I think it is too early to tell how I will do in this program.  What I do know is that I am thrilled to be here, working very hard, experiencing much personal growth, and enjoying every moment.  I do hope that I have good evaluations on my work that I’ve accomplished, and that I continue to do so throughout subsequent courses.  My opinion on qualitative research has changed dramatically and I am once again excited about learning.  My cohort members have opened my eyes to new worlds and concepts far removed from my isolated health care environment, and I love thinking of the multiple ways in which these connections will help all of us as we move through academic hallways, career trails, and a life of personal growth.

I could relate our class discussion with a personal story (stop reading right here if you are not interested).  As a five year old, I was beginning to cast doubt on the existence of Santa Claus.  I wanted to believe, as I thought there might be some negative consequences if I did not (like no more presents), but I just couldn’t get it to make sense within my cognitive reality.  He would not have fit down our chimney, how could he possibly make it around the world in one night, why were there no hoofprints on the snowy roof, flying reindeer didn’t seem plausible, and I continued to get gifts each Christmas even when I had been really naughty.  I discussed at length with my brother (at 6 years old, he was considered a credible expert) but we reached no conclusions and decided we would have to do an experiment in order to test our hypothesis.

How would we design our experiment? What were the ethics involved? What sort of methodology would we use? What kind of data would we need to reach a conclusion?  What would we do with the results? We thought about all of this very carefully, and that Christmas eve of 1975 we planned our kinderthesis.

Hypothesis

There is no Santa Claus – the gig is performed by an imposter, most likely dad.

Ethics

If our hypothesis was proven correct, we keep all results confidential from the younger siblings but we would share our findings with the older one.  We would make a pact to never divulge the knowledge to the parental units for fear of negative repercussion.  No reindeer would be harmed during the course of the study.

Methodology

We understood some of our limitations for qualitative methodology; we would not be able to stay awake late enough to directly observe the event or interview the participants.  We were out of time to secure grant funding for the project and therefore could not hire research assistants.

Assumptions

We would need to make some assumptions (that our dad doesn’t eat vegetables and loves cookies), and these assumptions were thought to be valid enough after several years of direct observation of his daily habits.  We acknowledged our possible bias as being close to and influenced by a power relationship with the subject matter, but thought that might be negated by the statement that we had nothing to gain from the results.

Experiment

The stockings were hung, the tree lights were on, and the plate of cookies was placed on the hearth, along with the usual carrots for the reindeer (8, plus one for Rudolph).  Just before tucking into bed, we snuck back into the living room and surreptitiously marked each carrot with blue marker.  Off to bed we went with visions of statistically significant results dancing in our heads.

Data

First thing in the morning, we raced down the hall with the rest of the kids and my brother and I looked gleefully at each other as we noticed all 9 of the carrots were gone and all that was left of the cookies were a few crumbs.

Analysis

There was a short delay prior to data analysis while we opened presents, but eventually we met to discuss the event.  We deduced that dad would have eaten the cookies, but certainly would not have eaten nine large carrots in the middle of the night.  We checked the garbage can; results were inconclusive and we were unwilling to dig further.  Then we checked the fridge and there they were – 9 big carrots marked with blue.  Aha!  We achieved inter-relator reliability by describing the context and showing the evidence to our older sister, who concurred with our findings.

Results

We were proud of our cleverness, but surprised by our lack of joy in the findings.  Here we had achieved what we had set out to do and proven our hypothesis; yet we were unhappy.  Trust had been broken and we felt lied to, we didn’t take as much out of the Christmas experience thereafter, and we felt ashamed to have asked a question to which we really had not wanted an answer.

Just as the son’s perspective changed a bit over time during the movie ‘Big Fish’, so did my own.  When my daughter now asks me if Santa is real, I reply that many people think he is.  When she presses, I answer with some questions; “What do YOU think?  If he’s not, who do you think brings the presents, and why are there chewed up carrots in the snow in the backyard?  Where do those hoofprints come from outside?  Why did you find that sleighbell in the yard?  Why would so many books be written about him? Why do so many kids around the world believe?” Last Christmas she told me as a knowing 8 year old: “Just because all the other kids believe in Santa, it doesn’t mean he’s real”.  Hmmmm…….I wouldn’t be surprised if Bill and Judith get to meet her in MALAT 2040.

The article was published in Respiratory Care Journal, which is peer-reviewed and can be found within medline.  This is the journal that is most directly applicable to my work, and I read it cover to cover each month.  This is also where my own little abstract was recently published, although I may not pursue publication of the article as the final statistical analysis of our data didn’t show what we hoped, although there is still some merit to publishing a study that says ‘we tried something, it didn’t work, I wonder why’.  I do hope to publish something as an outcome of this program, however, and it would fill me with pride to have it in this particular journal of my peers.  Shelley Mishoe has a PhD but is also a Respiratory Therapist, and this article gives a very insightful review of critical thinking skills necessary within our profession.

The article is very descriptive in its explanations of what a qualitative study is and why this particular topic lends itself well to qualitative methodology.  But what I love about it is how it demonstrates inductive research theories.  Just as Palys and Atchison (2008, p. 34) describe in their chapter 2 subheading “Starting from where you are”, the author has an insight into her subject matter and that has helped to guide the research.  She describes in the article how inductive research generates theory based on subject exploration and observation, why it is important to give as much context as possible to allow for reader generalization, and describes the checks and balances put into place for mitigating the bias caused by having the researcher literally and figuratively ‘too close’ to the subjects.  Have a read through it – it really helped me to reinforce the concepts we are learning in qualitative research design.  I think I also answered my own question that I posed in my post questions about research conflict below: it IS possible to do research on a subject you are close to, as long as your bias is transparent and you use strategies (Mishoe used member checks, audit trail, peer consultation, journaling, and reflections on subjectivity) to ensure your research will stand up to a critical eye.

Last thoughts and possible ideas for future research: health care simulation, building situational awareness in critical care, electronic communities of practice

References:

Mishoe, S.C. (2003). Critical thinking in respiratory care practice: a qualitative research study. Respiratory Care, 48(5), 500-516.

Palys, T., & Atchison, C. (2008). Chapter 2: Getting started. In Research decisions: Quantitative and Qualitative Perspectives (4th Ed.) (p. 34). Toronto, ON: Nelson Education Ltd.

Just as my cohort member Ann loves numbers, I love words, and tend to collect them just as a child might collect beautiful shells on a beach; each one unique.  Remember Judith’s lecture about building a scaffold for knowledge?  Words are a bit like that – a root built up like scaffolding with prefixes and suffixes, morphed with an affix, or joined with another to make a compound.  But the metaphor would need to end there; a real scaffold is still a scaffold if it’s been sitting for a hundred years, and if you pick it up and move it to a different place; still a scaffold.  Words are not like that.  Ostensibly they start as a sound until meaning is assigned and they are accepted into common language (neologism), but when they sit around for a hundred years, the meaning can change (semantics).  Moving them to a different location or context may also change the meaning (homonym).  These subtle shifts in connotation make words a powerful tool and serve an important purpose for situations in which, as some Hallmark cards say, “…words cannot express…”

I see lexicon meanings shifted all the time within the context of a hospital environment.  One example disturbs me each time I hear it – ICU physicians making difficult end-of-life decisions will often say during critical care rounds “(the patient) is declaring himself”.  The interpretation is that the patient’s condition has deteriorated to the point where it becomes apparent to everyone that there would be no possibly of recovery.  Declaring himself?  Declaring himself what?  Dying?

Often this statement precedes the decision to remove life support.  What bothers me about this phrase is that I wonder if the physicians are using it in order to give a perception that the patient is responsible for the decision to end his life.  Would it not be a better choice of words for the physician to state “Based on my knowledge and experience, the patients diagnosis, signs and symptoms, recent labwork and deterioration over the last several days, as well as the prognosis I’ve made, I have made a decision to remove life support.”  Ultimately the physician, in discussion with the family and members of the ICU team, is responsible for this decision, and it really has nothing to do with the patient making any declarations.  The meaning and use of this phrase within the environment of an intensive care unit are discussed in an interesting qualitative peer-reviewed study by Johnson, Cook, Giacomini, and Willms (2000, p. 287). The full-text link to this article can be found here.

Librarians are the gatekeepers for words.  My respect for librarians was recently enhanced during Thusday’s lecture on accessing RRUs extensive online library.  I’ve always been a big fan of librarians – in fact, I’ve secretly always wanted to be one; something about the Dewey Decimal Classification has always held appeal.  The RRU librarians did not have any impact on me (they were nice and did not throw sharp objects) but they certainly had an effect on my ability to search for research using technology.  Another librarian that I hold in high regard is Dean Giustini; a medical librarian and prolific blogger who passionately debates the merits of technology in health research.  Dean is a good writer and I have benefited from his expertise on several occasions.  His blog The Search Principle, (http://blogs.ubc.ca/dean/) makes for a great read.

Johnson, N., Cook, D., Giacomini, M., & Willms, D. (2000). Towards a “Good” Death: End-of-life Narratives constructed in an intensive care unit. Culture, Medicine and Psychiatry, 24, 275-295.

I think I’m slowly moving from ‘techie-wannabe’ to ‘techie-beginner’.  While I’ll never catch up to those in my cohort that do IT as a living, I knew I had made great strides last night when I was able to show one of them something he didn’t know! (well, ok, it was an application on my mac and he was a PC user, but still….).  Guess what’s on my bedside table?  I didn’t even bring a novel, I brought MACworld magazine!

Last night I connected wirelessly  within the Grant building, and was working with my team when a Skype video call came in.  My 8 year old daughter was skyping and I carried my laptop around the hallways of Grant building during our video chat.  At one point in the conversation I flipped my computer around and showed her a peacock.  Then I came back into our hot sweaty meeting room and introduced her to my teammates – she waved and showed off the popsicle she was eating. I do love technology.

The end of our third day of residency, and I feel as though I’ve been here for a month.  When thinking about blog topics, I’ve been choosing the thought that emerges from my conditioned behaviouristic plasticized elastic cognitive grey matter (a.k.a. brain) just before bedtime.  Generally this is the time of day when I try to relax and not think about anything at all, so I know if a niggling thought pops out, it deserves some reflection as to why.

Today’s thought was about conflict of interest within research.  Bill’s discussion during the ‘Introduction to Research’ lecture sticks with me when he described the potential conflict between teachers doing research on students (B. Muirhead, personal communication, July 27, 2009).  Colleen’s discussion today also gave a good overview of conflicts within research.

When thinking about research questions, I very much want to contribute something original to the current body of knowledge within my particular health care profession (Respiratory Therapy).  In fact, I may even want to stretch myself a bit – way out of my comfort zone – and perhaps take on a qualitative study, which I think would really be a new concept for all the quantitative thinkers in my field.

Therein lies the problem.  My chosen profession is very small – as of 2006, there were 537 registered therapists within British Columbia (Canadian Institute for Health Information, 2008). As the practice leader for therapists working within one of the largest healthcare employer organizations, can I do a qualitative study using them as subjects?  If the purpose of my paper is to determine if implementing a specific learning technology changes their practice, would this be the same potential conflict as a boss asking his employee if a new technology improved the speed of their work?  Would the therapists in my portfolio feel comfortable telling me that they did or did not improve the way they look after their patients – and if I were the one to implement this learning technology, would they feel obligated to respond affirmatively, thereby skewing the results?

These are questions I’ll take to Colleen.

Canadian Institute for Health Information. (2008). Canada’s Health Care Providers, 1997 to 2006, A Reference Guide. Retrieved July 29, 2009, from CIHI: http://secure.cihi.ca/cihiweb/splash.html

Image from Microsoft Clipart

What stands out for me so far? A sudden jump in my knowledge related to research. My work experience has taught me to critically evaluate research, to review and analyze research, to interpret research, and to transfer knowledge gained from research to professional medical practice. I know the difference between a preclinical trial – or ‘benchtest’ as we call it in the field – and a clinical trial, I can differentiate between in vivo and in vitro testing, and I can describe the benefits of a multicentre randomized controlled trial. I’ve run experiments on animals, I’ve applied for research grants and requested modifications to international protocols, I’ve submitted applications to ethics boards and presented independent work in front of hundreds of colleagues. I am not a statistician but I go out for coffee with them and postulate on the merits of survival analysis. Last week I may have introduced myself to my cohort members as having a ‘background’ in research. What didn’t I expect? To learn that there is another way….

All of my training and experience point to quantitative methodology. If you can’t measure it or count it, you can’t study it. If someone had asked me, for example, to determine how patients who survive their stay in the intensive care unit view their quality of life after a critical illness, I would have designed a research study that looked at number and intensity of physical activities pre and post hospitalization, and I may have assessed the number of times they consulted their physician for depression pre and post illness. I may have incorporated accepted gold standards of measurement for happiness scales, but it may not have occurred to me to talk to the patients and ask them how they’re doing.

I was certainly aware that qualitative studies existed, and may even have acknowledged that they have some merit in psychology or sociology publications, but in my mind I would have scoffed ‘artsy-fartsy mumbo-jumbo’ and felt smug about my ability to do ‘real’ research. When reading the first chapter of Palys and Atchison (2008, pg. 3) I saw myself in the description of self-righteous behaviour within the polemic groups of researchers.

I have never liked an insinuation that I am close-minded, and in fact I would list tolerance as one of my best attributes – of religion, race, sexuality, disabilities, gender, etc. I just didn’t know that I should be applying that tolerance to research styles. If I leave this program today, I’ll come away a slightly better person. I may always lean to the quantitative side, but at least I’ll be able to peek around the corner and check out the qualitative side without laughing. I hope I can do justice to both in my future research initiatives.

Palys, T., & Atchison, C. (2008). Perspectives on research. In (4th ed.), Research Decisions: Quantitative and Qualitative Perspectives (p. 3). Toronto, ON: Nelson Education Ltd.