STRIKE ACTION IN THE PUBLIC-HEALTH SECTOR

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CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY

INTRODUCTION

This chapter gives a detailed view on the research design chosen and its relevance to the current study. This chapter also includes the discussions on the study population and sample, research instruments, data collection and data analysis approach. The methodological approach was chosen with the aim to answer the research objectives. The research was conducted in three main phases preluded by a pilot phase using qualitative and quantitative methodologies, which is discussed in detail in this chapter.

RESEARCH PARADIGM

According to Taylor, Kermode and Roberts (2007:5), a paradigm is ―a broad view or perspective of something‖. Additionally, Weaver and Olson (2006:460) refer to a research paradigm as a pattern of beliefs and practices that regulate inquiry within a discipline by providing lenses, frames and processes through which investigation is accomplished‖. Therefore, to clarify the researcher‘s structure of inquiry and methodological choices, an exploration of the paradigm adopted for this study is discussed prior to the specific methodologies utilised in each of the phases of the study.
Qualitative and quantitative research approaches were applied in phases of this study, as needed for addressing the research aim and objectives. Qualitative and quantitative methods are used by researchers to collect data in social science. Qualitative methods include the researcher’s experience through techniques such as focus groups, case studies, interviews and personal observations. On the other hand, quantitative methods include hard facts illustrated in surveys and polls, while the advantage of qualitative research is to provide a richer, deeper understanding of a problem or question being observed (Smith 2008).
Therefore, to gain on the advantages of both methodologies and looking at the research aim and objectives, the researcher used both quantitative and qualitative research methods in different phases of this study. This was decided on in order to allow the researcher to make use of the most valuable features of each methodological approach (Kennedy 2009). Viewing the research problem through different paradigms enabled the researcher to develop a comprehensive knowledge base and an understanding of factors influencing nurses‘ involvement in strike action within the public-health sector. This approach also allowed for a detailed description of strategies to be implemented by nurse managers to curb nurses‘ strike action in public institutions (Singh 2014).
This approach allowed for methodological triangulation by using both qualitative and quantitative methods to collect and analyse data. Both methodologies assisted the researcher to understand the contributing factors for nurses‘ involvement in strike action and how to describe effective strategies for curbing strike action in the public-health sector (Smith 2008).
Employing the qualitative method allowed the researcher to:
• collect the primary data in a flexible, non-structured way that allowed emergence of new information and interpretations of factors influencing nurses‘ participation in strike action and describing proactive strategies for balancing human and professional rights of nurses and their responsibilities within a legislative and professional framework in South Africa
• interact with the research participants in their own language and environment conducive to the healthcare consumers
• understand the study phenomenon in detail
• obtain a more realistic and hands-on feel of the world that cannot be experienced in the numerical data and statistical analysis used in quantitative research
Implementing the quantitative method allowed the researcher to:
• state the research problem in very specific, definable and set terms
• specify clearly and precisely the independent and dependent variables
• follow the original set of research goals
• achieve high levels of reliability of the gathered data due to mass surveying
• test the research questions
• arrive at more objective conclusions by minimizing subjectivity of judgment
Due to budgetary constraints, this study was limited to four target provinces, namely EC, KZN, WC and GP. The provinces were selected since they feature the four major metropolitan areas in South Africa that had been affected by strike action both in 2007 and 2010. The selection of these provinces provided an acceptable national view on the study focus.
In the pilot phase, a qualitative exploratory approach was followed to explore factors identified through a literature review as contributing factors for nurses‘ involvement or non-involvement in strike action. This approach was used as a preliminary process to inform the researcher for effective construction of a questionnaire to assess and ascertain nurses‘ views on factors that influence their decision to strike or not to strike (Amora 2010).
In phase one, a questionnaire was constructed using insights from the pilot phase to quantitatively explore factors contributing to nurses‘ involvement in strike action. The questionnaire was also meant to determine the perceived value or non-value of strike action amongst nurses who participated. Using the quantitative approach in phase one allowed the researcher to reach a larger sample. A semi-structured selfadministered questionnaire was sent electronically or delivered to 80 public-health nurses that were selected for this study.
The participating nurses were selected on the basis of their level of involvement in strike action in 2007 and 2010. The quantitative approach in phase one was used by the researcher to quantify the problem and understand how prevalent it is by looking for projectable results to a larger population (Amora 2010).
In phase two, a quantitative approach was used. The questionnaire developed in phase one was adapted to the respondent being a nurse manager; the key concepts on factors contributing to public-health nurses‘ involvement in strike action remained the same. The quantitative approach was implemented in phase two to quantify objectively nurse managers‘ views on factors contributing to nurses‘ involvement or non-involvement in strike action and to determine their understanding of the changing working environment of nurse practice.
In phase three, an exploratory qualitative research approach was used to provide for an in-depth understanding of healthcare consumers‘ views on nurses‘ involvement in strike action. The purpose of phase three was not to generalise but to augment insight gained in phase one and phase two with the public viewpoint as recipients of healthcare services and being in some way affected by the problem addressed by this study.

RESEARCH DESIGN

A research design is the framework or plan for a study used as a guide in collecting and analysing data to address the central research questions (Creswell 2009:3; Polit & Beck 2008:49). In this study, a descriptive, exploratory and analytic design was followed, using both qualitative and quantitative approaches in subsequent phases of the study to meet the research objectives. According to Creswell (2009:3-4) and Plano Clark & Creswell (2010:65-67), a descriptive design provide accuracy by describing what exists, the frequency with which it exists, ascribe new meaning to a phenomenon and put information into categories or themes. Descriptive research is also known to yield both qualitative and quantitative data, as was the case with this study (Mokoka 2007:150). The phenomenon under study could be described in ways varying from narrative types of description to a statistical analysis (Babbie & Mouton 2003:81; Luttrell 2010:163; Mokoka 2007; Saldaña 2011:71:150).
The advantages of the exploratory approach are rooted in literature sources (Jackson 2014). The exploratory nature of the study resulted from the fact that strike action in the public-health sector in South Africa has become a persistent phenomenon (Babbie 2013:90). The research design was therefore not meant to draw definite conclusions but to increase the researcher’s understanding of the study problem. It helped the researcher to determine and understand the contributing factors for the involvement or non-involvement of nurses in public-healthcare facilities in strike action during 2007 and 2010.
The researcher aimed to uncover the factors that drive or influence the involvement of professional nurses in strike action while bonded to their ethical code of practice in South Africa. This was done with the purpose of describing proactive management strategies for nurse managers that would serve as a preventative measure for nurses‘ involvement in strike action. The experiences of a sample of nurses who participated and those who did not participate in strike action during 2007 or 2010 in South Africa were explored in the empirical research.
The exploratory part of the study in the pilot phase using a qualitative technique, helped the researcher to better understand the issues on strike action by nurses for effective construction of questions in a subsequent collection of data in phase one using a quantitative technique (Luttrell 2010:163; Saldaña 2011:71). A smaller sample of nurse managers from public-healthcare facilities that were affected by strikes in 2007 or 2010 was included in phase two. This was done to augment the findings of the study and understand nurse managers‘ views on factors contributing to nurses‘ involvement in strike action and to determine their understanding of the changing working environment of nurse practice.
The questionnaire from phase one was slightly adapted for nurse managers as respondents. In phase three, the qualitative techniques allowed the researcher access to the perspectives of healthcare consumers who utilised the public-healthcare facilities during strike action in 2007 or 2010. This allowed the researcher to explore the area of interest from the perceptions of both the nurses and the healthcare consumers.

ORGANISATION OF THE STUDY PHASES

A phase approach was used in this study and the phases are outlined below.
The pilot phase was meant to explore through qualitative techniques factors that contributed to the involvement of nurses in strike action amongst nurses working in public-healthcare facilities in GP that either participated or did not participate in strike action during 2007 or 2010.
Phase one was a quantitative phase meant to further explore factors contributing to nurses‘ involvement in strike action during 2007 and 2010 from a bigger group of nurses across the four provinces selected for the study. It was also to determine the perceived value or non-value of nurses‘ participation in strike action.
Phase two was conducted using quantitative techniques to determine the factors contributing to nurses‘ involvement in strike action amongst nurse managers and to determine their understanding of the changing working environment of nurse practice. Only nurse managers working at the public-healthcare facilities that were affected by strike action in 2007 and 2010 were selected for this phase.
In phase three, the researcher used qualitative techniques to explore perceptions and views of healthcare consumers on nurses‘ involvement in strike action and the perceived impact thereof. Healthcare consumers that participated in phase three were mainly outpatients that sought services at public-healthcare facilities in the four selected provinces during 2007 and 2010.
In order to describe the variety of research activities undertaken during this study, the data collection activities and associated analysis methods are systematically discussed in detail under each phase of the study.

PILOT PHASE: QUALITATIVE APPROACH

In the pilot phase, a qualitative exploratory approach was followed to explore the factors contributing to nurses‘ involvement in strike action or non-involvement. An in-depth interview guide was developed and appointments made telephonically with ten nurse participants working in public-healthcare facilities. The in-depth interviews were conducted to provide insight to the subsequent development of a semi-structured questionnaire that was used as a self-administered questionnaire in both phase one and phase two.

Population and sampling

According to Creswell and Plano Clark (2011:172), to address a research question, the researcher engages in a sampling procedure that involves determining the location or site for the research, the participants who will provide data in the study and how they will be sampled, and the recruitment procedures for the participants. These steps in sampling apply to both qualitative and quantitative research.
In the pilot phase, the researcher purposefully selected professional nurses that could provide the necessary information. Purposeful sampling in qualitative research means that the researcher intentionally selects or recruits participants who have experienced the central phenomenon or the key concept being explored in the study (Creswell & Plano Clark 2011:172).
Non-probability purposive convenience sampling was used for the benefit of time and cost to get representation of cases under investigation (Bowling 2011:206). The non-probability sampling approach is concerned with identifying cases that would enhance the researcher‘s understanding about the processes and interactions within the specific context of the study (Neuman 2003:211; Welman & Kruger 2001:61-62).
Gauteng was selected as the preferred province for the pilot phase because of its proximity and accessibility to the researcher. The decision was mainly driven by time and budgetary constraints.
• Population
The target population for the pilot phase was accessible nurses who reside in Gauteng that had or had not got involved in strike action but worked at any public-healthcare facility that was affected by strike action in 2007 and 2010. The nurses had to be registered in the SANC registry for nursing practice during the period of the study. The accessible population is defined as a population of participants available for a particular study or reasonably accessible to the researcher (Polit & Hungler (1999:209). According to Burns and Grove (2003:366), the sample in a study is obtained from the accessible population and findings are generalised first to the accessible population and then, more abstractly, to the target population.
• Selection criteria of participants
A purposive and convenience sampling approach was used to select professional nurses according to the following selection criteria (Bowling 2011:208; Creswell & Plano Clark 2011:173):
– All nurses selected should be working at any public-healthcare facility in Gauteng that was affected by strike action.
– The nurses should have been employed at such healthcare facilities during the strike periods in 2007 and 2010 and either participated or not participated in strike action in the same period.
– They should be conversant in English and reside in South Africa.
– Their names were supposed to be in the SANC registry for practicing professional nurses during the period of the study (Annexure C).
Purposive sampling required that one data-rich participant who met the criteria be identified first (McMillan & Schumacher 2006:320). The first participant was identified through a referral by the researcher‘s colleague who was a brother to the participant. Thereafter, nine participants were included on convenience basis. This means that successive participants were included by virtue of referral from participants themselves or colleagues of the researcher and family members of participants who were interacted with on a social basis (McMillan & Schumacher 2006:321). The ten participants thus identified fitted the criteria for inclusion. The researcher‘s standing as an outsider in the nursing discipline assisted in easily developing rapport and trust with the participants in absence of fear for victimisation.

Data collection

According to Burns and Grove (2002:49), data collection is the precise, systematic gathering of information relevant to the research purpose. Mokoka (2007:155) expresses that Brink (1999:148) identifies five questions that a researcher needs to ask when planning the data collection process. These questions pertain to the type of information needed to answer the research question, type of research instrument, who will collect the data, the setting and time frame for data collection.
The pilot phase included telephonic in-depth interviews conducted in September 2013 to determine whether similar themes as were observed in 2007 just after the strike action still remained (TNS Research Surveys 2007:1-4). This was done using a discussion guide with participating nurses to explore the study objectives. This data collection method is an effective way of soliciting and documenting the respondents‘ own words and information about their own experiences and opinions or views (Babbie 2013:232; Saldaña 2011:32-33).
Based on the literature review, a set of pre-determined discussion points was formulated for participants who participated in strike action and those who did not participate in 2007 or 2010 (Annexure D). Areas of information required were essential to bring into view the professional nurses‘ potential causes of involvement in strike action in a public-health sector (Babbie 2013:230). This took into consideration the professional obligations of nurses and their rights as citizens of South Africa and functioning within the essential services as regulated by law in South Africa. Data collection for the pilot phase took place early in 2013.

Preparation of the interview guide (schedule) – (Annexure D)

Before conducting in-depth interviews with the participants, the researcher defined the information that was required to allow the interviews to proceed smoothly and naturally (Babbie 2013:346; De Vos et al. 2005:293).
The information that was required from professional nurses during the in-depth interviews was related to factors influencing nurses‘ involvement or non-involvement in strike action and a perspective on their work circumstances and environment in general. The interview guide comprised of seven main discussion points to allow for an interaction between the interviewer (the researcher in this study) and the participant (Babbie 2013:346). The questions were discussed with the researcher‘s supervisor and two researchers experienced in qualitative research methods.
• Pre-testing the interview guide (schedule)
The research instrument should be pre-tested before the actual collection of data. The validity of interview data relied on shared assumptions and understandings of the discussion points. Pre-testing of discussion points included asking people to describe what they thought of when they listened to a question and about how they interpreted it. Respondents were informed that they were being interviewed for pre-testing the interview guide (Bowling 2009:301). In this study, most participants interviewed were willing to help and were honest enough to tell when the pointers for discussion were ambiguous and not easy to interpret.
In order to avoid pitfalls in the interview guide, the instrument was discussed with the study supervisor and other experienced researchers in qualitative research methods. The instrument was also pre-tested with four professional nurses in GP (due to close proximity) who also fulfilled the set participant criteria. These nurses were used solely to test the discussion guide prior the pilot phase of this study (Bernard 2013:237).
Pre-testing the interview guide helped the researcher to be more familiar with the areas of discussion and to come to grips with some practical aspects of the interviewing process. Pre-testing the interview guide entailed establishing the approximate time that would be required to conduct each interview, the necessary detail and clarity of the discussion points and even of the potential answers and necessary probes. The researcher had a pre-set time allocation for each interview but through the pilot study it was determined that the maximum required time for each interview was 35 to 40 minutes for a proper and informing discussion. Participants found the discussion points to be acceptable and relevant to them. Though one indicated a sense of discomfort when a discussion point related to the ethical code of practice and involvement in strike action was posed, it was within limits of tolerance.
• Structure of the interview guide (schedule) – (Annexure D)
The different sections focused on the following:
Section 1 – Perceptions of the nursing profession Section 2 – Perceptions of the strike action
Section 3 – Perceptions of the public on the nurses‘ participation in strike action

The in-depth interviews

Consent was obtained prior to conducting the interviews with nurses who worked in public-health hospitals or clinics that experienced strike action in 2007 or 2010. Purposefully selected participants who were selected as described in section 3.5.1 were contacted and the purpose of this study explained to them before voluntarily agreeing to partake in the study. The participants were contacted prior the in-depth interviews for formal appointments. They were prepared for the in-depth interviews and suitable times were arranged. The participants were informed that the interview will take approximately 35 to 40 minutes. Appointments were confirmed a day before the in-depth interview. Before commencing with the interviews, the researcher explained the information required, the format and the process of the interview. The researcher reiterated to the participants that they could withdraw at any stage of the interview if they wanted to.

Position of the researcher

The researcher is an environmental health practitioner by profession. She is employed as a senior researcher at the Department of Communications and her main line function is research in public opinion on the implementation of government policies. She manages projects that apply either qualitative or quantitative research methodologies depending on the topic of interest to the government related to its policies.
The researcher never practiced as a professional nurse or qualified as such, though her undergraduate academic development involved aspects of health. In her current work environment, the researcher places emphasis on matters of national priority – and health is one of them.
Her position as a researcher allowed her extensive access to participants for the collection of qualitative data, presenting a none-bias interaction given the occupation background of the researcher. This meant that she was an objective, authoritative, neutral observer. Therefore, no personal bias, values and assumptions are part of the reported findings. Open and honest relationships were developed between the researcher and the participants. The researcher was the agent of analysis and interpretation. Her position as an independent researcher outside the discipline of the nursing profession facilitated entry into the participants‘ world and encouraged effective participation with no pre-conceived ideas.
Identifying biases, personal values and interests regarding the research topic and process, and explaining how entrance was gained to the research site and how ethical issues were dealt with is crucial for the trustworthiness of the research findings. These were identified and acknowledged (Creswell 2009:184), such that the analysis and interpretation of the data is not adversely affected and not leading to invalid and unreliable conclusions.
To elicit relevant and honest views from the participants, the researcher allowed space for intuition by listening intently to what and how they responded to questions asked according to the interview schedule, and by using neutral probes when trying to elicit further information from respondents (Babbie & Mouton 2001:251).
The researcher understood her role in the interview process and allowed more time for the participants to state their views based on questions asked. The researcher created an atmosphere that was conducive for the interview by allowing the participants sufficient time to ponder their responses, avoiding the use of leading questions and at all times being sensitive to their reaction and feelings during the in-depth interview. It was also important to the researcher to show interest in the participants as well as in what they were saying when responding to questions.
During the in-depth interview, the researcher made provision for the participants to explain their views or responses where these seemed unclear. The in-depth interviews were recorded on audio tape and later transcribed verbatim for analysis.

Qualitative data analysis

Data was organised and analysed to elicit meaning (Polit & Beck 2010:463). This was an active and interactive process in which the researcher got immersed in the data. There are various methods available for qualitative data analysis. The researcher discovered patterns such as causal links among variables (Babbie 2013:411).
Data was transcribed verbatim into MS Word files, and the files were read for relationships and patterns. Similarities and differences were identified; words and phrases were grouped into clusters of similar ideas and concepts and highlighted in different colours. This aided in grouping similar concepts together and identifying the most commonly occurring concepts. The analysis of this phase was undertaken independently by the researcher and confirmed by a co-coder; the notes were compared to validate the concepts that occurred, and the findings interpreted (Creswell 2003:191; Saldaña 2011:90-97). The concepts that most commonly occurred during data analysis and interpretation of findings for the pilot phase were used to construct a questionnaire for phase one and phase two.
Audio-taped interviews were transcribed verbatim.
– Transcribed interviews were then read and re-read by the researcher and co-coder to identify patterns from the data.
– Themes were developed according to identified data patterns.
– Emerging data patterns were classified into major themes, firstly in the concrete language of the participant and then clustered into sub-themes, with their concrete meaning being transformed into the language of concept or science.
A conventional process of coding and thematic analysis was used in the study. Codes are a form of shorthand that a researcher repeatedly uses to identify conceptual re-occurrences and similarities in the patterns of the participants‘ experiences (Birks & Mills 2011:95). Codes assist with understanding what is happening in the data and what the data means (Charmaz 2006:45).

TABLE OF CONTENTS
CHAPTER 1: ORIENTATION OF THE STUDY
1.1. INTRODUCTION
1.2. THE BACKGROUND TO THE RESEARCH PROBLEM
1.3. PROBLEM STATEMENT
1.4. AIM OF THE STUDY
1.5. RESEARCH QUESTIONS
1.6. RESEARCH OBJECTIVES
1.7. SIGNIFICANCE OF THE STUDY
1.9. THEORETICAL FOUNDATIONS OF THE STUDY
1.10. THE RESEARCH DESIGN AND METHODOLOGY
1.11. STUDY POPULATION
1.12. SAMPLING
1.13. DATA COLLECTION
1.14. DATA ANALYSIS
1.15. VALIDITY AND RELIABILITY
1.16. ETHICAL CONSIDERATIONS
1.17. SCOPE AND LIMITATIONS OF THE STUDY
1.18. STRUCTURE OF THE THESIS
1.19. CONCLUSION
CHAPTER 2: LITERATURE REVIEW
2.1. INTRODUCTION
2.2. UNDERSTANDING THE STRIKE ACTION
2.3. OCCURRENCES OF STRIKE ACTION AS PART OF THE COLLECTIVE BARGAINING PROCESS
2.4. STRIKE ACTION IN THE PUBLIC-HEALTH SECTOR
2.5. TRADE UNIONS AND THEIR ROLE IN THE PUBLIC-HEALTH SECTOR
2.6. SOUTH AFRICAN NURSING COUNCIL
2.7. UNDERSTANDING THE NURSING PROFESSION WITHIN THE CODE OF PRACTICE
2.8. FACTORS INFLUENCING NURSES‘ INVOLVEMENT IN STRIKE ACTION
2.9. IMPACT OF STRIKE ACTION ON PUBLIC HEALTHCARE
2.10. LEGISLATIVE FRAMEWORK GUIDING THE PRACTICE OF NURSING IN SOUTH AFRICA AND INVOLVEMENT IN STRIKE ACTION
2.11. THEORETICAL FRAMEWORK OF THE STUDY
2.12. CONCLUSIONS
CHAPTER 3: RESEARCH DESIGN AND METHODOLOGY
3.1. INTRODUCTION
3.2. RESEARCH PARADIGM
3.3. RESEARCH DESIGN
3.4. ORGANISATION OF THE STUDY PHASES
3.5. PILOT PHASE: QUALITATIVE APPROACH
3.6. PHASE ONE: QUANTITATIVE APPROACH
3.7. PHASE 2: QUANTITATIVE APPROACH
3.9. TRIANGULATION
3.10. ETHICAL CONSIDERATIONS
3.11. CONCLUSION
CHAPTER 4: INTERPRETATION OF FINDINGS AND LITERATURE CONTROL
4.1. INTRODUCTION
4.2. ANALYSIS OF DATA AND INTERPRETATION OF FINDINGS
4.3. CONCLUSION
CHAPTER 5: OVERVIEW, THEORETICAL IMPLICATION,RECOMMENDATIONS, LIMITATIONS AND CONCLUSIONS
5.1. OVERVIEW
5.2. EMPIRICAL FINDINGS
5.3. THEORETICAL IMPLICATION
5.4. RECOMMENDATION FOR FUTURE RESEARCH
5.5. LIMITATIONS OF THE STUDY
5.6. CONCLUSIONS
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