The Duty of Loyalty and Whistleblowing Please respond to the fol.docx

"The Duty of Loyalty and Whistleblowing" Please respond to
the following:
· Analyze the duty of loyalty in whistleblower cases to
determine to whom loyalty is owed and who shows the greater
duty of loyalty. Support your analysis with specific examples.
Then, suggest at least one (1) change to an existing law.
· Reexamine the Citizens United decision in Chapter 1, and
determine which of the following groups has the greatest free
speech rights: corporations, public employees, or private
employees. Provide a rationale for your determination.
11 Combining Research Methods: Case Studies and Action
Research
Rebecca Jester
Introduction
In Chapters 7 and 8, we focused on the unique features of
quantitative and qualitative research. In this chapter, we aim to
demonstrate how research methods can be integrated and
combined to address specific research questions. The chapter
will provide an overview of two specific research designs:
action research and case studies, together with examples from
research projects conducted by the author. This chapter does not
aim to provide an in-depth philosophical debate related to case
study and action research approaches, but rather a practical
discussion of the merits, limitations and application of these
two approaches. We begin by discussing the concepts of ‘mixed
methods’ and ‘triangulation', first introduced in Chapter 2.
Mixed methods approaches
Traditionally, within health and social research, individuals
have aligned themselves with either the quantitative or
qualitative paradigm. However, in reality, many real world
research projects benefit from mixing or combining methods.
Mixed methods research can be accomplished either by using

specific approaches to research, such as action research or case
study, as discussed within this chapter, or by adopting a phased
approach within a study. This might involve the first stage
being exploratory within the qualitative paradigm, and the
results from this being used to form specific hypotheses for
testing within an experimental design, such as a randomized
controlled trial. Equally, a quantitative approach (say, a
questionnaire) might be used to gather data from a wide range
of people, with the results being used to develop a qualitative
interview schedule for use with a small sample of respondents.
Triangulation
Very often a research study is undertaken with multiple
datasets, mixed methodology or with different researchers, such
as at different sites. Triangulation is a very useful technique
that enables you to enhance and verify concepts. As Ramprogus
(2005, p. 4) suggests, ‘triangulation … tries to reconcile the
differences of two or more data sources, methodological
approaches, designs, theoretical perspectives, investigators and
data analysis to compensate for the weaknesses of any single
strategy towards achieving completeness or confirmation of
findings’. However, triangulation must be exercised with
caution; it is no substitute for robust and well-established
methods of establishing validity. Rather it is used to confirm or
affirm, and therefore verify findings.
Combining methods in practice
The author's research interests focus on applied clinical studies
related to the care and treatment of trauma and orthopaedic
patients. Applied clinical research often develops from the
identification of clinical problems and the need to develop
robust evidence to support practice, policies and protocols.
Often, clinical research questions necessitate the use of multiple
methods, which may include both quantitative and qualitative
approaches. Furthermore, if research findings are to be used to
underpin practice, and managers and health care professionals
are to be convinced to change practice based on research
evidence, it is important for them to be active partners in the

research process instead of being passive recipients of research
findings and decisions. Healthcare practitioners and managers
are bombarded with policy directives, efficiency targets and
new policy on a daily basis and often feel that the pace of
change is overwhelming. From observation, many practitioners
and managers are reluctant to engage in the process of
implementation of research findings because they do not
understand the research process or data analysis, or how to
interpret and implement the findings. We must strive, therefore,
to support healthcare professionals to be at least competent and
confident appraisers of research relevant to their practice.
Action research and case studies are two practical approaches
that put the patient/client and/or healthcare staff at the centre of
the research process, and indeed necessitate their active
participation. Being involved should help to demystify research
and improve understanding and translation into clinical
practice.
However, mixed methods approaches are not without their
challenges. Collins, Onwuegbuzie and Qun (2007) identify four
challenges to mixed methods research: representation,
legitimization or validity, integration and politics. The
challenge of integration of qualitative and quantitative
approaches is the most complex to tackle, and Collins et al. (p.
269) pose the question: ‘Is it appropriate to triangulate, expand,
compare or consolidate quantitative data originating from a
large, random sample with qualitative data from a small,
purposive sample?'
As researchers, we need to weigh the benefits of mixing
approaches within a single study against the challenges and
complexities that it involves. Most importantly, the approaches
taken must be justified as the most effective method of
answering the research question/s, and we must not permit our
individual biases toward particular paradigms to influence those
decisions. We now illustrate two ways in which methods can be
integrated within a single research design: action research and
case studies.

Action research
Action research has been used within the social sciences since
the 1940s. Kurt Lewin (1890–1947) is generally thought to be
the originator of the term ‘action research’ as a method of
researching a social system, while at the same time attempting
to change the system being studied. Many students and
healthcare practitioners are familiar with Kurt Lewin's work
related to change management theories and, specifically, force
field analysis (Value Based Management, 2009). This begins to
highlight the symbiotic relationship between generating new
knowledge through the research process and using this
knowledge to change practice or systems.
Action research is a form of enquiry that describes, interprets
and explains a social situation while at the same time
implementing an intervention aimed at change, improvement
and involvement. It is problem-focused, context-specific and
future-orientated, and founded on partnership between all
researcher(s) and participants (Waterman, Tillen and Dickson,
2001).
Action Point
From the description above, identify key words and concepts
that indicate action research may be a useful approach in
contemporary healthcare research. Think about the words you
have selected, and why.
Characteristics of action research
The words you have selected may relate to the key
characteristics of action research presented below, which are
adapted from Waterman and Hope (2008):
· • collaboration and participation;
· • developmental;
· • change and improvement;
· • practical and context specific;
· • cyclical;
· • involves reflection and reflexivity.
Within the context of contemporary healthcare research, most
funding bodies (such as Research for Patient Benefit; National

Institute for Health Research (NIHR), 2006) strongly encourage
or indeed insist upon research designs and approaches that
include the active participation of patients/service users/carers
and practitioners. There is an increasing realization that many
research studies do not influence clinical practice or policy, and
there is a need to increase emphasis on implementation of good
quality research. The cyclical nature of action research also
lends itself to healthcare, as there is a constant need to evolve
our evidence based practice and policy. There are several
models of action research, including the early action research
cycle developed by Kemmis and McTaggart (1982) which
includes: identification of the problem; investigation of problem
concepts and study of the related literature; designing the plan
of action to solve the problem; putting the plan into action and
monitoring changes to practice; reflection, changes and
modifications to the solution. This model is illustrated within
the case study of applied action research, later in this chapter.
Subsequent models include that of Hart and Bond (1995), which
includes: the stages of identifying a problem; using research
methods to assess the problem; planning and implementing
change; and evaluating the outcome of change.
Types of action research
Hart and Bond (1995) identify four types of action research:
· • experimental;
· • organizational;
· • professionalising;
· • empowering.
A number of authors, including Grbich (1999), purport that
these four types of action research run along a continuum,
whereby at the experimental end the researcher leads in all
aspects of research design and process and usually conducts the
study at the behest of senior managers within an organization
who perceive the need to ‘fix a problem’. The organizational
approach remains researcher-centric, but does include greater
negotiation and consultation with those working at grass roots,
that is, practitioners. Professionalising approaches begin to

embrace approaches to the design and process of the research,
where often the need to change practice through research is
identified by the practitioners and/or service users/carers
themselves, with the researcher acting as a guide and facilitator.
The empowering approach views the participants as co-
researchers who contribute equally to decisions about what the
problem is and which approaches of design and process are
needed. Ultimately, the empowering approach aims to lead to
emancipation of grass roots practitioners, service users and
carers, enabling them to break free from top-down approaches
to improve services and instigate change to policy and practice.
The empowering/emancipatory approach aims to foster a culture
of collective enquiry, reflection and problem solving. These are
important benefits, as once the action research project has
ended, change and continual improvement need to be sustained
by practitioners, managers and service users/carers.
Case Example 11.1: Pre-operative Fasting
The author, whilst engaged as a lecturer practitioner within a
specialist orthopaedic hospital, was approached by a number of
ward based nurses who were concerned about pre-operative
fasting policy and practice within the organization. The custom
was to withhold all fluids and food for patients from midnight
prior to surgery the following day, irrespective of what time the
patient was scheduled to have their surgery. A critical incident
where a patient's surgery was cancelled due to severe headache
bought on by dehydration prompted the nurses to raise their
concerns. The issue of concern was raised with the senior
consultant anaesthetist and the author, although a novice to the
technique, believed action research was the best approach to be
taken.
Kemmis and McTaggart's (1982) model of action research was
chosen to guide the process.
Identification of the problem
Patients were being starved for excessively long periods prior to
surgery. There were also frequent changes made to theatre lists
by surgeons, and often these changes were not communicated in

a timely manner to ward staff and patients. Nurses perceived
that post-operative nausea and vomiting were in part due to the
excessive fasting practices.
Investigation of problem concepts and study of the related
literature
The literature review revealed that it was safe for healthy adult
patients to drink clear fluids up to two hours prior to surgery
and consume food or milk up to six hours before. The researcher
then conducted a survey of fasting times, with a convenience
sample of 110 elective adult orthopaedic patients over a period
of one month. This survey revealed that the mean fasting time
was 11.94 hours and far exceeded the recommendations from
the literature review. The literature review had also highlighted
reasons why patients are starved for excessive periods pre-
operatively, including:
· • lack of knowledge by nurses about the physiology of gastric
emptying in healthy adults;
· • practice based on custom rather than on evidence based
research;
· • changing of theatre lists leading to uncertainty about what
time patients would be anaesthetized.
Designing the plan of action to solve the problem
In collaboration with the senior anaesthetist, three interlinked
actions were agreed. Firstly, anaesthetists were asked to start
prescribing the time patients could consume both food and
fluids. Secondly, the author implemented an educational
package for ward based nurses to improve their knowledge of
evidence based fasting practice (Jester and Williams, 1999).
Thirdly, pre-admission letters to patients informed them of the
new fasting practices and they were encouraged to drink clear
fluids up to two hours prior to their surgery, for example, at
6.30 a.m. for those on the morning list and 11 a.m. for those on
the afternoon list.
Putting the plan into action and monitoring changes to practice
Following a three month period during which nurses were asked
to report problems with the implementation of the new fasting

practices, a follow up survey was conducted on 106 adult
elective orthopaedic patients within the same clinical areas as
before. The follow up survey revealed that the mean fasting
time had reduced by 5.40 hours from the initial survey, but this
still meant that patients were, on average, not taking clear fluids
for around six hours prior to their surgery. The survey also
demonstrated that 60 of the 106 patients were prescribed a last
drink by an anaesthetist, while 46 were not. Of the 60 patients
who had a prescription for the last time of clear fluids, nursing
staff did not give the drink at the prescribed time to six patients
for the following reasons:
· • three patients were asleep and were not woken up for a
drink;
· • one patient refused the drink offered;
· • one patient had their position on the list moved up;
· • no reason was given for one patient.
(Jester and Williams, 1999)
Reflection, changes and modifications to the solution
This stage was used to explore why only 60 of the 106 patients
had been seen by an anaesthetist and had the last time for clear
fluids prescribed. This highlighted that for patients admitted on
the day of surgery, the anaesthetist often did not arrive at the
hospital in time to see patients before he/she needed to be in
theatre. Discussions with nursing staff also highlighted the fact
that frequent changes to theatre lists made nurses fearful of
encouraging patients to drink clear fluids up to two hours prior
to surgery. This was because surgeons would be unhappy if they
called for patients who could not go to theatre because they had
been given a drink. The reasons for frequent changes to the list
were investigated and this revealed that it was often because of
surgeons’ preferences, or occasionally because the correct
instruments were not available in theatre.
In this case illustration, it can be seen that action research was
truly cyclical because more work was needed to improve
communication between theatre staff and ward based staff.
Furthermore, improving efficiency around availability of

equipment was required, as was the need for the empowerment
of nurses to advocate for their patients’ rights.
Action Point
Reflecting on Case Example 11.1, what approach to action
research was adopted? (Take into consideration there may be an
amalgam of approaches.)
The approach taken in the worked example was predominantly
professionalising, as the clinicians identified the problem,
namely excessive pre-operative fasting periods for elective
orthopaedic patients. However, it can also be viewed as
adopting elements of the organizational approach, as the
research methods were determined by the researcher, rather than
in consultation with the clinicians.
Action Point
If you were replicating the study, what would you do
differently, and why?
To answer this question, you need to consider possible
limitations of the study and how these might be addressed.
Limitations appeared to include the following:
· • A further element of data collection was required at the stage
of ‘problem concepts investigated and related literature studied',
as the author did not explore the unique issues affecting fasting
practices within the organization. That is, there was an over-
reliance on the literature;
· • Not all staff groups were represented in the action research
process; specifically, there were no surgeons in the project team
and, because they were highly influential within the
organization, their support was needed to minimize changes to
theatre lists and to avoid conflict when nurses adopted the new
fasting policy;
· • There was no patient involvement; it would have enriched
both the data collected and the implementation of improved
policy to elicit patients’ views and preferences related to
preoperative fasting practice.
Limitations of action research
There are a number of criticisms of action research, which

include the emphasis on action and outcomes and the need to
instigate change, rather than to generate theory or a new body
of knowledge. Also, the researcher may have a conflict of
interest if the action research is at the behest of senior managers
(e.g. at the experimental/organizational end of the continuum).
However, action research is one of the few approaches that
offers the potential for clinicians, users and carers to be
engaged in all aspects of research design and process, which
greatly increases the chance that the findings of the research
will be implemented and sustained within the practice setting.
Case studies
Robson (2002, p. 178) defines a case study as ‘a strategy for
doing research which involves an empirical investigation of a
particular contemporary phenomenon within its real life context
using multiple sources of evidence’. Case study methodology
involves the in-depth recounting and analysis of experience. It
can be used to study phenomena in health and social care at an
individual level, such as one client or patient, or part of or a
whole organization, such as the trauma and orthopaedic unit or
an acute hospital. The researcher can adopt either a
retrospective (looking back) or prospective (looking forward)
approach to the case study. Yin (2003) proposes that case
studies are most useful when the researcher wants to ask how
and why questions. Case study is not an approach usually used
to test a hypothesis or determine cause and effect; it is mostly
concerned with the subjective richness of individual or
organizational experiences of a phenomenon (Zucker, 2001).
Thus, qualitative approaches to data collection and analysis are
often used. However, case study approaches can also adopt
quantitative approaches; for example, single-subject
experiments involve the individual or unit of research being
exposed to an intervention/treatment and data being collected
both before and after implementation of the treatment.
Furthermore, case studies can be used for exploratory,
descriptive or explanatory purposes; the specific approach taken
will depend on the nature of the research question(s) and the

degree of control the researcher has over the phenomena being
studied. Case studies are strong in reality and allow the
researcher to study the phenomenon within its social, political
and economic context.
Action Point
Suggest some data collection methods that would be suitable for
both prospective and retrospective approaches to a case study of
an individual or part of or a whole healthcare organization.
Some of these are summarized in Table 11.1.
Characteristics of case studies
Whether the case study involves an individual or part or all of
an organization, there are certain characteristics that must be
identifiable, which include:
· • clearly articulated research questions;
· • propositions;
· • unit(s) of analysis;
· • a determination of how the data are linked to the
propositions;
· • criteria to interpret the findings.
Title
ABC/123 Version X
1
Weekly Overview: Week 5
HCS/465 Version 2
2
Weekly OverviewWeek 5Overview
Week Five will explore the past, present, and potential future of
health care research. We will discuss health care changes that
have taken place over the last century and how evidence-based
research has changed the products, services, and practices of
health care throughout the industry. We will also look at how

external influences have shaped past and current research in the
health care industry.What you will cover
1. Past, Present and Future Perspectives in Health Care
Research
a. Explain how evidence-based research influences the health
care industry.
1) Mobile health technology
a) Mobile apps for medical records
b) Open notes (sharing clinician notes with the patient for
improved communication and transparency)
c) Electronic medical records
2) Tele-ICUs and Tele-medicine
a) Based on a study that found tele-medicine is broad and has
many different definitions
b) All sought to improve outcomes by increasing access to care
and medical information.
c) The purpose of tele-medicine and tele-ICUs is to:
(1) Provide clinical support
(2) Overcome geographical barriers
(3) Overcome financial barriers
(4) Improve health outcomes
3) Disease Prevention and Control

a) Promotes conversation among those in the medical field and
policy makers as to how to prevent disease
b) Advancing discoveries:
(1) Prevention of chronic illness and disease
(2) Exploration of new treatments
4) Economic Impact
a) State funded research completed by medical school and
teaching hospitals added almost $45 billion to economy
b) Direct impact includes institutional spending and how that
money is put back into the hospital, research, patients, advocacy
groups, and the community
5) Medicine/Health, Care/Health, and Wellness
a) Awareness of severe shortage of up-to-date scientific
research and the subsequent need for this research
b) Positive discoveries and treatments:
(1) Adamantanoma of the tibia (rare form of cancer) in Ethiopia
(2) Introducing evidence based development for long-term
health care in the Sudan
(3) Improvement in maternity care and reduction of infant
mortality rates in Zimbabwe
6) Facility Design
a) Promotes patient safety

b) Decreases the risk of Hospital Acquired Infections (HAI’s)
b. Compare external influences on health care research.
1) Political Influences
a) The Affordable Care Act (2010)
(1) The Affordable Care Act will expand coverage to over 30
million people
(2) Staff shortages (distribution shortfall) due to decreased
government reimbursement
(3) Medical professional right of conscience: The Affordable
Care Act does not protect health care employees to the degree
that they feel comfortable
b) The Doc Fix Bill (April 2015)
(1) Without this bill being passed, Medicare reimbursements to
physicians would have been cut by 24%
(2) The Doc Fix bill fends this action off for another year
2) Social or Public Influences
a) Advocacy groups
(1) Raising awareness
(2) Lobbying
(3) Right to Die (Death with Dignity Act)
b) Social groups

(1) Determining when people with serious illnesses need seek
advocacy or support
(2) Examine how people seek advocacy or support, look at
expectations of patients and caregivers
(3) Learning about how patients’ experiences and identify
elements of advocacy support that are the most useful
3) Financial Influences
a) Impact of Medicare on health care and patients
b) Impacts cost of care
c) Socioeconomic factors in specific demographics
d) Allocation of funds
4) Ethical Influences
a) Balancing care quality and efficiency
b) Improving access to care
c) Building and sustaining the health care workforce
(1) Workers who are competent and compassionate
(2) Ability to practice with integrity
(3) Not being overburdened by morally distressing situations
that cause burn-out or compassion fatigue
d) End of life issues
e) Allocating limited medications and donor organs

Copyright © XXXX by University of Phoenix. All rights
reserved.
Past, Present and Future Perspectives in Health Care Research
Textbooks:
Roberts, P., & Priest, H. (Eds.). (2010). Healthcare research: A
textbook for students and practitioners. Hoboken, NJ: Wiley-
Blackwell.
Cunningham, C. J. L., Weathington, B. L., & Pittenger, D. J.
(2013). Understanding and conducting research in the health
sciences. Hoboken, NJ: Wiley & sons.
Instructions: Please ensure to substantiate your response with
scholarly sources or a personal account of your own experience
in the work place. Cite and reference work! 150 to 175 word
count.
1. This overview begins an important discussion of what is
likely to be in your future as HealthCare Administrators. As you
read this doc, what do you believe will be 2-3 of the most
impactful changes in healthcare in the next 5-10 years??
Thoughts on this? See attached Weekly Overview- WK 5
2. Please highlight what you found most interesting about
Chapter 11. See Chapter 11 attached
3. Look at chapter 11 attached: Case Example 11.1: Pre-
operative Fasting-- this case offers a good perspective on how
communication amongst caregivers impacts the quality of
patient care. Communication is the foundation of our work in
Healthcare-- assuring the best possible outcomes for those
entrusted to our care. What do you think of the example
presented, its outcome & importance as regards the care of

those undergoing anesthesia for surgery? What do you think of
the research process presented?
4. Read and discuss the article: Health care reform by Roehr,
Bob (Jul 2008)
http://search.proquest.com.contentproxy.phoenix.edu/docview/2
31206765/fulltext/781B6DF24EFD4F3DPQ/3?accountid=458
5. Read and discuss the Improving Health Care Quality:
http://archive.ahrq.gov/research/findings/factsheets/errors-
safety/improving-quality/improving-health-care-quality.html
6. Chapter 8: Health Services Research: Scope and Significance:
When you review this document, kindly add your impressions.
How useful is this info now & how useful will it be to learn this
for your future as a HealthCare Administrator??
http://www.ncbi.nlm.nih.gov/books/NBK2660/
7. Read the paper "What Factors Influence National Health
Research Agendas in Low and Middle Income Countries?"
http://www.cohred.org/downloads/cohred_publications/rp5.pdf
8. Discuss your thoughts- Watch the segment "Public Demand
Versus Research Protocol" in the MS Wars: Hope, Science, and
the Internet.
http://fod.infobase.com/p_ViewVideo.aspx?xtid=52229
9. Explore the impact of NIH research page of the National
Institutes of Health website. Discuss your thoughts.
http://www.nih.gov/about-nih/what-we-do/impact-nih-research
10. Identify one innovation that has been developed in the last
20 years that has influenced the health care industry such as:
· Tele-Medicine

· Organ Transplants
· Use of Hospitalists for In-patient Hospital Care
· Use of Robots during surgical procedures
· Other examples--- obtain approval from Faculty --add your
example here for discussion & approval
Write a 700- to 1,050-word paper that discusses the following:
· Explain how evidenced-based research influences the health
care industry
· Discuss how your example has improved (or not) healthcare
delivery
· Discuss one external influence on healthcare research
Format your paper according to APA guidelines. Cite 2 peer-
reviewed, scholarly references to support your paper.

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