Journal of Nursing and Practice

Methodological Integration in Health Research: The Case of Institutional Ethnography, Interpretive Phenomenology, and Critical Discourse Studies

Abstract

Healthcare problems are complex, dynamic, and interdisciplinary, especially when promoting patient-centered care and communication or honouring patients' rights during clinical interactions and communications. Healthcare institutional culture and structures, everyday healthcare practices, and the diverse cultural orientations nurses, patients, and caregivers bring into nurse-patient-caregiver clinical interactions are complex yet dynamic. Understanding how patients' rights are reflected in nurse-patient clinical communications and the impact institutional culture and practices, personal experiences, and sociocultural norms and values have on that requires integrated qualitative research methodologies to explore the problem. Therefore, our aim in this critical review and discussion paper was to present and discuss a proposed integrated methodological approach to qualitative healthcare research. By reflecting on an ongoing doctoral research project on patients' rights in nurse-patient clinical communications, we offer and discuss an integrated methodological approach to qualitative health research through institutional ethnography, interpretive phenomenology, and critical discourse studies. The significance of this approach to qualitative health research and implication for policy and practice are highlighted. In conclusion, we invite qualitative health researchers to exercise intentional and careful planning and researcher reflexivity while engaging with this integrated methodological approach to qualitative health research.

Keywords

Integrated methodologies, Qualitative health research, Patients' rights, Nurse-patient communication

Background

In this critical review and discussion paper, we propose and demonstrate the need for methodological integration in qualitative health research. Drawing from our experiences of an ongoing interdisciplinary doctoral research project on patients' rights in nurse-patient clinical communication and interaction, expert recommendations from the interdisciplinary doctoral research committee, and the extant literature, we present and discuss the approaches and relevance of methodological integration in health research.

Healthcare problems are complex, dynamic, and interdisciplinary, especially when promoting patient-centered care and communication or honouring patients' rights during clinical interactions and communications. Effective communication in nurse-patient interactions is complex yet therapeutic, as it is essential for enhancing patient safety and developing trusting relationships among care providers, patients, and caregivers. The healthcare institutional culture and structures, everyday healthcare practices, and the diverse cultural orientations nurses and patients bring into clinical interactions make communication in the nurse-patient dyad complex [1,2]. Moreover, research has shown that differences in language, cultural patterns of behaviors, social values and beliefs, and socio-economic status between nurses and patients can affect communication and health outcomes during clinical interactions [3].

Furthermore, discourse analysis of social interactions in the healthcare setting has shown that communication in nurse-patient interaction involves a discursive production of power, knowledge, and ideological positioning [4,5]. Thus, care providers, patients, and caregivers co-create meanings and interpretations as illnesses are diagnosed, and care plans initiated, negotiated, and discussed. The context of interaction, power relations, ideological positioning, control, and dominance become crucial issues in clinical communications.

Patient-centered care and communication, as constituents of patients' rights in healthcare practices, require that care providers meet patients' needs, expectations, and perspectives, including respecting patients' uniqueness and dignity as humans [6-8]. Regarding patients' rights in clinical interactions, Mastors [9] observed that to honor patients' humanity entails respecting them as partners in their own care needs. Therefore, achieving patient-centered care and communication means that patients' rights are respected and their experiences, perspectives, and feelings incorporated into the care process. Patients' interpretations of what caring is and what it means to be cared for must be explored and integrated into nursing care practices [7,10].

Since clinical communications are dynamic and complex, we need to integrate different research methodologies to understand how patients' rights are reflected in nurse-patient clinical communications. Also, institutional culture and practices, personal experiences, and sociocultural norms and values must be examined to determine their influence on both patients' rights and nurse-patient clinical communications and interactions. Although integrated methods are far advanced in mixed methods studies [11-13], little is known about methodological integration in qualitative health research [14]. Moreover, despite that qualitative health studies usually report using more than one qualitative analytic approach, it is not often explicit how that was achieved, especially in the results and analysis sections of those studies.

We discuss how institutional ethnography, interpretive phenomenology, and critical discourse studies can be employed in an integrated methodologies study to understand patients' rights in nurse-patient clinical communication. As Wolgermuth [15] queries, how will a qualitative study look when varying epistemologies and methodologies are intentionally adopted. Thus, what is the significance of and practical modalities of integrating more than one qualitative methodology in health research? We attempt a response to this question and invite healthcare and nursing researchers to explore similar integrative methodological approaches in their studies. First, we briefly discuss the concept of qualitative methodological integration as applied in the ongoing doctoral research project. Following that, we present each methodology and then identify the essential commonalities and differences among them. Next, we demonstrate methodological integration using our study on patients' rights in nurse-patient communication in the hospital setting, and note some implications of this research approach in healthcare research before we conclude the paper.

The Concept of Qualitative Methodological Integration in Health Research

As used in this paper, qualitative methodological integration refers to the intentional process of systematically combining two or more qualitative methodologies in a single study to explore social problems. In other words, it is a systematic process emanating from a set of research activities continually taking place, aimed at achieving interdependence between various phases in qualitative health research [16]. Following Moran-Ellis, et al. [13], we argue that methodological integration demands a specific relationship between two or more qualitative methodologies, each retaining their paradigmatic nature but inter-meshed to produce an outcome more significant than the individual components. Our methodological integration is about engagement with two or more qualitative research methodological designs (e.g., ethnography, phenomenology, and critical discourse studies) in a single study. It differs from Moran-Ellis, et al.'s [13] and Tonon's [16] "integrated methods," which refer to mixed methods studies where different qualitative and quantitative data sources are combined in a single study. For details about how to achieve "integrated methods" in mixed methods studies see Fetters, et al. [11], Fielding, et al. [12], Moran-Ellis, et al. [13], and Tonon, et al. [16].

To implement qualitative methodological integration with two data sources (e.g., semi-structured interviews, participant observations or focus groups, and documentary materials) is not to achieve data source triangulation per se. Integration must involve capturing the different subjective realities of a social phenomenon as experienced by participants to fully understand the complexity, dynamism, and the chaotic nature of the problem. In a sense, qualitative methodological integration goes beyond combining data from different sources since interviews, observations, focus groups, field notes, documentary materials, arts, and photographs are familiar sources of data in qualitative studies. Yet, each data source may provide different information to the qualitative researcher. Thus, it is possible to employ a single data source (especially semi-structured interviews) in an integrated methodological study, as long as the data collection tool is designed to generate research data that can be subjected to an integrated methodological analysis, as discussed later.

The imperative of an integrated methodological approach to qualitative health research is to further an in-depth understanding of the complex social phenomenon in healthcare research. Methodological integration can produce converging evidence that may be more compelling than usually done in single methodological designed studies [12]. It enhances innovative and creative ways of exploring the complex and interconnected healthcare problems humanity is currently facing. In what follows, we present the qualitative methodologies we are employing in the ongoing doctoral research project.

A Brief Presentation of the Methodologies

A research methodology is a set of philosophical principles, strategies, and actions researchers employ to investigate social phenomena. It consists of ontological and epistemological assumptions about reality and how to access it [17]. We briefly discuss each methodology in this section in three broad themes: philosophical and theoretical background, data sources and analysis, and strengths and challenges. For details about each research methodology, interested readers can consult the relevant references cited.

Institutional ethnography

Ethnography is a research methodology with roots in anthropology and sociology [18,19]. Positivists' mode of inquiry influenced the early use of ethnography, as objectivism was emphasized in the description and presentation of the cultural groups they studied. Ethnography has since embraced the philosophies of both interpretive and critical research paradigms [17] and is widely used in many academic disciplines. As a research methodology, ethnography is used to study and describe people with shared cultures to understand their values and beliefs and how their context shapes their behaviors [17,18]. Ethnography is a way of seeing and understanding human behavior in context through the eyes of members of a shared cultural group. It is both a process because it is a systematic method of inquiry and a product because it produces a report that describes a group of people [10,18]. Ethnography privileges prolonged fieldwork and emphasizes that researchers have a sustained relationship with the people and the communities they study [20]. Over the years, ethnography has evolved into different forms, including critical, realist, clinical, focused, institutional, interpretive, and narrative ethnographies, and has been applied in various academic disciplines [21].

Institutional ethnography (IE), as a form of ethnography was developed by Dorothy Smith in her book, Institutional Ethnography as Practice, to explore social relationships in an institutional setup to understand how institutional rules, structures, contexts, and culture influence human behavior [21,22]. As a methodology for studying institutional culture, IE is commonly used in healthcare studies to explore how power, institutional hierarchies or structures, rules, culture, and context shape experiences through discourse and action, as mediated by text in its broader scope [1,19,21].

Data collection approaches include personal observations (either participant or non-participant) of daily interactions and practices, in-depth individual interviews (un/structured), and documentary materials/achieves [10,20-22]. Researchers spend a long time in those institutions and develop good relationships with study participants to understand and appreciate how human behaviors and experiences shape (or are shaped by) institutional culture and structures. Researchers build good relationships with participants, immersing themselves in the study setting through extensive fieldwork [21,22], engaging in iterative data collection and analysis, and triangulating different data sources to enhance rigor in their research.

A significant strength of IE and ethnography, in general, is the emphasis on building good relationships with participants and conducting extensive fieldwork. Thus, prolonged engagement with participants and persistent observation can add salience and credence to the study [14]. This approach allows researchers to observe and study behaviors and experiences as lived versus as reported. Within the clinical setting, observing everyday practices can offer the researcher a clear picture of how institutional culture, social structures, and power relations impact behavior and experience [21]. One challenge of IE, like other forms of ethnography, is its overemphasis on extensive fieldwork. Furthermore, undertaking in-depth participant observations can significantly interfere with privacy and security issues. Institutional rules and structures can also make the researcher's work very hard and frustrating [20,23], especially when researching healthcare institutions and prisons. For details on ethical challenges around IE, readers can consult Pacheco-Vega and Parizeau, et al. [24], Sarangi, et al. [23], Waldram, et al. [20], among others.

Interpretive phenomenology analysis

Interpretative phenomenology analysis (IPA) originated from phenomenology and has roots in philosophy, social psychology, and education [18]. As a philosophical inquiry, phenomenology focuses on studying people's lived experiences about a phenomenon to understand the essence of the experience [25,26]. IPA as a qualitative inquiry was developed by Jonathan Smith, a health psychologist who observed that people, in their daily lives, engage in interpretive activities to make sense of their experiences [27,28]. IPA draws ideas from the philosophies of phenomenology, hermeneutics, and idiography to understand people's lived experiences [25-27].

Hermeneutics considers interpretation and self-understanding of experiences as delivered through an individual's language and culture. This philosophy assumes that "human beings are embedded in their life-worlds, linked to social, cultural and political contexts" [29]. Therefore, language, cultural context, and interpretations are significant, with the meaning of an experience taking center stage in IPA. Furthermore, through idiography, a commitment to unique personal experiences is achieved [30]. Thus, IPA's idiographic principle entails that detailed attention is paid to an individual's subjective lived experiences regarding a particular phenomenon [31]. The principles of phenomenology, hermeneutics, and idiography guide IPA researchers to understand the meaning of lived experiences within varying situated contexts by attending to how individual participants interpret the meanings of their experience and the researcher's interpretation of the participants' experiences within the cultural context of the phenomenon [29].

Because IPA focuses on exploring the meaning of individuals' lived experiences by paying attention to language use and the cultural context of experience, participant selection and data collection must be carefully done. Individuals with in-depth experiences of the phenomenon under study are purposively sampled. Moreover, IPA uses small homogenous samples to obtain an idiographic account of the participants' experiences [26,27,31]. In-depth semi-structured individual interviews with open-ended questions are common data collection methods in IP studies to allow participants to share their lived experiences [26,27]. Such interviews must be dialogic and person-centered to enable participants to present and interpret their lived experiences. The open-ended questions focus on exploring participants' emotions, thoughts, memories, meanings, and interpretations around their experiences. Munhall [29] advises that IPA researchers must integrate interpretive questions during their dialogue with participants to gain the participants' interpretations of their experiences. Also, documentary sources (reflexive journals of personal experiences, personal diaries, and memoirs) can be valuable data sources in IPA inquiry [18].

Data analysis in IPA is flexible and allows researchers to be creative. A case-by-case analysis of participants' transcripts must be conducted to identify individuals' unique experiences, interpretations, and meanings of the phenomenon under research. Pietkiewicz and Smith [26] and Miller, et al. [27] recommended two data analysis phases. Thus, (a) developing a descriptive account of how participants experience the phenomenon, focusing on what matters to each participant, examining relationships, values, and interpretations through participants' emotional and perceptual language use, and (b) moving beyond descriptions to interpret and account for participants' interpretations of their experiences within the phenomenon's sociocultural context. The researcher also renders their interpretations of participants' experiences while interrogating their own assumptions, values, knowledge, perceptions, and biases to fully understand what it means to be in the participants' position.

Researchers achieve rigor by observing the theoretical principles of phenomenology, hermeneutics, and idiography from the study design, data collection, analysis, to report writing phases [32,33]. Descriptive and interpretive analyses must be conducted, paying attention to the context, divergent, and convergent experiences among participants, and theme selection in the final report should be based on their prevalence, relevance, and transparency. The emphasis on idiography and a multi-level analysis in IPA is crucial because through the details of participants' experiences, researchers can identify novel or unexpected perspectives of a social phenomenon [26,27]. IPA also allows researchers to invest their interpretations on the participants' experiences and clarify their assumptions, perceptions, knowledge, and biases. IPA is suitable for studying most healthcare-related problems, including addictive, chronic, and infectious illnesses, as these often invoke stigmatization and other emotional and psychological challenges on patients. Besides, IPA has flexible guidelines that researchers can adapt and creatively work with to explore social problems.

How to define a homogenous population and find such a sample of participants with shared experiences of the phenomenon can be challenging in IPA. Pietkiewicz and Smith [26] and Miller, et al. [27] have acknowledged that due to the level of details and analysis required, IPA can be time-consuming and challenging for researchers new to the methodology. Moreover, because IPA focuses more on the meanings of participants' lived experiences, interviews can be very emotional, as participants bring to live past emotional traumas and feelings of shame, guilt, and awkwardness [26].

Therefore, researchers undertaking IPA studies have ethical responsibilities, including being reflexive and attentive to participants' emotions during interviews.

Critical Discourse Studies and the Discourse Historical Approach (DHA)

Critical discourse analysis (currently, critical discourse studies - CDS) is a research program or school that employs a heterogeneous set of methodologies and theoretical approaches to analyse language use as a form of social practice [34-36]. CDS' goal is to systematically analyze, interpret, and critique text in discourse as a site for the ideological manifestation of power and make visible power relations in social interaction [35]. CDS explores naturally occurring language use and language units larger than isolated words and sentences. It is interdisciplinary and focuses on language use in context, and oriented towards solving complex social problems [36]. As an academic program, CDS has drawn ideas and methods from diverse disciplines, including psychology, formal and text linguistics, rhetoric, sociolinguistics, literary studies, and critical theory, as well as contributions from various scholars, including Meyer, Fairclough, Wodak, van Dijk, van Leeuwen, among others [36,37].

Concepts such as 'discourse,' 'power,' 'ideology,' and 'critical' are crucial in CDS. Discourse is defined as language use in speech and text and considered a form of social practice in which there is a connection between social relations, social structure, and discursive events and situations [36]. Thus, discourse can be analyzed as text (e.g., vocabulary choices, speech forms, voice, and grammar features), a discursive practice, (looking at how text is produced, distributed, and consumed), or a social practice, concerning how power and ideological relations are formed, negotiated, and challenged [38]. Ideology is conceived as a perspective, a worldview, or a system of related mental representations, values, and beliefs shared by a specific group of people [39]. Ideologies constitute an essential means of creating, sustaining, and transforming shared social identities, including unequal power relations through narratives and discourses [39]. Power, on the other hand, entails the ability to enforce one's will and perspectives (including using physical force, violence, or control of resources) against others' interests within a social relationship [39]. Critique, as applied in CDS, is derived from Critical Theory. To be critical means that researchers must critically examine social problems to improve social life and must be self-critical and reflexive as they engage in research.

Different approaches to CDS with distinctive methods and analytic techniques include the dialectical-relational approach (DRA) by Norman Fairclough, the discourse historical approach (DHA) by Ruth Wodak and Martin Reisigl, and the sociocognitive approach (SCA) by Tuen van Dijk, among others [35,36,40]. The DHA of CDS recommends fieldwork and ethnography, where participants with experiences of the social problem under study can be interacted with. Data sources include participant observations, focus groups, audio-visual recordings, interviews, archival materials, internet sources, and all kinds of documentary sources [39,41]. Since the goal of CDS is to analyze, understand, and explain language use (discourse) as a social practice through which power and ideology are constituted, the DHA privileges data as text (oral, written, and visual) and the context of discourse [39].

The DHA analyses data in three stages: (i) Identifying the specific content and topics of discourses, (ii) Examining the discursive strategies in the discourse, (iii) And identifying and analysing the linguistic means employed in those discourses [39]. Reisigl and Wodak [39] have proposed (a) Using nomination strategies to identify persons, objects, actions, and processes in the discourse, (b) Noting how agency is assigned to the social actors, objects, events, and processes, (c) Exploring how argument claims are justified, (d) Examining how arguments perspectives and viewpoints are expressed and positioned, as well as (e) How utterances are articulated, intensified, or mitigated. Triangulation of different data sources, theoretical frameworks, and analytical approaches are recommended while iteratively collecting and analysing data. DHA report can be written in an ethnographic thematic or narrative style, and must influence policy, practice, or a social change.

An ethical risk or challenge in using CDS/DHA is how to distinguish researchers' advocacy roles from their hidden political agendas [36] since the outcome of CDS research ought to have a practical utility. The issue of 'participant's paradox' and 'ethics of interpretation' [23] can arise. Thus, to what extent can researchers attach or dettach themselves from the group they observe, given that during participant observation, the researcher is also being observed. Further, when transcribing discourses into text, how much detials should be preserved or lost without biasing the interpretive outcomes of the data. These issues require constant reflection in any CDS study.

Commonalities and Differences among the Methodologies

One essential feature among all the methodologies is their compatibility with the interpretive (also called humanistic, constructivist, and naturalistic) research paradigm. The interpretive paradigm assumes that reality is constructed and interpreted according to individuals' ideological and cultural backgrounds, and that knowledge is subjective, personal, and unique and can be acquired through multiple sources [17,18]. Researchers try to understand participants' values, experiences, beliefs, meanings, and interpretations of a social phenomenon through these methodologies. These philosophical positions imply that research is not a neutral process, and neither can the researcher be completely objective since the researcher decides what to study, what data to collect, and what analytical framework to use [23]. Further, researchers become the primary data collection instrument. They create and sustain good relationships with research participants and work reflexively with their assumptions and the data. Interviews, focus groups, and participant observations are familiar data sources, even though each methdology may have its unique focus when using these methods. The essential differences among these methodologies are summarized in Table 1.

Achieving Methodological Integration in a Nurse-Patient Communication Study

We propose how institutional ethnography, interpretive phenomenological analysis, and critical discourse studies can be integrated into a single study on patients' rights in nurse-patient communication and interaction, the value of methodological integration in healthcare research, and how to achieve that.

Methodological integration at the study design phase

Planning an integrated qualitative methodological study begins at the study design phase. Thus, based on the purpose of the study, any two or more of the qualitative research methodological designs can be carefully considered and selected. A qualitative health research project must have a broad aim for an integrated methodological approach to be used. For example, in the ongoing research project, we are interested in how patient rights are observed in nurse-patient communications and interaction in the hospital setting, with specific objectives of identifying healthcare institutional level barriers and facilitators of effective clinical communications, exploring the lived experiences of nurses, patients, and caregivers around patients' rights in the everyday communicative practices, and discussing ways in which the lived experiences of nurses, patients, and caregivers could be used to influence health policy and practice around patient rights. As a result, institutional ethnography, interpretive phenomenology, and the discourse-historical approach of critical discourse studies are employed in the project.

Despite each methodology's relevance in studying patients' rights in nurse-patient communication, achieving the above methodological interdisciplinarity will require deliberate actions on the researchers' part. Nursing researchers can achieve this methodological integration in two ways, depending on the nature of the project and its objectives, resources and time availability, and whether or not a research team or an individual is conducting the study.

Methodological integration at the data collection and analysis phase

Data collection intruments can be design to capture data for integrated methodological analaysis. Figure 1 illustrates how the methodologies presented earlier are being integrated in the project.

Although Figure 1 appears to present a linear process, qualitative study designs, data collection and analysis, and report writing are often iterative and non-linear, as qualitative researchers move back and forth throughout the research process. For instance, in our ongoing study, the participant observation guide is designed to capture data on pattern behaviours (e.g., language use practices, social interaction patterns, spatial organizations and how it influence human relationships and interaction). While making fieldnotes on these observations, we intend to question our interpretive assumptions on the observed data by seeking participants meanings and interpretations through informal interactions. Our semi-structured interview questions are also designed to capture individual participants' experiential and informant data while focus group interviews will explore group dynamics and experiences around patient rights in nurse-patient interaction. With these designs in mind, data gathering can proceed in two ways.

First approach: We will either use different data collection methods to gather specific sets of data targetting each methedology's needs based on our research questions, as illustrated in Figure 1. For example, participant observations can be strictly employed to observe everyday language use practices in different care contexts within the hospital among nurses, patients, and caregivers and how clinical communications and interactions are performed. Detailed field notes are then written about these observations. Barriers to therapeutic nurse-patient communication and instances of patient righ violation or promotion can be noted in these fieldnotes and their contexts of occurrence. In-depth individual interviews will focus on obtaining phenomenological data about patients', nurses', and caregivers' lived experiences around patient rights and clinical communication practices, while relevant documentary data will be collected and analyzed using the DHA of CDS to examine healthcare institutional ideologies, power dynamics, discursive practices, and how these impact patients' rights. Each of these specific data sources, including focus groups, will be explicitly tailored to each methodology's specific needs to achieve the overall objectives of the given research project.

The second approach: Alternatively, we can subject each interview, focus group, observational or documentary data materials (transcripts and documents) to multiple coding and analysis. For instance, each single interview transcript can be coded and analyzed to identify ethnographic, interpretive phenomenological, and critical discourse content/information. Thus, for each transcript or documentary data material, we can begin from content analysis to identify key words and phrases from which content categories are built, and further developed into ethnographic, IPA, or CDS themes for further analysis and interpretation. Although this approach can be labour intensive, undertaking multiple analysis of each data item will allow researchers to immerse themselves in the data thoroughly. It will further help us to explore how each component of the data seen from the ethnographic, phenomenological, and critical discourse perspectives complement each other, thereby helping to deepen our understanding of the problem and produce rigorous research outcomes [17]. As Maggs-Rapport [14] argued, implementing methodological triangulation is crucial to telling a credible story in healthcare research whilst at the same time ensuring that data collection and analysis are carried out in a thorough and unprejudiced manner in order to produce credible results.

Methodological integration at the report writing phase

For innovativeness, creativity, and to achieve true qualitative integrated methodological inquiry, research reports must demonstrate methodological integration. Now, having identified the ethnographic, phenomenological, and critical discourse content (codes, categories, and themes) from each data item and set, the findings of an integrated methodological study must be reported while still maintain the philosophy of integration. For our ongoing study, ethnographic findings will be presented thematically to show the broad ethnographic patterns of behavior, clinical practices, communication barriers, and how institutional culture, rules, and everyday care practices are embodied in nurse-patient clinical communication and interactions. Within each broad ethnographic theme, interpretive phenomenological lived experiences will be discussed through narratives to render the individual lived experiences, meanings, and interpretations meaningful within the broader ethnographic patterns. Issues of power, ideological positioning, and everyday discursive practices, as constitutive of discourses will then be interwoven throughout the individual lived experiences and broad ethnographic patterns using critical discourse analytic approaches.

Alternatively, the broader ethnographic thematic patterns can be presented as case studies with detailed descriptive ethnographic context of each case within the larger study. These case studies will then be supported by narrative reports of individual lived experiences and interpretations to illustrate the cases presented. Within the narratives in each case study, power relations, ideological positioning, and discursive practices that are re/produced as discourses are then interrogated. These tri-level or multi-level analysis and discussion of the research findings can provide both depth and breadth on the everyday complex healthcare problems that health researchers are faced with, especially around patient rights and patient-centred care in clinical communication and interaction.

Why Methodological Integration in the On-going Research Project

As Figure 1 illustrates, methodological integration is essential in exploring patients' rights in nurse-patient communication during clinical interactions because institutional culture, structures/hierarchies, everyday healthcare practices, and participants' subjective experiential knowledge can have different impacts and interpretive values on care outcomes.

Firstly, by employing institutional ethnographic approaches to participant observation of daily clinical practices (e.g., patient history taking, clinical consultation sessions, ward rounds, etc.), we can understand and provide a richly descriptive account of the everyday discursive practices and routines within specific care contexts. How institutional work processes and care practices impact social relationships and how ethical nursing practices and patients' rights provisions are navigated in such interactions can be observed. With this knowledge, we can explore how the institutional culture, structure, and care practices lead to certain patterns of behavior and care outcomes among nurses, patients, and caregivers. Barriers to effective communication and building therapeutic relationships, and ways to minimize them can be identified and examined.

For instance, studies have employed institutional ethnography to explore clinical ethics in HIV care [1], to examine how institutional internal structures, policies, and practices influence family experiences of neonatal intensive care services [22], to investigate everyday care practices at a medical ward [2], and to study eating disorders in a care home around politics and political economics of insurance companies, and why eating disorders are so culturally and therapeutically charged in the US [42]. In Kaposy et al.'s [1] study, it was found that HIV patients' social circumstances impacted their health and well-being, with most clinical ethical dilemmas caused by factors outside the clinical setting, including provincial social policy decisions. Kaposy and colleagues observed that clinical interactions and the management of ethical issues were integral to the everyday experiences of poverty, social inequality, and power imbalances. In Wolf, et al. [2], it was revealed that the culture of care that focused on routines, tight deadlines, and the highly structured care environment left little room for interprofessional coordination. This situation affected both care providers' and patients' ability to achieve patient-centered care.

Secondly, with IPA and using data obtained from person-centered individual narrative interviews, we will examine how patients, caregivers, and nurses experience and make sense of care and communication in nurse-patient interactions. By engaging with the participants' lived experiences and interpretations as well as our interpretations of participants' experiences, in-depth knowledge about what patients' rights mean to patients and nurses, how it is achieved (or not) in clinical interactions, and how institutional culture and everyday nurse-patient practices impact both patients' rights and clinical communications can be produced. For example, McCabe [43] used IPA to explore patients' experiences of nurse-patient communication and reported that nurses were more focused on completing medical tasks than communicating with patients, which diminished patient-centered communication experiences among patients. McCabe [43] further noted that nurses' lack of knowledge about what patients want and the lack of healthcare institutions' attention to communication promoted nonpatient-centered communication outcomes. Similarly, Joolaee, et al. [8] employed IPA to study patients' and their companions' experiences of caring relationships and patient rights practices in an Iranian hospital. Joolaee and colleagued discovered that the defining features of caring relationships among patients were nurses' ability to effectively communicate with them, to show them compassion, and to align care practices according to patients' individual unique needs, including showing respect and providing patients with information and support.

Thirdly, by engaging with the DHA of CDS, we will study textual data, including relevant institutional documents (e.g., patients' record forms, healthcare posters, information leaflets, etc.), to understand how power relations and ideological positioning are constituted in clinical discourses and practices. As Holtgraves and Kashima [44] indicated, language is a semiotic tool for meaning-making and exchange, and its use can have unintended consequences among its users. Thus, we will critically analyze clinical discourses (in text and other semiotic forms) to understand how nurses, patients, and caregivers position themselves or are positioned in different social spaces. We will also examine the communicative styles participants employ in talk, and how they achieve communicative alignment or resistance. Moreover, how the micro-politics of institutional talk, the context of interaction, and the participants' characteristics impact patients' rights can be made visible by critically examining patients' rights documents, healthcare code of ethics, and specific healthcare institutional policy documents. We can map out ideological positions and how they influence institutional practices, relationships, and healthcare service provision from these analyses.

For instance, Liu, et al. [45] utilized Fairclogh's dialectic-relational critical discourse approach to explore medication communication during medical ward rounds. The authors found that medical communications had spatial dimensions, including public, private, and semi-private discourse spaces. Liu and colleagues revealed a discursive display of power relations within medical teams in which consultants were the ones to initiate ward rounds and talk during these rounds, while nurses' voices were at the periphery and only became manifest when detailed patient information was requested or when nurses had to advocate for patients.

Patient involvement in such discourses was minimal, even when these occurred at their bedside. Similarly, Carr [4] explored how institutional practices and behaviors were mediated through language use in an addiction care home in the US. She observed that therapists delineated what a healthy talk was and employed an ideology of inner inference. With that ideology, patients' language use became a window into their inner state of mind and a predictive tool for understanding therapeutic and institutional culture and practice. By employing the same ideology, the patients with addiction problems learned to speak in particular ways (flipping the script) that conformed to the therapists' expectations and to be seen as healthy speakers [4].

The above sampled studies only examined the healthcare problems within their own ontological and epistemological assumptions. Combining two or more of these methodological designs could have illuminated each problem explored further than possibly achieved in each respective study.

Implications of Integrated Methodologies on Health Research, Policy, and Practice

The significance of a methodological integration in a single study is that the weaknesses of each methodology is complemented by the strengths of the others, thereby leading to innovativeness and creativity in qualitative research. Findings of a methodological integrated study is likely to provide a deeper picture about healthcare problems as different aspects of reality based on participnats' experiences are interrogated. Diverse insights are provided on healthcare problems, evidence-based care practices are enhanced, and policymakers are better equiped to design health policies that embrace the complex and interconnected dimesions of healthcare phenomena. Nonetheless, researchers intending to engage with or implement methodological integration in their qualitative health research must be aware that ethical, theoretical, and practical challenges abound, which require careful planning and reflexive thinking throughout the research process.

Conclusion

Our aim in this paper was to discuss a proposed approach to qualitative health research-integrated methodologies-and to illustrate how an ongoing doctoral research project is engaging with this approach to qualitative health research that uses institutional ethnography, interpretive phenomenology, and critical discourse studies. We have provided different ways to achieve methodological integration and the significance of engaging with different qualitative methodologies in health research. Despite the value of this approach to healthcare research, achieving methodological integration requires careful and intentional planning. We therefore call on health researchers interested in this qualitative research approach to embrace reflexivity throughout the research process.

Ethics Approval and Consent to Participate

Not Applicable

Consent for Publication

Not Applicable.

Availability of data and materials

Not applicable.

Competing Interests

The authors declare that they have no competing interests.

Funding

The authors have not received any funding for the conduct, preparation, and publication of this paper.

Authors' contributions

Both authors conceived the topic. PMP recommended some articles, AK searched and added more sources, and drafted the paper. PMP reviewed the paper for intellectual content. Both AK and PMP read and approved the final version.

Acknowledgments

We express our gratitude to author AK's doctoral committee members for their valuable comments, suggestions, and critique of an earlier version of this paper.

Authors' information

Abukari Kwame is a Ph.D. candidate in Interdisciplinary Studies in the College of Graduate and Postdoctoral Studies, University of Saskatchewan, currently working on a project that explores patients' rights in nurse-patient clinical communications and interactions in the hospital setting. He holds two Master of Philosophy degrees in Indigenous Studies and English Linguistics. Kwame's research interests include language use in social interaction, health communication, medical anthropology, First/Second language acquisition, African traditional medical knowledge, and Indigenous and qualitative research methodologies.

Pammla M. Petrucka is a professor in Nursing and has international research experience from Africa, Asia, and the Caribbean. Pammla has published extensively in the field of nursing. Her research interests are vast, including child and maternal health, Indigenous peoples' health, global health, and vulnerable populations, with extensive experiences in qualitative research and indigenous research methodologies. Pammla is co-editor of the BMC Nursing journal and a reviewer for many other academic journals.

References

1. Kaposy C, Greenspan NR, Marshall Z, et al. (2017) Clinical ethics issues in HIV care in Canada: An institutional ethnographic study. BMC Medical Ethics 18: 9.
2. Wolf A, Ekman I, Dellenborg L (2012) Everyday practices at the medical ward: A 16-month ethnographic field study. BMC Health Serv Res 12: 184.
3. Crawford T, Candlin S, Roger P (2017) New perspectives on understanding cultural diversity in nurse-patient communication. Collegian 24: 63-69.
4. Carr ES (2011) Scripting addiction: The politics of therapeutic talk and American sobriety. Princeton University Press.
5. Major G, Holmes J (2008) How do nurses describe health care procedures? Analyzing nurse-patient interaction in a hospital ward. Aust J Adv Nurs 25: 58-69.
6. Institute of Medicine (2001) Crossing the quality chasm: A new health system for the 21st century. National Academy Press.
7. Johnsson A, Wagman P, Boman A, et al. (2018) What are they talking about? Content of the communication exchanges between nurses, patients and relatives in a department of medicine for older people: An ethnographic study. J Clin Nurs 27: e1651-e1659.
8. Joolaee S, Joolaei A, Tschudin V, et al. (2010) Caring relationship: The core component of patients' rights practice as experienced by patients and their companions. J Med Ethic Hist Med 3: 1-7.
9. Mastors P (2018) What do patients want, need, and have the right to expect? Nurs Adm Q 42: 192-198.
10. Coughlin C (2012) An ethnographic study of main events during hospitalization: Perceptions of nurses and patients. J Clin Nurs 22: 2327-2337.
11. Fetters MD, Curry LA, Creswell JW (2013) Achieving integration in mixed methods designs: Principles and practices. Health Serv Res 48 Part II: 2134-2156.
12. Fielding NG (2012) Triangulation and mixed methods designs: Data integration with new research technologies. J Mixed Meth Res 6: 124-136.
13. Moran-Ellis J, Alexander VD, Cronin A, et al. (2006) Triangulation and integrated: Processes, claims, and implications. Q Res 6: 45-49.
14. Maggs-Rapport F (2000) Combining methodological approaches in research: Ethnography and interpretive phenomenology. J Adv Nurs 31: 219-225.
15. Wolgermuth JR (2015) Driving the paradigm: (Failing to teach) Methodological ambiguity, fluidity, and resistance in qualitative research. Q Inqu 1-8.
16. Tonon G (2019) Integrated methods in research. In P Liamputtong (eds), Handbook of Research Methods in Health Social Sciences 681-694.
17. Hussain MA, Elyas T, Nasseef OA (2013) Research paradigms: A slippery slope for fresh researchers. Life Sci J 10: 2374-2381.
18. Creswell JW, Poth CN (2016) Qualitative Inquiry & Research Design: Choosing among five approaches (4th edn). Sage.
19. Spinnewijn L, Aarts J, Verschuur S, et al. (2020) Knowing what the patient wants: A hospital ethnography studying physician culture in shared decision making in the Nethelands. BMJ Open 10: 1-9.
20. Waldram JB (2012) Hound pound narrative: Sexual offender rehabilitation and the anthropology of therapeutic intervention. University of California Press, Berkeley, USA.
21. Rashid M, Caine V, Goez H (2015) The encounters and challenges of ethnography as a methodology in health research. Int J Qual Methods 14: 1-16.
22. Rowland E, Manogaran M, Bourgeault IL (2018) Institutional ethnography as a unique tool for improving health systems. Healthcare Manag Forum 32: 143-147.
23. Sarangi S (2015) Communication research ethics and some paradoxes in qualitative inquiry. J Appl Linguist Prof 12: 94-121.
24. Pacheco-Vega R, Parizeau K (2018) Doubly engaged ethnography: Opportunities and challenges when working with vulnerable communities. Int J Qual Methods 17: 1-13.
25. Paul KB (2017) Introducing interpretive approach of phenomenological research methodology in environmental philosophy: A mode of engaged philosophy in the Anthropocene. Int J Qual Methods 16: 1-10.
26. Pietkiewicz I, Smith JA (2014) A practical guide to using interpretative phenomenological analysis in qualitative research psychology. Czasopismo Psychologiczne - Psychol J 20: 7-14.
27. Miller RM, Chan CD, Farmer LB (2018) Interpretive phenomenological analysis: A contemporary qualitative approach. Couns Educ Superv 57: 240-254.
28. Smith JA, Flowers P, Larkin M (2009) Interpretive phenomenological analysis: Theory, method, and research. Sage.
29. Munhall PL (2013) Interpretive phenomenology. In CT Beck (1st Edn), Routledge international handbook of qualitative nursing research. Routledge Handbooks Online 145-161.
30. Smith JA (2017) Interpretative phenomenological analysis: Getting at lived experience. J Posit Psychol 12: 303-304.
31. Love B, Vetere A, Davis P (2020) Should interpretive phenomenological analysis (IPA) be used with focus groups? Navigating the bumpy road of "iterative loops," idiographic journeys, and "phenomenological bridges". Int J Qual Methods 19: 1-17.
32. Peat G, Rodriguez S, Smith JA (2019) Interpretive phenomenological analysis applied to healthcare research. BMJ Evid Based Nurs 22: 7-9.
33. Smith JA (2011) Evaluating the contribution of interpretative phenomenological analysis. Health Psychol Rev 1: 9-27.
34. Wodak R (2011) Critical discourse analysis and critical linguistics. In: J Zienkowski, J-O Östman, J Verschueren (Eds), Discursive pragmatics: The handbook of pragmatics highlights.
35. Wodak R, Meyer M (2009) Critical discourse analysis: History, agenda, theory, and methodology. In: Wodak R, M Meyer (Eds) Methods for critical discourse analysis. Sage 1-33.
36. Wodak R, Meyer M (2016) Critical discourse studies: History, agenda, theory, and methodology. In: Wodak R, Meyer M (Eds), Methods of critical discourse studies (3rd edn) Sage.
37. Liu K, Guo F (2016) A review on critical discourse analysis. TPLS 6: 1076-1084.
38. Regmi KD (2017) Critical discourse analysis: Exploring its philosophical underpinnings. Afric Rev of Soci Sci Methodol 2: 93-107.
39. Reisigl M, Wodak R (2016) The discourse-historical approach (DHA). In: R Wodak, M Meyer (Eds), Methods of critical discourse studies (3rd Edn), Sage 23-61.
40. Unger JW (2016) The interdisciplinarity of critical discourse studies research. Palgrave Commun 2: 1-4.
41. El Naggar S (2015) Multimodality in perspective: Creating a synergy of the discourse historical approach and the framework of visual grammar. In J Wildfeuer (Edn), Building bridges for multomodal research: International perspectives on theories and practices of multimodal analysis p. 149-166.
42. Lester RJ (2019) Famished: Eating disorders and failed care in America. University of California Press.
43. McCabe C (2004) Nurse-patient communication: An exploration of patients' experiences. J Clin Nurs 13: 41-49.
44. Holtgraves TM, Kashima Y (2008) Language, meaning, and social cognition. Personal Soci Psychol Rev 12: 73-94.
45. Liu W, Manias E, Gerdtz M (2012) Medication communication during ward rounds on medical wards: Power relations and spatial practices. Health 17: 113-134.