NUR 608 Module 3 Final Paper: Qualitative Study Design Example

Escalating From a Distance: An Interpretive Description Design for Studying How Rural Nurses Decide to Seek Help for Deteriorating Patients

Student Name

Edson College of Nursing and Health Innovation, Arizona State University

NUR 608: Qualitative Research Design and Methods

Instructor Name

Month Day, Year

Escalating From a Distance: An Interpretive Description Design for Studying How Rural Nurses Decide to Seek Help for Deteriorating Patients

Revised Problem Statement and Research Questions

Feedback on the foundations paper asked me to narrow the problem to escalation decisions, rather than the whole process of recognizing deterioration, and to define "escalation." The revised problem is this: in rural critical access hospitals, registered nurses must often decide whether, when and how to seek help for a deteriorating patient when no physician or advanced practice provider is on site, yet little is known about how they make those decisions. Escalation here means any action a nurse takes to bring additional clinical expertise or resources to a patient, including calling an on-call provider, activating a tele-ICU consult, requesting transfer or calling a colleague for a second opinion.

Primary question: How do RNs working in critical access hospitals describe their decisions about seeking more help for a deteriorating patient, including timing and route, when no provider is on site?

Secondary question: What do these nurses describe as helping or hindering their escalation decisions?

Background in Brief

Reviews of recognition and response to deterioration show that nurses often sense change early, seek validation before acting and are influenced by confidence, relationships and organizational support (Odell et al., 2009; Massey et al., 2017). This literature comes mostly from urban hospitals with on-site teams. Rural critical access hospitals have small staffs, often no intensive care unit and long transfer distances, conditions under rising pressure as rural hospitals close (Kaufman et al., 2016).

Conceptual Framework

I will use Tanner's clinical judgment model, with its phases of noticing, interpreting, responding and reflecting, as a sensitizing framework rather than a structure to test (Tanner, 2006). In interpretive description, a framework orients attention without dictating categories (Thorne, 2016). Tanner's model will shape interview prompts, for example asking what first drew the nurse's attention, but analysis will remain open to aspects of escalation the model does not name, such as negotiating with an off-site provider or the moral weight of deciding alone.

Design

The study uses interpretive description, chosen because it generates practice-relevant knowledge and draws on the researcher's clinical understanding while requiring reflexive examination of it (Thorne, 2016). The design is cross-sectional, with one in-depth interview per participant and an optional follow-up interview to explore emerging ideas.

Setting and Sample

Setting: critical access hospitals in Arizona and neighboring states, reached through state rural hospital associations and nursing networks. Sample: registered nurses who have worked at least one year in a critical access hospital and who have escalated care for a deteriorating inpatient or emergency patient in the past year. Purposive sampling will seek variation in years of experience, shift worked, hospital distance from tertiary care and access to tele-ICU support, followed by snowball sampling where networks are small.

Sample size: I estimate 14 to 18 participants, guided by the concept of information power, which holds that fewer participants are needed when the aim is narrow, the sample is highly specific to the aim, an established framework informs the study, interview dialogue is strong and analysis is case-focused (Malterud et al., 2016). My aim is narrow and the sample specific, which lowers the number needed, while the variation I seek across hospital types raises it. Final size will be decided during the study as analysis shows whether new interviews still add to understanding.

Data Collection

Semi-structured interviews of 60 to 75 minutes will be held by secure video, because participants are spread across rural areas and work long shifts. Each interview will center on one or two specific recent escalation events, asking the nurse to walk through the event from first concern to outcome, then exploring the reasoning, the people involved, what helped or hindered and how the nurse felt afterward. Focusing on specific events reduces general statements and brings out the detail interpretive description needs. A brief demographic form will collect years of experience, hospital characteristics and tele-ICU access. Interviews will be recorded with consent and transcribed verbatim, and I will write a reflexive memo after each one.

Field Considerations

Nurses in small hospitals may know one another and me, since I worked in rural emergency care. I will not recruit from the hospital where I worked. Interviews will be scheduled around shifts, with an option for split sessions. Video may limit rapport, so I will open with time for introductions and explain my nursing background and my role as a researcher.

Analysis and Interpretation

Analysis will follow reflexive thematic analysis, which suits interpretive description's aim of building patterns of meaning across accounts while attending to variation (Braun & Clarke, 2006). Steps: familiarization through repeated reading and listening; initial coding, beginning with the first transcripts so that early analysis can shape later interviews; clustering codes into possible themes; checking those themes against the transcripts and the spread of the sample; defining and naming themes; and writing up. Analysis will move back and forth between parts and the whole, as interpretive description recommends, asking what the findings mean for practice (Thorne, 2016).

Legitimacy and Transferability

To support credibility, I will keep a reflexive journal, discuss coding with a peer debriefer who has no rural clinical background and offer participants a summary of themes for comment. For dependability, every coding decision and memo will be dated and kept as a record another researcher could follow. For transferability, I will provide thick description of the hospitals and nurses so readers can judge how far findings apply to their settings (Lincoln & Guba, 1985). Reporting will follow the COREQ checklist for interview studies (Tong et al., 2007).

Ethical Considerations

The study will seek institutional review board approval. Risks are mainly emotional and professional: nurses may recall distressing events or describe decisions that a regulator or employer could question. Protections include informed consent that explains limits of confidentiality, removing names of patients, colleagues and hospitals from transcripts, reporting hospital characteristics only in ranges, giving participants the option to skip questions or stop and providing a list of support resources. Because rural professional communities are small, any quotation that could point to a person or hospital will be altered, and consent forms will say plainly that anonymity in a small community has limits.

Strengths and Limitations

Strengths include a methodology designed for practice-relevant questions, an event-focused interview approach that elicits detail and a sample designed for variation. Limitations include reliance on recalled accounts rather than observation of decisions as they happen, possible self-selection of nurses with strong views and the risk that my clinical background narrows what I notice, which the reflexive strategies are meant to address.

Conclusions and Lessons Learned

The design aims to describe how rural nurses reason and act when help is far away, in terms that could inform rural escalation protocols, tele-ICU use and education for nurses entering rural practice. Writing it taught me three lessons: that narrowing a problem makes every later decision easier; that sample size in qualitative research is an argument, not a formula; and that my clinical experience must be examined in writing throughout the study rather than set aside.

References

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa

Kaufman, B. G., Thomas, S. R., Randolph, R. K., Perry, J. R., Thompson, K. W., Holmes, G. M., & Pink, G. H. (2016). The rising rate of rural hospital closures. The Journal of Rural Health, 32(1), 35-43. https://doi.org/10.1111/jrh.12128

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. SAGE.

Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). Sample size in qualitative interview studies: Guided by information power. Qualitative Health Research, 26(13), 1753-1760. https://doi.org/10.1177/1049732315617444

Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses' recognition of and response to patient deterioration? An integrative review of the literature. Nursing Open, 4(1), 6-23. https://doi.org/10.1002/nop2.53

Odell, M., Victor, C., & Oliver, D. (2009). Nurses' role in detecting deterioration in ward patients: Systematic literature review. Journal of Advanced Nursing, 65(10), 1992-2006. https://doi.org/10.1111/j.1365-2648.2009.05109.x

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04

Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (2nd ed.). Routledge.

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357. https://doi.org/10.1093/intqhc/mzm042