title: Multiple triangulation and collaborative research using qualitative methods to explore decision making in pre-hospital emergency care.
abstract: Paramedics make important and increasingly complex decisions at scene about patient care. Patient safety implications of influences on decision making in the pre-hospital setting were previously under-researched. Cutting edge perspectives advocate exploring the whole system rather than individual influences on patient safety. Ethnography (the study of people and cultures) has been acknowledged as a suitable method for identifying health care issues as they occur within the natural context. In this paper we compare multiple methods used in a multi-site, qualitative study that aimed to identify system influences on decision making.
  
  
  
  The study was conducted in three NHS Ambulance Trusts in England and involved researchers from each Trust working alongside academic researchers. Exploratory interviews with key informants e.g. managers (n = 16) and document review provided contextual information. Between October 2012 and July 2013 researchers observed 34 paramedic shifts and ten paramedics provided additional accounts via audio-recorded 'digital diaries' (155 events). Three staff focus groups (total n = 21) and three service user focus groups (total n = 23) explored a range of experiences and perceptions. Data collection and analysis was carried out by academic and ambulance service researchers as well as service users. Workshops were held at each site to elicit feedback on the findings and facilitate prioritisation of issues identified.
  
  
  
  The use of a multi-method qualitative approach allowed cross-validation of important issues for ambulance service staff and service users. A key factor in successful implementation of the study was establishing good working relationships with academic and ambulance service teams. Enrolling at least one research lead at each site facilitated the recruitment process as well as study progress. Active involvement with the study allowed ambulance service researchers and service users to gain a better understanding of the research process. Feedback workshops allowed stakeholders to discuss and prioritise findings as well as identify new research areas.
  
  
  
  Combining multiple qualitative methods with a collaborative research approach can facilitate exploration of system influences on patient safety in under-researched settings. The paper highlights empirical issues, strengths and limitations for this approach. Feedback workshops were effective for verifying findings and prioritising areas for future intervention and research.
authors.affiliation: Public Health Section, ScHARR, University of Sheffield, Sheffield, UK. m.johnson@sheffield.ac.uk.
authors.forename: Maxine
authors.identifier: 0000-0003-0850-234X
authors.initials: M
authors.lastname: Johnson
authors.affiliation: Public Health Section, ScHARR, University of Sheffield, Sheffield, UK.
authors.forename: Rachel
authors.initials: R
authors.lastname: O'Hara
authors.affiliation: Sheffield Emergency Care Forum, Sheffield, UK.
authors.forename: Enid
authors.initials: E
authors.lastname: Hirst
authors.affiliation: Department of Psychology, University of Bath, Bath, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Weyman
authors.affiliation: Emergency & Urgent Care Research, Health Services Research Section, ScHARR, University of Sheffield, Sheffield, UK.
authors.forename: Janette
authors.initials: J
authors.lastname: Turner
authors.affiliation: Emergency Medicine, Health Services Research Section, ScHARR, University of Sheffield, Sheffield, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Mason
authors.affiliation: Centre for Health and Social Care Research, Kingston and St George's University, London, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Quinn
authors.affiliation: Yorkshire Ambulance Service NHS Trust, Wakefield, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Shewan
authors.affiliation: Primary and Prehospital Health Care, Community and Health Research Unit, College of Social Science, University of Lincoln, Brayford Pool, Lincoln, UK.
authors.forename: A Niroshan
authors.initials: AN
authors.lastname: Siriwardena
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000488:Allied Health Personnel / Q000458:organization & administration / Q000706:statistics & numerical data*; D000552:Ambulances / Q000706:statistics & numerical data; D003299:Cooperative Behavior; D003625:Data Collection / Q000379:methods; D003657:Decision Making; D004632:Emergency Medical Services / Q000458:organization & administration / Q000706:statistics & numerical data*; D004739:England; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D055815:Young Adult
keywords: Ambulance service; Ethnography; Multi-method research; Patient safety; Pre-hospital; Qualitative