book that, with the help of visual material, would document the daily and nightly work responsiblities of nurses across a variety of types of health-care settings. Lisa wanted to profile what nurses are routinely expected to do during a typical 10.5 to 13.5 hour shift, and what they are capable of achieving notwithstanding the strains from deficiencies in physical and human resources that one inevitably expects in the public health system of a developing country.
During the first two weeks of July, while in the process of seeking authorization from El Salvador’s Health Ministry to carry out the observation and photography, Lisa also received crucial advice and support from the Ministry’s Nursing Unit (Unidad de Enfermería). Several Nursing Unit officials, and members of the Unit’s Research Nucleus, helped in selecting hospitals and clinics that would represent a good cross-section of types of MINSAL establishments. They also acted as a crucial liason with the heads of nursing in these institutions, introducing her to them so that she could coordinate dates and, in the case of the hospitals, to decide on the particular units or wards that were feasible for both observation and photography.
The research sites that Lisa chose for this phase of the study were the Cancer Unit and Intensive Care Unit of a specialized or “third level” hospital (specifically, Hospital Benjamín Bloom, which is the National Children’s Hospital), the Internal Medicine ward at Hospital Saldaña, which is a second level hospital, a community clinic (Unidad Comunitaria de Salud Familiar), and a Community Health Team (Equipo Comunitario de Salud or ECOS). Launched in 2009/2010 as part of the expansive health-care reform of the FMLN-Funes government (2009-2014), the ECOS are intended to make health services – diagnosis, treatment, and education – available to the large proportion of Salvadoreans whose access to care had been curtailed for decades by a mix of poverty, neoliberal user-fees, geography, and governmental neglect. Observation and photography of the ECOS nurses took place as she conducted home visits with several community members in a rural region of the San Salvador department.
Participant-observation is called such because the researcher is not a mere passive observer, but rather, asks questions, converses with the people being observed, and records observations. Lisa's observation and interaction with the nurses who volunteered to participate in this phase of the study was geared to finding out what are their principle stresses and physical challenges during the shift; how they improvise to provide care; what their direct and indirect care actions consist of; the differences between the functions of professional or degree nurses and auxiliares[4] and how nurses are treated by patients, patients’ family members, and other members of the health-care team. Lisa conducted semi-structured interviews with several of the nurses who allowed her and Jim to observe and photograph them.
[1] Palys, Ted and Chris Atchison. 2014. Research Decisions: Quantitative, Qualitative and Mixed Methods Approaches. 5th edition. Toronto: Nelson Education.
[2]Alford, Robert. 1998. The Craft of Inquiry: Theory, Methods, Evidence. New York: Oxford University Press. Alford points out that historical analysis also typically makes its way into the interpretive mode of inquiry.
[3] Focusing on only one country reflected an insufficiency of time available to secure authorizations and carry out the research in two countries. The choice of El Salvador over Nicaragua mainly reflected a more well-developed set of contacts and supports for the e-book project there (owing in turn to the arbitrary decision to complete the preliminary report for El Salvador before that of Nicaragua). It also turned out that prioritizing El Salvador responded to greater urgency in completing the e-book in time to have a meaningful policy impact, given the electoral cycle; Presidential and legislative elections were scheduled for February 2014.
[4] The “auxiliar” job title corresponds roughly with Licensed Practial Nurse (LPN) in most of Canada and the U.S., and with Registered Practical Nurse (RPN) in Ontario.