Critical Reflection of How Research Ethics Processes Provide Protection for Health and Social Care Research Participants

Undertake a critical reflection of how research ethics processes provide protection for participants in health and social care research.

There is undeniable evidence that ethics has been at the forefront of medicine dating back to 400 BC when the Hippocratic oath (Edelstein, 1954) was first declared.  All physicians studying medicine are required to undertake this mandatory oath (Kumar, 2010).  Unfortunately, there have been many corrupt and unethical practices within research studies over the last century at the expense of helpless and vulnerable participants (Ellis, 2016).  During the Second World War it became apparent that some of the Nazi Doctors violated the directives of the Hippocratic Oath including the fundamental principle, first do no harm – primum non nocere (Spitz, 2005).  As a result of the subsequent Nuremberg trials due to these experimental atrocities, the Nuremberg code was published in 1947 with the fundamental ethic principle being voluntary consent (Ross, 2012).  The Declaration of Helsinki was adopted and published by the World Medical Association in 1964.  Furthermore, the declaration has been amended seven times, the most recent being in 2013 at the General Assembly (General Assembly of the World Medical Association, 2014).  Its purpose is to provide guidance to clinicians working in clinical research with the main focus on responsibilities of researchers for the protection of research participants.

Medical research on humans is widely accepted, moreover, it is recognised that vulnerable and unwell patients are also required to take part in medical research studies in order for progress to be made (Ross, 2012).  Ross (2012), further argues that all participates engaged in research are vulnerable and at a disadvantage due to them knowing less than the researcher.  The very fact that the participants being used in the research process are patients within a primary healthcare establishment make them likely to be someway vulnerable as the reason they are attending could be due to poor health.  Furthermore, this vulnerability could lead to concerns pertaining to understanding the research subject which in turn would affect accurate feedback.  It is important to understand that there will be categories of patients who are more vulnerable than others.  The University of Sheffield (n.d.), describes three basic kinds of vulnerability which are: vulnerability to physical harm, social harm and psychological and emotional distress.  It is therefore paramount to take these factors into consideration when undertaking research in any form.  Additionally, amongst the classifications of patients who are apparent to be likely vulnerable in research are: participants whose ability to apply informed consent is in doubt, participants who may socially not have the ability to apply freely informed consent and participants whose circumstances may improperly influence decisions to consent (The University of Sheffield, n.d.).  It is widely documented that protecting the rights and welfare of participants is a fundamental principle within ethical research (National Bioethics Advisory Commission, 2001).  Research is fundamental for the care, health and wellbeing of patients within health and social care.  Ultimately, research should therefore enhance the evidence base, advance care improvement and minimise any doubts (HRA, 2017).  While health and social care research collates mainly anonymous statistical data and poses minimal risk to participants, a procedure of consent is still required.  This could be in the form of a consent paragraph detailing the risks, voluntary participation, right to withdraw and anonymity/confidentiality.  Although participants are not signing an individual consent form, consent is achieved by virtue of completion (Hearn, 2017).  There are minimal risks identified for participants completing the patient experience tool.  Participant identification within an anonymised questionnaire is the foremost risk.  As a result of participation, the patient may identify themselves through free text comments by declaring an illness/condition that only they are diagnosed with within the practice.  Furthermore, by identifying workplaces, ranks or roles the participants may become recognised.  It is thus important to highlight that these patient identifiable information are not included in free text comments.  Essentially, loss of time and boredom is a discomfort for most participants (Polit and Beck, 2017), it is paramount therefore that the tool being utilised is not overly time consuming.  An estimated time range of completion should be identified within the consent paragraph.  To minimise this, participants could utilise the time whilst waiting for their appointment within the patient waiting area.

Ethics in its simplest form define a process of moral principles, standards and values which guides society in making the right and wrong decisions in everyday life (Ross, 2012).  Moreover, law sets the minimum benchmark of acceptable human behaviour whereas ethics drive beyond the law determining whether or not the decisions are right or wrong rather than if they are legal.  Ethic and moral beliefs can be contributory factors in forming laws (Essien, 2012).

The Belmont report (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, Bethesda, Md, 1978) summarises three primary ethical principles for research involving human participation which are considered and balanced against each other. (Polit and Beck, 2017).   The three principles are:

Respect for Human Dignity

Polit and Beck (2017), emphasise the need to respect the autonomy of participants ensuring that they decide voluntarily to undertake participation in a study without jeopardising their relationship with the researchers.  There is to be no forcible action which include penalties for not participating or generous rewards to encourage participation.  Participants invited to undertake the patient experience feedback would not be at risk of prejudicial treatment due to the anonymised format.  Furthermore, that participant can choose whether or not to complete the feedback questionnaire.

Beneficence

Beneficence is explained by Polit and Beck (2017) as minimising any harm, moreover, maximising benefits to the participant.  Ellis (2016), simply describe beneficence as “Doing good”.  Beauchamp and Childress (2013) argue that within healthcare there is an obligation to help patients and physicians are expected to refrain from causing any harm.  Reflection upon the purpose of collating patient satisfaction feedback meets the principle of beneficence.  No harm would be caused and the results would be acted upon to improve primary healthcare. This would benefit the whole patient population and not just the participant (Parahoo, 2014).

Justice

There is an obligation of parity in the dissemination of risks and benefits in the third principle from the Belmont Report (Bowling and Ebrahim, 2005).  Polit and Beck (2017) agree and further breakdown the principle into the participants’ right to privacy and right to fair treatment.  Privacy should be maintained throughout and at no stage the research is to be more invasive than it is required to be (Polit and Beck, 2017).  Participants should not be chosen through their weaknesses, entirely focusing on the research requirements.  Furthermore, participants that decline partaking in the research study must not be detrimentally treated and their decision is to be respected (Polit and Beck, 2017).

Within the UK, ethical approval must be at the forefront of all research.  The Health Research Authority (HRA) have most recently published the latest version of UK Policy Framework for Health and Social Care Research (HRA, 2017).  Furthermore, the framework now covers all four countries of the UK in accordance with the Care Act 2014 (Legislation.gov.uk, 2014).  Previous to this, they each had their own Research Governance Frameworks.  These processes protect all involved by defining ethical behaviour and having a risk based approach to quality assurance within health and social care research, enabling confidence in all personnel due to first-rate quality research (HRA, 2017).

Critically evaluate how qualitative research contributes to evidence based practice in health and social care

Qualitative research was introduced into healthcare in the 1970s when it was identified by nurse researchers that multiple issues and primary theories pertaining to legislators and specialists could not solely be acted upon through quantitative research methods (Parahoo, 2014).  Qualitative research is explained by Gelling (2015) as a methodology which sanctions investigations into social and individual experiences, leading to further understanding of the aspects inspiring these occurrences.  More importantly, Addo and Eboh (2014) expressed the opinion that qualitative research assists the healthcare teams to provide empathy which is patient-centered.  According to Aveyard (2014, p. 59), this approach can also be termed as ‘naturalistic research’ due to the exploration of phenomena within the natural setting.

As explained by Polit and Beck (2017), there are two paradigms which are used by the nursing fraternity within research which are the positivist and constructivist paradigms.  Within this section of the assignment the constructivist paradigm will be reviewed as it relates to qualitative research.  Similarly, Saks and Allsop (2013) describe this as the interpretivist paradigm which seeks to interpret an understanding of participants experiences and is beneficial in clarifying complex phenomena.  In the same way, Creswell (2014) explains that aim of the research is to base it on the individuals outlook of the subjects being studied.  The researcher recognises the influence on the research using their own understandings and background. Furthermore, he states that for the researcher to gain most valuable information, “the more open-ended the questioning, the better” Creswell, (2014, p. 8).  Complementary to this, Ross (2012) expounds that interpretivism is supported by two assumptions: the first being qualitative research is reliant upon subjectivity and second that multiple valid realities exist.

Depending upon the research question, participants and the focus of the research; researchers have multiple methodological styles which they can adopt.  By utilising such methods, a greater understanding and quality improvement could be achieved in forthcoming analyses (Pope, van Royen and Baker 2002).  Theorists describe that there are various methodologies; Parahoo (2014) identifies four main approaches as phenomenology, ethnography, grounded theory and discourse analysis.  Complementary to this, Gelling (2015) discusses that whilst the varying approaches are similar, researchers are fundamentally required to decide on what type of information to collate and how to evaluate the findings.

Holloway (2017), describes the varying differences in the methodologies as follows, phenomenologists contemplate and highlight a phenomenon and reveal the lifeworld, ethnographers’ main emphasis is on customs and culture, whilst grounded theorists examine social collaboration and practices.

Phenomenology aims to recognise and relate to the everyday experiences of individuals. This is an approach to gauge perceptions of experience within healthcare as the participant is able to describe experiences such as chronic illnesses, pain levels and related stressors (Ross, 2012).  This valued approach contributes to evidence based practice in healthcare due to the gaining the patients’ experiences which could aid clinicians in treatment pathways.

In order to mitigate potential preconceptions, bracketing is adopted in phenomenological research.  This ensures that only the experiences of the participants are included in the study and not that of the researcher (Creswell, 2014).

Ethnography is a qualitative approach which concentrates on studying the patterns of social or cultural groups in a holistic style within their natural settings endeavouring to avoid theoretical predeterminations (Polit and Beck, 2017). Furthermore, Ellis (2016) explains that an emic perspective can be utilised to obtain an inside view from a current associate of the group being studied. Within healthcare this could be a hospital, a ward or the local community.  Gerrish and Lathlean (2015) explain that this methodology requires researchers to partake in extensive fieldwork.  During the fieldwork process, researchers also record their own individual feelings, thoughts, problems encountered and biases. Observation is the principle data collection method through the researcher residing in the society for weeks, sometimes even years in order to appreciate the cultural nuances (Finnegan, 2014).  Moreover, he explains that interviewing individuals regularly allows data collection on cultural issues.

An advantage of ethnographic studies in healthcare and medical education is that the data collection may change significantly during the research which may require further questions to be produced, ultimately ensuring that the best treatment and care pathway is followed (Goodson and Vassar, 2011).

Moreover, Savage (2000) explains that ethnography is beneficial in healthcare and can be utilised formally in understanding the overall organisation by comparing what individuals say and what they actually do.  Additionally, it can assist in the identifying patients experiences and observations during particular illnesses and patient services.

It is emphasised by Goodson and Vassar (2011) that one of the main limitations of the ethnography method is the sample size.  This is essentially due to the length of time necessary to undertake extensive fieldwork.  Lengthy interviews are also conducted which also limits the sample size.  This is further supported by Savage (2000), where he additionally highlights the limitation of large costs during the fieldwork phase.  Informed consent is also an important requirement during ethnography due to the vulnerability of ill patients and inexperienced staff members.

Grounded Theory is a conventional qualitative research process which is considered to be the most methodical in its approach, furthermore, it is used widely within the nursing research cadre much like phenomenology (Ellis, 2016).  In contrast to ethnography and phenomenology, grounded theory provides an awareness of the phenomena being studied rather than only descriptive analyses (Finnegan, 2014).  Moreover, opposed to interpreting hypotheses from prevailing theories, grounded theory examines the information which is grounded in the thoughts and opinions of the sample being researched.  Notwithstanding, Gelling (2011) explains that dissimilar to phenomenologists, to develop theories, grounded theorists not only use interviews but include all data sources such as research, historical literature, imageries and observations.

Parahoo (2014) explains that the purpose of discourse analysis is to discover the connotations, principles and aims in interactions between individuals.  It is regarded as a relatively new approach used by nurse researchers.  The principal data sources are collated from participants either through conversations, exchanges through participants and between interviewer and participant.

Broeder and Donze (2010) expressed the opinion that qualitative research within evidence based practice is favoured by the nursing community as the supporting evidence is through patients’ experiences and discussions.  The correlation of the approaches and outcomes mimic that of their everyday practice of caring for the patient.  However, it is debated that qualitative research is not always believed to be as trustworthy as quantitative research in evidence based practice.  While this is the case, researchers continue to strive towards identifying the significance of qualitative research within evidence based practice to associate researchers and healthcare professionals (Broeder and Donze, 2010).

Data collection within qualitative research is a paramount role of the researcher.  Moreover, the researcher is deemed to be an integral part of the collection process.  However, this can be viewed as having both positive and negative outcomes on the data. This is due to the difficulties in identifying any elements of bias from the researcher.  On the other hand, the researcher is reckoned to be the main strength due to the collection of comprehensive data (Ellis, 2016).

According to Ross (2012), focus groups, observation and interviews are three data collection methods which qualitative researchers are inclined to use. These methods are critical in order to succeed in collecting participants thoughts, opinions and perceptions.

Focus groups research is a customary data collection method in the field of healthcare.  The group are involved in collective delivery of information through reflecting on a set of issues or a particular topic (Holloway, 2005).  Moreover, it could be argued that focus groups are especially important within health research as many decisions are made in a social environment opposed to that of solitude (Bowling and Ebrahim, 2005).  Nevertheless, one of the main disadvantages of focus groups is that a dissentious group or assertive individual can dominate the entire debate which prevents self-effacing personalities articulating their points of view (Parahoo, 2014).

Observation, especially participant observation has been utilised for over a century and is a fundamental means of data collection within the ethnographic field of qualitative research (Kawulich, 2005).  Whilst observation is considered an important method of data collection, Holloway (2005), argues that it may be best suited to complement other methods of data collection.  Moreover, some limitations exist in this method of data collection such as how much participation the researcher wants to get involved in the studies and furthermore, there could be elements of researcher bias (Kawulich, 2005).

Critically reflect upon how quantitative research provides a valuable contribution to the development of evidence-based health and social care.

This assignment aims to provide a thorough and explanatory critical reflective account focusing on evidence based practice and the important role that quantitative research has within it.

Evidence-based practice is best expressed by Sackett et al (2000, p. 3) as “the integration of best research evidence with clinical expertise and patient values”.

Moreover, within nursing, encompassing government and professional initiatives, evidence-based practice is delivered by aiding individual patient values, needs and preferences integrating the best available research evidence. (Emanuel et al, 2011).

Sackett et al (1996) explain that evidence based medicine is a dynamic process which requires healthcare workers to review and adopt current best evidence otherwise there is a risk that the patients’ health may suffer due to the practice being outdated.  Therefore, it is imperative that appropriate information sources are exploited; examples of which are clinical databases and health information portals.  Once results are received they are required to be critically reviewed by an appropriate clinician to ensure they are dependable and precise (De Brun, 2013).  Subsequently, research results can be implemented into practice plans and procedures or clinical guidelines.

Quantitative research involves a scientific, systematic process for collecting statistical information at the point of issue to a solution (Polit and Beck, 2017).  Quantitative research includes investigating relationships among variables, is used to define new occurrences or conditions and is utilised in testing effectiveness of healthcare treatments and interventions (Burns, Gray and Grove, 2014).  Furthermore, quantitative research is associated with positivism which comes with the view that knowledge can be confirmed by the senses and data gathered can be verified and measured in an empirical manner, much like natural science.  This is in contrast to qualitative research which is connected to constructivist analysis (Polit and Beck, 2017).  Moreover, it is argued by theorists that due to its scientific links, quantitative research is more trustworthy than qualitative research within healthcare. This is further evident within healthcare guidelines and policies (Ross, 2012).

Quantitative research is associated with the positivist paradigm, this is argued to be the most popular and often classed as the “default option” within healthcare, the objective of dividing facts from beliefs (Finnegan, 2014).  Moreover, he expresses his opinion that quantitative research and positivism is entrenched within the Defence Medical Services research and hierarchical structure of the Armed Forces.  Based on the ideas of Grinnell and Unrau (2014) the positivist researcher endeavours to meet the following gold standards: (1) complete objectivity, (2) measurability, (3) using standardised procedures, (4) duplication and (5) reducing uncertainty.  Post-positivism and positivism depend on quantifiable and assessable methodologies to the study of phenomena (Parahoo, 2014).  Furthermore, it is argued that only data which is able to be tested and has been observed directly can be acknowledged as acceptable.  Subjective experiences are considered not to be quantifiable numerically and as such deemed unacceptable knowledge, based on positivism (Ross, 2012). On the contrary, Saks and Allsop (2013) explain that there is an element of subjectivity within positivist research methods due to researchers interpreting results and creating the questions.  Furthermore, this view is supported by Finnegan (2014), due to qualitative research methodologies, processes and designs regularly convening side by side with positivist visions.

Post-positivism, also known as critical realism is a paradigm of many social science and scientific methods of analysis which lends itself to both quantitative and qualitative research (Ross, 2012).  Post-positivism preserves the belief in quantification and deduction relating to positivists views however there have been many changes in theories and philosophers currently view this paradigm as a modest method of positivism (Ross, 2012).  Complementary to this, Finnegan (2014) goes on to suggest that post-positivism gravitates near qualitative research due to influential factors such as the researcher’s values, awareness and experience potentially contaminating the data.

Most quantitative research begins with an idea or hypothesis, data collection follows a deductive approach for creating a strategy to test the theory (Ellis, 2016).  Quantitative researchers are required to analyse statistical data and furthermore require data collection methods which can accommodate for measuring a chain of events or sampling large groups of participants.  The predominant data collection methods are experiments and surveys (Ross, 2012).  Complementary to this, Gerrish and Lathlean (2015) provides supporting theoretical descriptive that whilst conventional experiments and surveys are used; questionnaires, non-participant or structured observations are additionally pertinent to quantitative research.

Questionnaires are arguably the most common form of data collection in health and social care research (Parahoo, 2014).  Additionally, the theorist exclaims that questionnaires and surveys are both interchangeable.  However, surveys are a data collection method which can encompass one or more data collection methods, such as observation, questionnaires and interviews.  Questionnaires would be utilised if information is required expeditiously as the data can be processed using technology.  A disadvantage of using electronic questionnaires is often due to lack of depth, the data can be very superficial (Ross, 2012).

Experiments are identified as a study which the researcher is in command over the selection of participants, main focus and the levels of the regressors within different experimental environments (Grinnell and Unrau, 2014). Similarly, and in contrast to surveys which examine interconnections, experiments are intended to exert influence on associations and to test independent variables (Ross, 2012).  It is argued, that randomised control trials are considered to be the gold standard for assessing the efficiency of interventions within evidence-based practice due to their dependability and systematic rigour (Akobeng, 2005).  Cartwright (2007) challenges this idea that randomised control trials are the gold standard; moreover, she suggests that there is no agreed best method.  She debates that the best method is negotiated using a case-by-case basis dependent upon the prior and current information available in order to draw causal inferences about a study population.  Randomised control trials are mainly applied within evidence-based practice when trying to evaluate which form of treatment is superior to another (Parahoo, 2014).

Non-participant observation is principally applied within research when endeavouring to understand some phenomena in its natural setting (Mills, Durepos and Wiebe, 2012).   Furthermore, non-participant observation adopts a validated systematised schedule for data collection in quantitative research unlike qualitative research which utilises a more unstructured method of data collection (Gerrish and Lathlean, 2015).  Ordinarily, the researcher conducting non-participant observation does not get involved actively within the study, moreover, the participants may or may not be aware of the researchers’ involvement (Ross, 2012).  Notwithstanding, this method is often criticised as the target population may modify their acts of behaviour in reaction to being monitored if the observation is overt; this is often referred to as the Hawthorne effect (Parahoo, 2014).

Structured observation is a data collection method used in evidence-based practice where features of the phenomenon to be researched are predetermined, frequently using handheld technology or checklists as data collection tools.  Moreover, there is a requirement for all knowledge gained from the findings to be regimented (Parahoo, 2014).  Furthermore, an advantage of structured observation is that, if necessary, additional observers can be employed where substantial amounts of data is required to be collected.  Utilising standard procedures ensures that the various observations collated can be quantitatively compared (Sapsford and Jupp, 2006).  Similarly, in regards to reliability and validity Gerrish and Lathlean (2015) highlights the importance of developing a trustworthy means for data collection and moreover, by adopting the systematised, predetermined observation schedule will reduce bias.  All employed observers are required to undertake the requisite training in the observation schedule, recording and coding data to certify trustworthiness of the study.  It is further recommended that before the live study is performed, a pilot experiment should be carried out to enable any problems to be remedied (Gerrish and Lathlean, 2015).

One of the main advantages of quantitative research is that it can supply information and statistics to measure various difficulties within evidence-based practice such as quality of life, nursing care, beliefs and attitudes, delivering data on the establishment, knowledge and performance evaluation (Parahoo, 2014).  Furthermore, it is expressed that quantitative information identifies valuable patterns and trends, for comparison purposes, particularly within larger populations.  The methodologies backing quantitative research are analytical, provable and scientifically and logically rigorous (Saks and Allsop, 2013).

In contrast, there are limitations in using quantitative research in healthcare, it is argued by theorists that traditional quantitative researchers are narrow focussed as they tend to concentrate on limited phenomena in their studies opposed to patients’ experiences which are often complex and varied in nature (Polit and Beck, 2017).  Likewise, some philosophers claim that the methods which positivist researchers adopt are false, due to them measuring hypothesis rather than the lived experiences by the patient. Furthermore, it is deemed that quantitative research is restricted at understanding how people make decisions in social and relationship settings (Saks and Allsop, 2013).

Background and Rationale

Patient experience questionnaires are often used in primary care settings to measure patients’ views.  In 2011, the NHS National Quality Board, introduced the NHS Patient Experience Framework in order to highlight the fundamental elements of patients’ experience (DoH, 2011).  Similarily, The Patients Rights (Scotland) Act 2011 was passed by parliament in 2011.  The aim of the Act is to improve patients’ experiences of healthcare services (Scottish Parliament, 2011). For the past ten years, an annual GP practice survey is undertaken by an independent research company on behalf of NHS England to give patients the opportunity to feedback their experiences within their own GP practices and wider NHS services (Ipsos, 2017).  Moreover, it is estimated that over five million patients are sampled in the UK using various means of survey which can be utilised for measuring patient experience across primary care (De Silva, 2013).  In a previous study, 1390 questionnaires were analysed throughout different geographical locations within Great Britain and it was found to be an effective and trustworthy system for appraising patient experience within primary healthcare (Grogan et al, 2000).  In contrast, a qualitative interview study with ten GP practices in four different primary care trusts in England established that many doubts existed on the credibility of the GP patient survey.  These concerns may inhibit healthcare staff from potentially creating required changes to general practice (Asprey et al, 2013).

Although the healthcare legislation as applied to the NHS is not compulsory for the Defence Medical Services (DMS), it chooses to apply it the same way (Piper and Lamb, 2014). The DMS assures quality healthcare by encouraging a service improvement culture at every level. Capturing patient experience is one aspect of this. Independent satisfaction surveys are conducted using Armed Forces Continuous Attitude Survey (AFCAS) (AFCAS, 2017).  The metrics evaluated are satisfaction ratings for access to medical facilities, treatments and effectiveness of medical care. Whilst there has been no change in personnel satisfaction over the past three years with more than 75% satisfaction, there are no accounts of the 25% who are potentially unhappy with their care.  Furthermore, the Defence Doctrine commands that the standard of healthcare delivery from the DMS is equivalent to or superior than that of the NHS (Piper and Lamb, 2014.  Moreover, Surgeon General’s (SG’s) DMS Research Strategy emphasises the requirement of a “hierarchy of research” to be achieved within the next two decades in order to increase the operational effectiveness of the Armed Forces (Bernthal, 2015).

Subsequently, the DMS Quality Improvement Working Group within Defence Primary Healthcare (DPHC) introduced a patient question bundle for inclusion within local patient experience surveys for strategic continuance.  The purpose of this question bundle is to allow specialist services and medical facilities the autonomy to invest in their local surveys, whilst allowing both the Chain of Command (CoC) and Stakeholders sight of quality markers identified by patients’ experience.  Not doing this was one of the key failings detailed in the Francis Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013).  Despite this, the NHS has again been subjected to heavy criticism by Sir Bruce Keogh following his review of 14 hospital Trusts due to failure in prioritising the importance of patient feedback to enable enhancement of care quality improvements (Keogh, 2013).  Moreover, it is advocated that measuring patient experience is a fundamental element of evaluating performance which enables improvements to healthcare quality.  This is beneficial to both the organisation and the patient aiding the military’s operational effectiveness.  Therefore, in meeting the expectancies of the DMS and the patients it is paramount that all medical treatment facilities provide a system to measure the quality of care (Piper and Lamb, 2014).

The DPHC patient experience question bundle focuses on 2 themes, (1) Quality and (2) Stakeholders.  Questions as follows:

Quality

1. If your friends, family and colleagues were able to use this facility would you recommend it to them?  Tell us why you gave that response.

2. Do you feel that we listen to your comments, compliments or complaints? Tell us why you gave that response.

3. Do you feel involved in decisions regards your care? Tell us why you gave that response.

Stakeholder (NHS Armed Forces Commissioner)

4. If you were referred to an NHS facility in the last 6 months, and your friends, family and colleagues were able to use that facility would you recommend it to them?  Tell us why you gave that response.

5. Was your appointment at a convenient time? Tell us why you gave that response.

6. Was your appointment in a convenient location? Tell us why you gave that response.

While there is no definitive system for measuring patients’ experience across all healthcare delivery organisations (Piper and Lamb, 2014), it is important to evaluate this new patient experience tool which was introduced within DMS January 2017.

Research Question:

Is the DPHC mandated question bundle an effective tool for monitoring patient experience in the military populace?

Aim:

The aim of this study is to investigate the effectiveness of the DPHC mandated question bundle in monitoring patient experience within the military population in the DPHC Scotland and North region.

Methodology

This study will be a mixed method service evaluation.  It will involve retrospective data analysis, semi-structured interviews and focus groups.

SG’s department collates quarterly returns from all DPHC regions in relation to the patient experience questionnaires.  Once the data is analysed by SG’s a report is forwarded to all Regional Headquarters.

20% of all quarterly patient experience returns from the three different geographical and demographic practices will be analysed retrospectively. The three practices will be Leuchars Station in Fife, Scotland, Royal Air Force (RAF) Leeming and RAF Linton on Ouse both in North Yorkshire, England.  The reasons behind using these three practices within DPHCSN is due to differing demographics and they represent different occupational groups.  A large families practice within an operational Army Station, a large families practice at a busy operational RAF Station and a small families practice at a RAF training establishment respectively.

The recruitment process for the focus groups will be via email, telephone and face-to-face invitations.  Patient focus groups at each of the three practices will last for approximately 90 minutes, consisting of manageable groups of 10-12 participants and the researcher as moderator.

Semi structured interviews will be held with stakeholders in order to receive feedback to understand the usability of the mandated question bundle tool.  The recruitment process for these participants will be following consultation with SO1 Health Care Governance at SG’s department.  Once identified, the participants will be contacted via email and the purpose of the study will be explained.

Data Analysis

The written and free text data from questionnaires will be analysed using qualitative descriptive analysis using coding methods to find common themes.  This requires identifying and interpreting, likenesses, problems, subjects and differences which are disclosed by the participants.  This lets the researcher view the observations through the eyes of the participant (Sutton and Austin, 2015).  Furthermore, the multiple choice questions within the questionnaire will be analysed using descriptive statistics as well as quantitatively ensuring that these values coordinate and depict the individualities of data collection (Salkind, 2017).

The focus groups will be guided by themes which are comparative to the DPHC mandated question bundle. The moderator will be able to facilitate open discussion around these themes to get a more indepth view. It is recognised that focus groups can enhance patient participation within a continuous quality improvement process in primary healthcare whilst understanding the intricacies involved in patient experiences.  Furthermore, due to the face to face interaction within focus groups, unpredicted matters that are not identifiable in surveys can be discovered (Schwarz et al, 2000).

Semi-structured Interviews will each last about thirty minutes and a conversation guide similar to the SG question set will be utilised. These will be recorded with permission, dictated and thematically analysed . The recordings will be stored in a locked drawer in the researchers locked office and destroyed on completion of the evaluation. There will be no identifiable information associated with the recordings for data protection and Caldicott purposes.

Any emergent themes which present during the focus groups and interviews will be recognised, documented and analysed.

Ethical Considerations

Ethical consideration for participants must be at the forefront of any research studies as they have a right to know if subjected to any research process. Moreover, at the heart of every research study should be informed consent (Department of Health, 2005).

Whilst ethical approval is not required for this research study, prior approval must be obtained from the Coc as per “Guidance on undertaking Medical or Healthcare Research, Audit and Service Evaluations” (Ministry of Defence, 2013).

Due to the military being a hierarchical organisation it is important to avoid the risk of coercion when recruiting participants.  Researchers and participants within focus groups are required to use first name terms and avoid using ranks, civilian clothing should be worn and avoidance of any correspondence which may reveal rank, an example of which would be disclosing a job title/post.  Furthermore, additional assurance is required within the military populace to ensure that nothing is disclosed to participants CoC as this could prevent participants from partaking in the study (Bernthal, 2015).

Bias Considerations

In attempting to prevent any bias and to maintain objectivity, there are a number of considerations to make. These include but are not limited to using a standardised template for data collection, using multiple personnel to check the data collected, ensuring no reviewer bias, any discrepancies found being discussed and an agreed way forward pre-planned, making sure all personnel involved are in civilian attire and at a neutral venue which is accessible to all participants to reduce coercion and a responder bias.

It is essential that the operational tempo and morale of the participants is taken into consideration whilst recruiting from the military populace, otherwise there is a risk that the participant’s enthusiasm and willingness to fully engage in the study will be affected, risking reduced data collection.  Likewise, an appropriate geographical location near participants accommodation or work is required to be considered when conducting focus groups to enable them to attend with minimal disruption (Bernthal, 2015).

Although, all medical practices use different patient experience tools, they are governed by SG to include the mandatory question bundle, which will be studied in this proposal. The study will attempt to consider any differences in patient experience tools – their usability and access considerations in the narrative produced.

Conclusion

It has been established that this research proposal is to investigate the effectiveness of the DPHC mandated question bundle in monitoring patient experience within the military population in DPHCSN.  This is due to there being no definitive system for measuring patients’ experience across all healthcare delivery organisations (Piper and Lamb, 2014).

In order to achieve this study, mixed methodology of quantitative and qualitative research is to be employed to look at retrospective data analysis, semi-structured interviews and focus groups within three primary healthcare practices in DPHCSN.   Within the military population, it is paramount that avoidance of coercion is adhered to, this can be extremely difficult due to the nature of the military being a hierarchical organisation.  Recruiting of participants needs to be carried out in neutral manner with no ranks or positions disclosed and reassurance that confidentiality is paramount with no information reaching the participants CoC.

It is realised that there are many problems with Patient Experience Tools however this study hopes to find useful information to guide especially the military experience and shape future DMS plans as requested by the Framework for Patient and Public Participation in Armed Forces Commissioning (NHS England, 2017). This research will add to the body of evidence to ensure the tool becomes a validated one for this purpose in this specific population set.

References

Addo, M. and Eboh, W., 2014. Qualitative and quantitative approaches. The Essentials of Nursing and Healthcare Research, pp.137-154.

Akobeng, A.K., 2005. Understanding randomised controlled trials. Archives of Disease in Childhood, 90(8), pp.840-844.

Asprey, A., Campbell, J.L., Newbould, J., Cohn, S., Carter, M., Davey, A. and Roland, M., 2013. Challenges to the credibility of patient feedback in primary healthcare settings: a qualitative study. British Journal of General Practice, [e-journal] 63(608), pp.200-208. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 5 November 2017].

Aveyard, H., 2014. Doing A Literature Review in Health And Social Care: A Practical Guide. 3^rd ed. GB: OPEN UNIVERSITY PRESS.

Beauchamp, T.L. and Childress, J.F., 2013. Principles of biomedical ethics. 7th ed. New York: OXFORD UNIVERSITY PRESS.

Bernthal, E.M.M., 2015. The challenges of undertaking (qualitative) research on a military population. Journal of the Royal Army Medical Corps, [e-journal]161, pp.i3. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 20 November 2017].

Bowling, A. and Ebrahim, S., 2005. Handbook of health research methods: investigation, measurement and analysis. Maidenhead: MCGRAW-HILL EDUCATION (UK).

Broeder, J.L. and Donze, A., 2010. The role of qualitative research in evidence- based practice. Neonatal network, 29(3), pp.197.

Burns, N., Gray, J. and Grove, S.K., 2014. Understanding Nursing Research: Building an Evidence-Based Practice. [e-book] Saunders. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 3 January 2018].

Cartwright, N., 2007. Are RCTs the Gold Standard? BioSocieties, [e-journal] 2(1), pp.11. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 4 January 2018].

Creswell, J.W., 2014. Research design.  4th ed. internat. Los Angeles: SAGE.

Department of Health, 2005. Research governance framework for health and social care [online]Available at <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/139565/dh_4122427.pdf.> [Accessed 20 October 2017].

Edelstein, L., 1954. The Hippocratic oath. 2nd ed. Baltimore: John Hopkins Press.

Ellis, P., 2016. Understanding research for nursing students. [e-book] Learning Matters. Available through: Google Books < https://books.google.co.uk> [Accessed 20 October 2017]

Emanuel, V., Day, K., Diegnan, L. and Pryce-Miller, M., 2011. Developing evidence- based practice among students. Nursing times, [e-journal] 107 (49-50), pp.21. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 4 January 2018].

Essien, W., 2012. Strategic Management. [e-book] Bloomington: AuthorHouse. Available through: Google Books < https://books.google.co.uk> [Accessed 22 November 2017].

Finnegan, A., 2014. Conducting qualitative research in the British Armed Forces: theoretical, analytical and ethical implications. Journal of the Royal Army Medical Corps, [e-journal] 160(2), pp.135. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 4 January 2018].

Gelling, L., 2015. Qualitative research. Medline, [e-journal] 29 (30), pp.43-47. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 4 January 2018].

Gelling, L., 2011. What is the difference between grounded theory and phenomenology? Nursing times, [e-journal] 107 (4), pp.25. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 5 January 2018].

General Assembly of the World Medical Association, 2014. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. The Journal of the American College of Dentists, [e-journal] 81(3), pp.14. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 5 November 2017].

Gerrish, K. and Lathlean, J., 2015. The Research Process in Nursing. 7th. ed. GB: Wiley-Blackwell.

Goodson, L. and Vassar, M., 2011. An overview of ethnography in healthcare and medical education research. Journal of Educational Evaluation for Health Professions, [e-journal] 8. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 15 December 2017].

Grinnell, R.M. and Unrau, Y.A., 2014. Social work research and evaluation. 10th ed. Oxford: Oxford University Press.

Grogan, S., Conner, M., Norman, P., Willits, D. and Porter, I., 2000. Validation of a questionnaire measuring patient satisfaction with general practitioner services. Quality in Health Care, [e-journal] 9(4), pp.210. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 10 January 2018].

Holloway, I., 2017. Qualitative research in nursing and healthcare. 4th ed. Chichester, West Sussex: Wiley Blackwell.

HRA, 2017. UK policy framework for health and social care research. [online]Available at: <https://www.hra.nhs.uk/planning-and-improving-research/policies-standards-legislation/uk-policy-framework-health-social-care-research/> [Accessed 8 January 2018].

Kawulich, B., 2005. Participant Observation as a Data Collection Method. Forum : Qualitative Social Research, [e-journal] 6 (2). Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 10 January 2018].

Keogh, B., 2013. Review into the quality of care and treatment provided by 14 hospital trusts in England. [online] Available at: <https://www.nhs.uk/nhsengland/bruce-keogh-review/documents/outcomes/keogh-review-final-report.pdf> [Accessed 10 January 2018]

Kumar, A., 2010. Hippocratic Oath, 21st Century. Indian Journal of Surgery, [e-journal] 72(2), pp.171-175. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 10 October 2017].

Legislation.gov.uk, 2014. Care Act 2014. [online] Available at: <http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted> [Accessed 5 January 2018].

Mills, A., Durepos, G. and Wiebe, E., 2012. Encyclopedia of Case Study Research [e-book] Thousand Oaks, California: SAGE. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 10 January 2018].

Ministry of Defence., 2013. Defence Instructions and Notices (DIN) 2013DIN05-035: Guidance on undertaking Medical or Healthcare Research, Audit and Service Evaluations. London: MOD.

MOD, 2017. Armed Forces Continuous Attitude Survey 2017. [online]Available at:  <https://www.gov.uk/government/statistics/armed-forces-continuous-attitude-survey-2017> [Accessed 10 January 2018].

National Bioethics Advisory Commission.,2001.  Ethical and Policy Issues in Research Involving Human Participants.(Review), 31(1) pp.7.

National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, Bethesda, Md, 1978. The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. [online] Available at: <https://videocast.nih.gov/pdf/ohrp_appendix_belmont_report_vol_2.pdf> [Accessed 1 November 2017].

NHS England, 2017. Framework for Patient and Public Participation in Armed Forces Commissioning. [online] Available at <https://www.england.nhs.uk/wp-content/uploads/2017/01/armed-forces-participation-frmwrk.pdf.> [Accessed 5 January 2018].

Parahoo, K., 2014. Nursing research: principles, process and issues. 3rd ed. Basingstoke: Palgrave Macmillan.

Piper, N. and Lamb, D., 2014. The patient experience: measuring the quality of care in the Defence Medical Services. Journal of the Royal Army Medical Corps, [e-journal] , pp.000221. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 10 December 2017].

Polit, D.F. and Beck, C.T., 2017. Essentials of nursing research. 9th ed. Philadelphia, Pa: Wolters Kluwer.

Pope, C., van Royen, P. and Baker, R., 2002. Qualitative methods in research on healthcare quality. Quality and Safety in Health Care, [e-journal] 11(2), pp.148-152. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 1 December 2017].

Ross, T., 2012. A survival guide for health research methods. Maidenhead: McGraw-Hill Education (UK).

Sackett, D.L., Straus, S. E., Richardson, W. S., Rosenburg, W., Haynes, R. B., 2000. Evidence-based medicine : how to practice and teach EBM. [e-book] 2nd Edinburgh: Churchill Livingstone. Available through: Google Books < https://books.google.co.uk> [Accessed 22 December 2017]

Sackett, D.L., Rosenberg, W.M.C., Gray, J.A.M., Haynes, R.B. and Richardson, W.S., 1996. Evidence based medicine: what it is and what it isn’t. (it’s about integrating individual clinical expertise and the best external evidence)(Editorial). British medical journal, [e-journal] 312 (7023), pp.71. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 22 December 2017].

Saks, M. and Allsop, J., 2013. Researching health: qualitative, quantitative and mixed methods.  London: SAGE.

Salkind, N.J., 2017. Statistics for people who (think they) hate statistics. 6^th ed. London:SAGE.

Sapsford, R. and Jupp, V., 2006. Data collection and analysis. 2nd ed. London: SAGE.

Savage, J., 2000. Ethnography and health care. BMJ : British Medical Journal, [e-journal] 321 (7273), pp.1400-1402. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 22 November 2017].

Schwarz, M., Landis, S.E., Rowe, J.E., Janes, C.L. and Pullman, N., 2000. Using focus groups to assess primary care patients’ satisfaction. Evaluation & the health professions, [e-journal] 23 (1), pp.58-71. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 10 January 2018].

Scottish Parliament, 2011. The Patients Rights (Scotland) Act 2011. [online] Available at <http://www.gov.scot/Topics/Health/Policy/Patients> [Accessed 5 January 2018].

Spitz, V., 2005.  Doctors from Hell The Horrific Account of Nazi Experiments on Humans. Ethik in der Medizin, [e-journal] 19(3), pp.236-237. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 8 October 2017].

Sutton, J. and Austin, Z., 2015. Qualitative Research: Data Collection, Analysis, and Management. The Canadian journal of hospital pharmacy, [e-journal] 68(3), pp.226. Available through: Anglia Ruskin University Library website http://libweb.anglia.ac.uk [Accessed 10 December 2017].