CHAPTER 3: METHODOLOGY

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1 The purpose of this chapter is to build your case as to why grounded theory is best methodology to inquire into your research purpose. It has a number of features to cover: 1. It needs to explain what types of methods have been used by others to explore similar type research purposes, and build the case as to why these are not the most ideal to inquire into YOUR research purpose 2. It needs to present a comprehensive and concise overview about what grounded theory is. To do this you must demonstrate understanding of: a. The epistemological purpose of grounded theory research and how it differs to other inductive methodologies b. Different types of grounded theory methodologies and a justification of which best suits your research purpose. Once you have chosen, then stick to this particular formulation and do not deviate. c. The process of doing grounded theory research in relation to the grounded theory tradition you have selected. 3. If you are doing a professionally based research project, you will need to address the role of professional/personal insight, as highlighted in bold. CHAPTER 3: METHODOLOGY INTRODUCTION The previous chapters identified three main themes as being relevant to this research. Firstly, that different discourses of health care ethics contain differing ways of framing and focusing knowledge of health care ethics. Secondly, that the implications of pre-framing and pre-focusing knowledge is that knowledge generation is grounded within a priori disciplinary preconception and ideas about what health care ethics ought to be about. Thirdly, that social scientific methods of inquiry into health care ethics enables a better analysis and understanding of social processes that focus and frame health care ethics. This involves asking about how matters become an ethical concern, how they are attached to particular forms of activity, what ideologies and knowledge has arisen around this activity. These three themes are important in how we understand the education of health care ethics because different discourses about health care ethics contain differing ideas about how to understand and inquire into health care ethics, which contain both implicit and explicit ideas and values about its purpose (Gerwitz and Cribb, 2010). Empirical work into health care ethics is a useful means to explore and reduce the gap between academic ideas about ethics and the practical experience of lived ethics (Gerwitz and Cribb, 2010). Importantly it can provide a richer and more relevant account of ethics that does more than simply add to academic thought. The value of empirically informed ethics therefore is to provide a richer naturalistic ethics, and one that leads to a more relevant thinking about health care ethics that is not preframed within a priori assumption. As there is limited insight into how academics know about

2 and convey understandings about health care ethics, the purpose of this research is to empirically inquire into how academics focus and frame their understanding of health care ethics. The purpose of this chapter is two-fold. Firstly, it is to discuss in more detail the value of using empirical research in inquiry into health care ethics, and secondly to justify the selection of grounded theory methodology as being the most appropriate methodology to this inquiry.

3 EMPIRICAL RESEARCH INTO HEALTH CARE ETHICS Empirical inquiry into the concepts of ethics is a developing, but not new field (Sugarman, Pearlman, and Taylor, 2007). Examples include Davis (1960) who found that doctors feigned uncertainty in polio patients prognosis in order to ensure compliance with the prescribed treatment regime. Quint (1965) found practices of information control in order to prevent patients from knowing their diagnoses. Glaser and Strauss (1965) described how doctors maintained closed awareness contexts for dying patients which constrained patient choice to such an extent that Friedson (1975) identified it as a threat to individual liberty. Anspach (1993) found that poor decision-making in bioethics mapped onto how ethical problems developed over time in neonatal units, and Zussman (1997) found that the ethical concerns of bioethicists had little impact on the daily work of staff in intensive care units. Chambliss (1996) forwards a social organisation of ethics in which nursing ethics is presented as a power struggle between nursing and medical staff, with nursing (the less powerful) using the moral argument as a means of achieving control. Chambliss concluded that ethical problems are structurally created within organisations and it is the social context in which ethical questions are formed. There are various approaches to doing empirical ethics, such as pragmatic hermeneutics (Widdershoven and Van der Scheer, 2008), phenomenological and naturalized accounts of empirical ethics (Lindemann,Verkerk and Urban Walker, 2009). However variance as to how to do empirical ethics has led to empirical ethics being questioned by both philosophers and social scientists. Philosophers, on the one hand, criticise empirical ethicists efforts to develop prescriptive conclusions from descriptive evidence (Harris, 2001; Garrard and Wilkinson, 2005) and on the other hand, social scientists criticize empirical ethicists poor understanding of complex methodologies and methods developed from within the social science disciplines (Ashcroft, 2010, Hedgecoe, 2004; Hurst, 2010). There have also been several attempts to categorize types of empirical ethics. One of the first authors in the field, Hope (1999), suggested six ways and Sugarman and Sulmasy (2001) listed eight approaches to using empirical work in ethics 1. Jacoby and Siminoff (2008) provide a useful means of grouping empirical work into four types, as follows. The first and most common type of empirical research is the linear model (Lindemann Nelson, 2000). These studies seek to define current practices, opinions, beliefs, can be descriptive or 1 Debate as to the purpose of empirical ethics, and the role of empirical ethicists has been debated in the thematic issues of The American Journal of Bioethics and Bioethics have dedicated thematic issues to empirical ethics. In the former Kon (2009) constructed four categories and in the latter, Molewijk,Stiggelbout and Ottem et al. (2004) distinguished five types of ethicists: prescriptive applied ethicists, theorists, critical applied ethicists, particularists, and integrated empirical ethicists 1.

4 explanatory in nature, and may or may not be hypothesis-driven and set the stage for further research and direct efforts in improving care. Such studies ask questions such as How many people are willing to make advance directives? or How do people with chronic illness experience their illness? (Lindemann Nelson, 2000). This includes looking at attitudes from different perspectives (e.g. nurses, physicians, patients, and families) and laying the groundwork for future inquiry, assessing projects designed to bring these perspectives in line with one another, the efficacy of end-of-life care programmes, and studies that seek knowledge that might help people who need to make difficult choices. A second approach is the social science critique. This type of research demonstrates that the reality of practice does not always match the theoretical ideal and identifies gaps between ethical ideals and the reality of health care. For example, research into medical error found that providers often fail to disclose errors to patients (Gallagher, Waterman and Garbutt., 2006). The third approach of empirical inquiry considers how to bring practice closer in line with ethical ideals. Whilst much work has focused on the first two types of research, there is relatively little research into the effects of potential solutions. This type of research builds on previous work, designing and testing methods to help professionals care for patients in ways that are more consistent with ethical norms. For example, Dixon-Woods et al. (2007) demonstrated significant shortcomings in the use of any written consent documents, raising the question of whether merely altering a form could ever sufficiently improve the consent process. The final approach integrates social science data into health care ethics (Haimes, 2002; Hedgecoe, 2004). This fourth type builds on the work of the previous three types of research through systematic analysis of multiple empirical publications to form the basis of an argument to change an ethical norm. These approaches to empirical inquiry each have a purpose in the understanding of health care ethics, but importantly, they address the difference between the theoretically constructed ethics and the ethics as lived. There is some conflict however, as to whether empirical research can only descriptively illuminate current practice and not inform normative ethics in a meaningful sense. This makes social science inquiry subservient to normative ethics because the research is used to provide data for the ethicists to use (Zussman, 2000). In this sense, empirical research functions to support predetermined philosophical argument, leading to the claim that empirical ethics is the handmaiden of philosophy (Haimes, 2002). Others assert that empirical inquiry into the concepts of health care ethics does have significant implications for refining ethical norms. Here, empirical methods seek to ascertain whether a particular philosophical argument brings about the changes to practice that cohere

5 with the argument. Turner (2009a) argues that there should be inquiry into the subject of bioethics, but that there can also be some inter-disciplinarity between philosophers and empiricists in order to develop a more responsive and considered health care ethics. Alternatively, De Vries (2007) calls for a distinctive empirical base from which the concept of health care ethics is the object of scrutiny. Evans (2003) further argues that inquiry into health care ethics should be distinct from its normative base. Evans identifies two types of rationalisation of bioethical evidence; a thin rationalisation which asks what a doctor or a patient would do in a similar situation given the universal ends of (for example) the four principles, as often found in the more descriptive lay of the land type studies, or a thick rationalisation based on values and heterogeneity which are publicly debatable. Evans argues that there are few studies that aim for a thick rationalisation because research methodology is bound within pre-conceived frameworks, which in turn reproduces and validates that particular framework. To explain the relationship between empirical and theoretical ethics, Dunn and Sheehan et al. (2012) argue that both the theoretical and empirical try to put forward arguments that aim to convince and be convincing. To be convincing, a recommended course of action cannot be presumed to be right on this account alone but must also be prescriptive, or recommend some course of action. To do this, individuals experiences and understandings must be depicted as good or bad, right or wrong, or ethically acceptable or problematic. This is done using a number of strategies; if a quantitative approach is used, a claim can be made about the majority view, and arguments held by a majority or minority using statistical analysis and generalization of findings can be documented. If a qualitative approach is used, claims relating to thick descriptions of the ethical dimensions in context can be made. These strategies of convincingness are bound within the epistemological foundations of the methodologies developed to validate empirically derived arguments. This internal methodological validity can be identified in the strategies, or frameworks of inquiry, used in the empirically driven accounts of empirical ethics. Attempts to convince the audiences of the persuasiveness of these arguments might include claims about the generalisability or representativeness of the data, the use of techniques to ensure analytic rigour and the management of subjectivity and the constructed nature of social reality through reflexive research methods. Dunn and Sheehan et al. (2012) however state that both philosophical and empirically driven ethics fail to do so; philosophical arguments fail because they do not properly engage with the context in which the claim is intended to have effect and empirical evidence fails because of its failure to engage adequately with normative argument and their criteria of validation. Importantly, what academics such as Turner (2009b), De Vries (2007)

6 and Dunn et al. (2012) highlight, is the problematic nature of inquiry that stems from a priori foundation. It is therefore important to consider both the disciplinary foundations and research lens through which knowledge generation about health care ethics is conducted, and to expose a priori assumption that the lens casts upon the process of knowledge generation. The value of empirical research should rather be based on methodological appropriateness and rigour rather than the disciplinary affiliation of the researcher. This requires the researcher to be open about any a priori disciplinary or empirical assumptions and preconceptions, and to select the most appropriate methodology that best provides the tools to inquire into the research phenomena. The remainder of this chapter therefore seeks to provide a more practical narrative about potential preconceptions in relation to the purpose of the research and my role as the researcher. METHODOLOGY Ways of thinking about phenomena contain ontological, epistemological and theoretical assumptions that link the research aims, methodology, methods and analysis. Generally, assumptions that guide the research process fall into paradigms (a set of ideas about how we might study and explain the world). Denzin and Lincoln (2005) identify five paradigms within which the generation of research and knowledge operates; positivism, interpretivism, realism, post-positivism and critical realist. These terms are used primarily by methodologists and social theorists to describe and evaluate the theoretical assumptions underlying different approaches to research, but in research practice, they are not always distinctly divided, and few researchers describe themselves as being only a positivist, interpretivist or realist researcher (Denzin and Lincoln, 2005). Many studies use a combination of positivist, interpretivist and realist ideas, and generally produce either qualitative or quantitative data. Quantitative inquiry sits within the positivist tradition, is objectivist in its ontology and seeks meanings that are deductive and objective (Bryman, 2008). Qualitative inquiry sits within the interpretive tradition which views social phenomena as socially constructed and research in this paradigm is concerned with understanding phenomena through the meanings people attach to experiences (Greenhalgh, 2001). The ontology and epistemology accepted in this research assumes that knowledge is not static, but as emergent and transforming. It is accepted that for research to be relevant, researchers should use methods that conceptually explain what is going on in the substantive context. Grounded theory, (Glaser and Strauss, 1967), provides a methodology that enables concerns of social participants to emerge in context (Charmaz, 2006 and Goulding, 2002) and is therefore useful for studying topics of a social nature.

7 GROUNDED THEORY A central premise to this inquiry is that there is a need to question how knowledge about health care ethics is conveyed. Underpinning this is the assumption that disciplinary knowledge is bound within a priori assumption about that knowledge. It is important therefore to identify a methodology that is not wholly pre-framed and which allows evidence to emerge without being pre-defined by the discipline, research paradigm or researcher. Grounded theory provides a methodology that uses method which is not pre-bound within epistemological or disciplinary pre-conceptions. It is a methodology that allows for patterns in the data to explain the research question. This is important to this research because the purpose is to explore how academics convey understandings of health care ethics. Grounded theory is an inductive methodology that systematically collects and analyses data in order to generate theory about patterns of human behaviour in social contexts. Glaser (2005) writes that this theory is intended as an alternative to paradigms: [Grounded Theory] is not an either/or method. It is simply an alternative to positivistic, social constructionist and interpretive qualitative data methods (Glaser, 2001, p. 6). The value of this methodology is that it steps back from preconceived disciplinary values and known paradigms by taking a neutral view of behaviour in a substantive context (Simmons, 2006). The methodology does not attempt to understand social phenomena as the individual participants in that social phenomena see it, but rather it uncovers patterns in their experiences. The focus of grounded theory methodology is on social processes or actions, by asking about what happens and how people interact in the social context, it seeks to uncover patterns in social life that participants might or might not be aware of. This makes the data the focus of analysis, which is analysed to illuminate patterns and social process in that data that explains the research question. As such, it is a methodology that develops data from simple description through to conceptualisation in order to explain the social phenomena in question. It is therefore a practical pattern finding method that reduces interpretation through an a priori theoretical framework or the subjective interpretation of the researcher. Because of these features, grounded theory methodology is useful to address the critique that empirical inquiry is descriptive and subservient to philosophically driven inquiry, or that empirical inquiry is theoretically bound within preconceived ideas about the phenomena, either through the lens of the research framework or the researcher.

8 However, doing grounded theory is difficult, and there are few practical examples about how it should best be done. The grounded theory tradition is diverse. Part of this problem is a lack of clear understanding about its foundations as a research method and confusion about different types of grounded theory. The differences between Glaser and Strauss are well documented and the general feeling is that they emerged after the publication of Strauss and Corbin s Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory (1990). This text introduced different terminologies and complex coding procedures to make grounded theory more tangible (Strauss and Corbin 1990, Goulding, 2002). Glaser (1992), however, observed that Strauss changed the premise of grounded theory through forced, full, conceptual description (Glaser, 1992) resulting in a different methodology that is not actually grounded theory. For Glaser (2001), grounded theory should only explain the phenomenon under study, and by using the coding matrices as featured by Strauss and Corbin, only conceptualisation based on the researchers preconceptions will be developed, rather than theory as grounded in data which is the overall purpose of grounded theory (Glaser, 1992: 123). There is much discussion in the literature about what characteristics a grounded theory study must have (Morse, Stern and Corbin,. 2009), and the main differences between Glaser and Strauss s later grounded theory are presented in Figure 1. FIGURE 1: COMPARISON OF THE TWO SCHOOLS OF GROUNDED THEORY Glaser Begins with a general idea of where to begin Neutral questions Development of conceptual theory Theoretical sensitivity (the ability to perceive variables and relationships) from immersion in data Theory grounded in data A basic social process should be identified The researcher is passive exhibiting disciplinary restraint Data reveals theory Coding of data and the constant comparison of data enable patterns to emerge. Strauss Begins with a general idea of where to begin Structured questions Conceptual description (description of situations) Theoretical sensitivity from methods/tools Theory as interpreted by the observer Basic social processes need not be identified The researcher is active Data is structured to reveal the theory Coding is defined by technique leading to micro analysis of word by word data

9 Two coding phases: simple (fracture the data and group) and substantive (open or selective to explore emergent patterns) to develop concepts that explains the phenomena Regarded as the true grounded theory Three types of coding: open (identifying, naming, categorizing, describing phenomena); axial (the process of relating codes to each other) and selective (choosing a core category and relating others categories to it) Regarded as a form of qualitative data analysis (QDA) rather than grounded theory Although there are differences between Glaser (1967) and the Strauss models, it is worth identifying that grounded theory was not meant to be used as a prescriptive framework. Rather the original intentions were to keep the discussion open minded and to stimulate rather than freeze thinking about inquiry in the social sciences (Glaser and Strauss, 1967). This in turn has led to grounded theory being re-interpreted and as leading to other types of grounded theory such as Charmaz's Constructivist Grounded Theory, Clarke's (2005) postmodern situational analysis, a realist or adaptive approach (Layder, 1998), a hermeneutics approach (Rennie and Fergus, 2006) and a feminist approach (Weust and Merriet-Grey, 2005). Whichever is preferred, what is important is that the researcher is clear about which type of grounded theory to use in relation to their research purpose, and to understand the differences between the selected grounded theory and the original grounded theory, and remain true to the type of grounded theory they select. If not, there is a risk of confusion and dilution of the grounded theory, affecting the credibility of the research. This research uses Glaser and Strauss s original grounded theory because of the more open approach to data analysis it provides (Stern, 2007). Glaser s approach is favoured for this research because of the systematic process of data collection and constant comparison that allows patterns grounded in the data to emerge (Glaser, 1978). It is a methodology that is not used to test or reaffirm existing theory, and is useful when little is known about a social phenomenon and/or to provide a fresh slant on current understandings (Goulding, 1998). Because there is little existing consideration about how academics convey disciplinary knowledge in health professional education, and because an underpinning premise to the rationale of this work is to explore what informs disciplinary preconceptions, grounded theory is useful because it is not tied to any one epistemological stance. THE GROUNDED THEORY PROCESS The fundamental components of a grounded theory study are set out in Figure 2. Figure 2 is developed from ideas about grounded theory in the literature and personal notes taken at the grounded theory seminar I attended in July These components may appear in

10 different combinations in other qualitative studies; however a grounded theory study should have all of these. Figure 2: Fundamental components of a grounded theory study Component Stage Description Literature Sources Openness Throughout the study Grounded theory methodology emphasises inductive analysis. Induction moves from the particular to the general: it develops new theories from many observations. This means that grounded theory studies tend to take an open approach to what is being studied. The emphasis of a grounded theory study may evolve as it becomes apparent to the researchers what is important to the study participants. It is important for the researcher to be reflexive in their reasons for undertaking the research, and how they might shape the data collection, analysis and findings. This is important to develop the quality and credibility of the emergent grounded theory. Bryant and Charmaz (2007) p1-3; Charmaz (2006) p2-6; Clarke (2005) p4-21 Analysing immediately Analysis and data collection In a grounded theory study, the researchers do not wait until the data is collected before commencing analysis. In a grounded theory study, analysis must commence as soon as possible, and continue in parallel with data collection, to allow theoretical sampling (see below). Bryant and Charmaz (2007) p12,13, 301; Glaser (1992) p102; Charmaz, (2006) p20 Coding/ comparing Analysis Data analysis relies on coding - a process of breaking data down into much smaller components and labelling those components - and comparing - comparing data with data, case with case, event with event, code with code, to understand and explain variation in the data. Codes are eventually combined and related to one another to become abstract, and Bryant and Charmaz (2007) p. 80,81, Glaser and Strauss, (1967) p Charmaz, (2006) p42-71

11 are referred to as categories or concepts. Memowriting Analysis The researcher writes memos throughout the project. Memos can be about events, cases, categories, or relationships between categories. Memos are used to stimulate and record the researchers' developing thinking, including the comparisons made (see above). Bryant and Charmaz (2007) p ,281, 282,302. Glaser and Strauss, (1967) p108,112. Charmaz, (2006) p72-95 Theoretical sampling Sampling and data collection Theoretical sampling is central to grounded theory design. A theoretical sample is informed by coding, comparison and memo-writing. Theoretical sampling is designed to serve the developing theory. Analysis raises questions, suggests relationships, highlights gaps in the existing data set and reveals what the researchers do not yet know. By carefully selecting participants and by modifying the questions asked in data collection, the researchers fill gaps, clarify uncertainties, test their interpretations, and build emerging theory. Bryant and Charmaz (2007) p304, 305, 611. Glaser and Strauss, (1967) p Charmaz, (2006) p Theoretical saturation Sampling, data collection and analysis Qualitative researchers generally seek to reach saturation in their studies. Often this is interpreted as meaning that the researchers are hearing nothing new from participants. In a grounded theory study, theoretical saturation is sought. This is a subtly different form of saturation, in which all of the concepts in the substantive theory being developed are understood and can be substantiated from the data. Bryant and Charmaz (2007) p306, 281,611. Glaser and Strauss, (1967) p Charmaz, (2006) p114, 115 Production of a substantive theory Analysis and interpretation The results of a grounded theory study are expressed as a substantive theory, that is, as a set of concepts that are related to one another in a cohesive whole. As in most social science, this theory is considered to be fallible, Bryant and Charmaz (2007) p14,25. Glaser and Strauss, (1967) p Charmaz,

12 dependent on context and never completely final. (2006) p The first component in Figure 2 identifies the need for the researcher to be open during the research process. In grounded theory, this means being sensitive to what is happening in the research area in order allow issues of importance to the social participants to be exposed during the simultaneous data collection and analysis process and therefore requires the researcher to be sensitive to the ways in which the researcher and the research process have shaped the data collection and data analysis. Central to this is possible prior assumptions and experience, which can influence inductive inquiries. Dey (2007) forwards that the researcher s background and experience provides informs how we respond to the data, and that research findings are a product of the data, plus what the researcher brings to the analysis. From my capacity as a lecturer in health care ethics in health professional education programs, I have some knowledge and experience of the phenomena under consideration, and it is because I feel there is a lack of understanding about it that this research has been instigated. This was identified in the prologue, and is further discussed and is further identified in the following chapter. Grounded theory generates two types of grounded theory: a substantive theory and a formal theory (Glaser and Strauss, 1967). A substantive theory is grounded in data in a specific area of investigation and traces patterns amongst a few cases, finding concepts that specify patterns in that context. Formal theories aim to provide a generic conceptualization that applies to a broader population experiencing a common phenomenon. It is formed through the testing of substantive theory across various different contexts and incorporates the systematic review of grounded theory studies in relation to that phenomenon. This research aims to generate a substantive grounded theory about how academics know about and convey their understandings about health care ethics in the higher education context. A grounded theory approach aims to develop an abstract conceptualisation about social phenomena in both the substantive context, but one that also has potential formative application. Grounded theory is a useful methodology in doctoral inquiry because it provides the opportunity to demonstrate critical and independent reasoning, the ability to conceptualise, design and implement research methodologies and to provide unique insight into specific social phenomena. However, although grounded theory meets these requirements, it is not

13 an easy methodology to understand and use properly. As with most research methods grounded theory has it criticism. CRITICISM OF GROUNDED THEORY The foundational roots of grounded theory have been questioned. The practical development of the theory is detailed in the The Discovery of Grounded Theory (Chapter V). This original construction of grounded theory can be confusing, and when it is considered, tends to be done so in terms of the disciplinary backgrounds of Glaser and Strauss. Glaser s background was in positivism (the term co-variable is a quantitative term) and Strauss s background was in symbolic interactionism. However, Glaser and Strauss originally argued for a move from positivism and criticised symbolic interactionism (Suddaby, 2006) and were highly critical of both types of research, noting that monographs based on qualitative data consisted of lengthy, detailed descriptions that resulted in very small amounts of theory and quantitative research as confirming existing theory rather than testing or challenging theory (Glaser and Strauss, 1967). Neither Glaser nor Strauss has written that the perspectives of those studied should be voiced unless they were subsumed into the over-arching goal of theory development. Rather, they say that the researcher is an active sampler of theoretically relevant data, not an ethnographer trying to get the fullest data on a group (Glaser and Strauss 1967). Pre-framing grounded theory through a theoretical lens, such as symbolic interactionism, precludes other perspectives and pre-determines what data will be collected and used, how it should be collected and limits the analyst s conceptual abstraction from the data. Glaser and Strauss s aim was rather to systematise qualitative research in order to obtain the best of the method (Glaser and Strauss 1967). Grounded theory was developed as a response to the quantitative and qualitative practices of the time, to respond to positivistic, preconceived research that pre-imposed theory onto social phenomena at that time, and to make qualitative research more robust (Glaser, 2001). The idea of the grounded theory methodology developed in the 1950 s from Lazarsfield s 2 consideration of what makes good quantitative research. Lazarsfield identified that preframed quantitative studies of social class, voting and unemployment was showing theory to be incorrect, and so started to correct theory in line with research based on the data. From this, Lazersfield started to amend and develop the theory based primarily on the data, and on data that was based on sound methodology. This though was not grounded theory, as Lazersfield was correcting existing theory against existing data. Glaser and Strauss took Lazersfield s approach a step further by collecting qualitative data in a substantive area 2 Lazersfield was founder of the Columbia University Bureau for Applied Social Research.

14 without pre-framing the research within existing theory or a preconceived framework, but used the data to develop theory. The important premise underpinning grounded theory methodology is that grounded theory is not necessarily always free from theoretical frames, but rather that it does not have to be confined to any one lens (Grounded Theory Institute Seminar, 2011). It is also important to recognise that Glaser considers all research as interpretive in the sense that all research has some means of pre-determined data collection, analysis and validation. The most important question here is not what pre-imposed framework the research sits in, but rather when does interpretation kick in? (Grounded Theory Seminar, July 2011). For Glaser, grounded theory is about finding out how people resolve dilemmas. If grounded theory is to be pigeon-holed into a framework, it should be within an inductive framework because grounded theory aims to conceptually explore how people make sense of social phenomena and how people best resolve dilemmas. If grounded theory is forced into a pre-conceived epistemological or theoretical framework, there is a risk that pre imposed ways of thinking will force the data collection and analysis. If this is the case, the research is not grounded because it has been pre-conceived by the researcher which pre-empts inquiry. What grounded theory does is to allow relationships in data to be conceptualised into explanations about what is happening in the data, the main concerns expressed by participants in the data and how these concerns are overcome. Grounded theory therefore provides a methodology to develop an understanding of social phenomena that is not pre-formed or pre-theoretically developed. The place of theory in grounded theory features in the critical consideration of grounded theory, and is very much linked to the previous discussion. Glaser and Strauss (1967) called the method grounded theory because a theory can be systematically obtained from quantitative and qualitative data to generate a theory that accounts for a pattern of behaviour which is relevant and problematic for those involved (Glaser, 1978, p.93). However, why theory is seen to be the desired result is not so clear and there is a lack of clarity about what theory means in relation to grounded theory. Detailed discussion of theory is beyond the scope of this chapter, but broadly speaking, ways of talking about theory relate it to varying levels of grandeur and explanatory power. In everyday language, theory refers to a speculative view, idea or hunch. Within the context of research, theory has more specific meanings and different definitions that commonly relate to different levels of theory (Pellegrino, 1974). Alternatively, Fish (1989, p ) writes that theory can broadly be about (i) patterns and (ii) explanation and prediction. Mouzelis (1995) suggests that the distinction between patterning and explanation/prediction has been blurred, and points to two types of theory used by social scientists; (i) theory as a tool for thinking and (ii) theory as

15 a set of statements that tells us something about the social world which might be seen through empirical examination. In the former sense, theory is about bringing ideas together, while in the latter sense it relates to generalisation following systematic and extensive data collection, and testing of the generalisation for the purpose of verification and falsification. Here grand theories say something about the nature of reality (ontology) and the nature of knowledge (epistemology), where macro-theories focus on local systems (e.g. symbolic interactionism, socio-cultural learning theory) and micro-theories relate to action at the level of the individual. Grounded theory aims to produce theories that explain social phenomena and these explanations can be substantive (micro) or formative (macro) (Glaser and Strauss, 1967). The theories developed through grounded theory analysis are akin to models that explain how social participants go about resolving their main concerns. They are meant to be illuminative of social practices that are not always overtly evident, and it is through the systematic data collection and analysis process that patterns emerge and can be refined to present a working model. This working model can then be used to consider what change could occur in the social context, but only if these patterns are seen. Grounded theory therefore is an empowering process that can be used to inquire in to social practices, and this is possibly why it has been accepted in the health and education professions. Another problem with using grounded theory in doctoral research relates to Glaser and Strauss s assertion that the researcher should not look at the literature before entering the research field as this may result in pre-conceptions and pre-imposed frameworks that can contaminate the data collection and analysis process. This is because the emergent concepts can only emerge once the data collection and analysis has started. It is then that the literature can be explored in relation to the emergent concepts. Goulding (2002), however, states that this does not necessarily mean that the researcher is expected to enter the field ignorant of any theory or associated literature relating to the phenomenon, and Andrews (2006) and Ekstrom (2006) identify two types of literature review that can be used in relation to grounded theory. One is in an area that puts the study in some sort of context; the other is to use literature as data to fully integrate the theory (Andrews, 2006). The literature in this research has been used to present a contextual literature review of the most relevant concepts related to the education of health care ethics. An integrated literature review, which considers literature in light of the emergent grounded theory, is presented in chapter six. There are also few examples of how to do grounded theory in the literature (Morse, Stern and Corbin, 2009) and those that do exist have focused on Strauss and Corbin's methods (Wasserman, Clair and Wilson, 2009). An exception is Charmaz's description of her study of

16 chronic illness. Many research studies also label their work grounded theory but do not follow the basics of the methodology (Dixon-Woods and Booth and Sutton, 2007), although this may be because there are few practical examples of grounded theory in use in the literature. VALUE OF GROUNDED THEORY Grounded theory starts from the premise that empirical inquiry should explore social phenomena by looking at what people experience, what problems there may be, and how they go about resolving those problems. Grounded theory in essence seeks to present substantive theories that reflect what people experience and what people do. To do this, grounded theory methodology looks for patterns in the data using a specific method of data collection and analyses. It is an inductive methodology in that it is led and guided by the experiences of people in the inquiry, and the findings reflect patterns in those experiences. This is important because grounded theory methodology does not seek to pre-impose theoretical notions about what/how social phenomena should be viewed. This differs from other types of qualitative inquiry, for example, in ethnography, there are collective assumptions in the knowledge base of what ethnography is, and ethnographers act within the implications of those assumptions. This means the researcher is pre-imposing ideas about how social phenomena is to be understood through the lens of ethnography, but this might not necessarily be what is going in that social phenomena. A similar parallel can be drawn with theoretical constructions about ethics: normative ideas about ethics reflect disciplinary based notions about ethics, as opposed to what might be happening in an ethical encounter. Empirical ethics is a step towards understanding how ethics plays out in the social context, however it is bound within two differing sets of assumptions: 1) about how to frame empirical findings within pre-imposed ideologies about knowledge and research. As such, it may simply represent the framework within which the research sits, as opposed to what is really occurring in the social context; 2) empirical work can seek to explore the normative concepts within the social context. The problem here is that the focus of inquiry is predefined and pre-determined, and as such, research activity seeks to explore the a priori defined concept. Findings are, therefore, related to the concept, rather than exploring if the concept is evident in the social context. What grounded theory does is free the researcher from the constraints of working within a research/knowledge disciplinary base to inquire into phenomena and to allow emergent patterns that explain that phenomena. This however does not mean we

17 should not think about ontology and epistemology, rather that we need not be defined by it. However it also means that grounded theory research needs to be clear and transparent about how it is being done and analysed. The grounded theory researcher therefore needs to understand ontological and epistemological frameworks of understandings of phenomena, but not be limited by them. The grounded theory researcher needs to understand the purpose and process of grounded theory, and be prepared to identify the type of grounded theory and stick to a typology of grounded theory and be prepared to work through its process of data collections and analysis in order to allow patterns to emerge. Most importantly the grounded theory researcher must understand that it is patterns in the data that will inform us about social phenomena, rather than our interpretations as researchers. By looking for emergent patterns in the data, the grounded theorist is looking at data, not individuals, and it is patterns in data that can give us clues about social phenomena. CONCLUSION This chapter has considered the value of using empirical research in inquiry into health care ethics and identified the selection of grounded theory methodology as being appropriate to meet the objectives of this research. The value of situating this research within the social sciences is to get closer to developing an understanding of issues that matter to those in the practice context and to move understanding forward in a well-reasoned and well-informed direction.