Integrating quantitative and qualitative approaches: an approach applied to the study of

Intensive Care

Presented by Ruth Kowalczyk

Intensive Care

“ A service for patients with potentially recoverable diseases who can benefit from more detailed observation and treatment than is generally available in the standard wards and departments.”

King’s Fund Panel (1989)

Why study Intensive Care?

• Little research done

• Expensive service

• Increasing demand

• Highly politicised mistakes

Why study effectiveness?

• Within the NHS

• Within Intensive Care

Performance measures

• Effectiveness

• Efficiency

• Customer satisfaction

• Staff satisfaction

• Growth

Factors affecting ICU management

ICU management

Demand

Workload

Diagnostic diversity

Effect of other units

Case mix

LocationResources

Technology

Unit size

£

Staffing

Work routinePersonnel

Personalities

PoliciesStructure

Research Questions

• What does managerial effectiveness actually mean to intensive care?

• Is there a way to compare units with others like themselves?

• Can the performance of a unit be improved by adopting the policies or practices of another unit?

Research Questions

• How do the policies of a unit affect the practices of the unit staff?

• How does the management structure of a unit affect its performance?

Answering the Research Questions

Managerial effectiveness

Comparing units

Improving performance

Impact of policy on practice

Effect of structure on performance

Statistical analyses & mathematical modeling

Answering the Research Questions

Managerial effectiveness

Comparing units

Improving performance

Impact of policy on practice

Effect of structure on performance

Observation & interviewing

Statistical analyses & mathematical modelling

Mixing Methods

• Qualitative methods – as a prerequisite to quantitative methods

– to supplement quantitative methods

– to examine areas not amenable to

quantitative methods

Pope & Mays, 1995

Mixing Methods

Quantitative methods Qualitative methods

What How Why

Quantitative & Qualitative methods

• Correlation, ANOVA and regression

• Data Envelopment Analysis

• Case study, including – Observational study

– Semi-structured interviews.

• Semi-structured interviews in 4 ICUs identified by quantitative analysis.

Limitations to DEA in complex situations

• Conflicting output measures

• Outputs or inputs?

• Low correlations

Careful interpretation of results

Intensive Care in context - Patient movement

AE DGH

Other ICUsICU

HDU

Surgery Medic ine

Patient movement Crucial l ink

Integration of ICU within the Hospital

• ICU nurses as distinct sub-culture

ICU

• work• knowledge• relationship with doctors

Integration of ICU within the Hospital

• An integrated unit is more likely to have– better patient survival,

– more transfers out,

– ability to maintain occupancy standards,

– nurse post-basic training,

– no intercollegiate recognition.

Quantitative & Qualitative methods

Method

Framework

Ontology Realism

Evaluative Research

Evaluation research

Key features of evaluation :-

• Value & Worth

• Real World Research

• Diversity

Utilisation of research

• Involving stakeholders

• Context

• Process v. outcome

• Whose needs?

• Incremental

• Time span

Key features of Realism

• Stratified Ontology

• Retroduction

• Mechanism in Context Outcome

• Emergence

References

• Pope C. & Mays N., Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research, BMJ, 1995; 311: 42-5.

• King’s Fund Panel, Intensive Care in the UK, Anaesthesia, 1989; 44: 428-31.

Other Useful References

• Mingers J., The contribution of critical realism as an underpinning philosophy for OR/MS and systems, JORS, Vol. 51, No. 11, November 2000.

• Pawson R. & Tilley N., Realistic Evaluation, 1997, Sage, London.

• Robson J., Real World Research: A resource for social scientists and practitioner researchers, 1993, Blackwells, Oxford.

• Sayer A., Realism and Social Science, 2000 , Sage, London.