Factors influencing nurses' advocacy role in level two public hospitals in the North West Province of South Africa Olivia Ngami orcid.org/ 0000-0002-7126-5673 Dissertation submitted in partial fulfilment for the degree Master's in Nursing Science at the North-West University Supervisor: Prof C.S. Minnie Date of submission: 16 August 2021 i PREFACE REPORT OUTLINE This report was compiled in the article format according to the North-West University (NWU) Manual for Master’s and Doctoral Studies (NWU, 2016:22). Following the guidelines, one manuscript was drafted following the instructions of the Curationis Journal. Resultantly, repetition of sections is inevitable, with some sections repeated verbatim. The following structure will be followed: • Chapter 1: Overview of the study • Chapter 2: Literature review • Chapter 3: Article manuscript: The characteristics of factors influencing nurses' advocacy role in level two Public Hospitals in the North West Province. • Chapter 4: Evaluation of the study, limitations, and recommendations for future nursing advocacy role in practice, for education purpose and policy formulation. The study was conducted and reported on by the researcher – Olivia Ngami, Open Researcher and Contributor Identification Number (ORCID), 0000-0002-7126-5673, under the supervision of the study leader, Professor C.S. Minnie. The referencing style used was the NWU Harvard style, as in The North-West University Referencing Guide (NWU: 2018), except for Chapter three, where the author guidelines for Curationis were used. ii DECLARATION I declare that this research has been conducted solely by myself. It has not been submitted elsewhere except at the NuMIQ research focus area North-West University. It has never been submitted in whole or in part in any previous application for a degree. Except where stated otherwise by reference or acknowledgement, the work presented is entirely my own. I declare that I have followed the University policy regarding plagiarism and have complied by acknowledging all the work done from other sources. I declare that the data has been kept with confidentiality throughout the stages of data handling and that I conducted the research in my capacity as a research student. 15 August 2021 Mrs Olivia Ngami Clinical Preceptor (Nursing, Neph Nursing, NM NE) Potchefstroom Campus Tel: +27 (0) 18 299 2759 Email:23795875@nwu.ac.za Website: www.nwu.ac.za Mev Olivia Ngami Clinical Preseptor (Nursing, Neph Nurs NE) Potchefstroom Kampus Tel: +27 (0) 18 299 2759 Email: 23795875@nwu Website: www.nwu.ac.z iii ACKNOWLEDGEMENTS What my eyes can't see, I still believe, everything spoken to me, there is no word, that can come back void, I will trust the report of the Lord. While I'm waiting, I'm getting stronger, my faith is rising Lord (Travis Green) I would like to express my sincere gratitude to the following: My Deepest gratitude goes to God. The author and the perfector of my faith. The Lion of Judah, His Name is Jehovah. He reigns supreme above all the heavens and earth, King of Glory. He said, ask, and it shall be given, knock, and the doors will be open. Heaven is his throne, and the earth is His footstool. He is the Lamp that lights my path. If it had not been for the Lord who was always by my side, I would have drowned: in the water. All the Glory and Honour belong to Him. I made it on a wing and prayer. Romans 8:28: It all works together for good to them who are called to His purpose. My Husband, Mr Thembile Ngami. You have been nothing short of a blessing. I know we are not perfect, but the love you have shown me is perfect in my eyes. Thank you for the support, constant encouragement, and all the effort taken to assist me with our house chores; I appreciate that. In that, you have allowed me time to do my work while you took care of us. I LOVE YOU. To Bonginkosi and Elihle Ngami, I look at your faces and see the love that radiates in you. I was sometimes not a present mom, but always a functional mom. Your love for me as your mother never changed. I have taken away so much from you, but you still gave unconditional love. I love you today and always; never forget that. My Supervisor and NuMIQ Director, Professor C.S. Minnie, I wouldn't have had an opportunity to do this research study if you didn't see the potential in my study. For that, I am eternally grateful. I thank you for the guidance and the opportunity to do this. Prof Tinda Rabie, Dr Annemarie Van Wyk, Dr Nicholien Scheepers, Dr Khumo Shopo and Dr Elsabѐ Bornman, thank you for being there when I felt like giving up; your support and encouragement were the wind beneath my wings. G40, our office, Anna-Therese Swart and Mariska Oosthuizen-Van Tonder, thank you so much for the support. The prayers and office chats to debrief pulled me through. iv My friends Noxolo Nthaba, Dolly Itumeleng, and Bernice Mokele, you made things easy for me; your encouragement and support made things easy for me. I will always hold you dear to my heart. To Samantha Krausѐ, you have been a light where my eyes were blinded by darkness. To the HWSETA Postgraduate bursary department, North-West University Bursary Department, UCDP Grant, my study might have taken long, but the grace I had received for funding has been immensely appreciated. I am humbled by the gesture to fund me to complete my studies. Gerda Beukman, our ever-willing Librarian, I am grateful for all the work you have contributed to my studies by retrieving information and sourcing articles for me; I am forever grateful. Ms Elinda Harmse, thank you for the impeccable work you did for co-coding. Ms Susan van Biljon, your patience and kindness towards me with technical editing humbles me. Thank you. Dr Eddie Bain, my heartfelt gratitude for the Language editing. Lastly, my sincere gratitude goes to the study participants who took their time to participate in this study. May God richly bless them and meet them at their point of need as they continue to stand in the gap for our patients. The only impossible journey is the one you never began~ Anthony Robbins. It was a long journey for me - next round loading. v ABSTRACT BACKGROUND Nursing advocacy has been a topic of much discussion in the nursing literature for several decades. The researcher was interested in contributing to quality patient care by empowering nurses in their advocacy roles. OBJECTIVES The objective was to explore and describe the factors that influence nurses' advocacy roles METHOD A qualitative descriptive inquiry was conducted using focus group interviews with professional nurses as participants who were purposefully recruited. Interviews were conducted in all the level two public hospitals in the North West Province. The data were thematically analysed using Creswell's eight steps of data analysis to identify common themes (Creswell, 2014:209). RESULTS Three main themes were identified. These findings were as follows: managerial and environmental factors such as lack of management support and nurses' lack of training influence the advocacy role of nurses negatively. The second finding was personal factors such as empathy, sympathy, and assertiveness positively influenced the nurse's advocacy role. The last finding was patient-related factors such as compromised patients' rights, autonomy, religious and cultural beliefs affecting the nurses' advocacy role either negatively or positively. A unique finding of the study was that language differences could also influence the ability of nurses to advocate for their patients. CONCLUSION Overall, several factors can influence the nurse either positively or negatively when advocating for patients. Nurses need to be empowered in their nursing advocacy role to provide quality patient care within a public hospital setting to advocate for their patients. Keywords: Nurse, Advocacy, Provincial hospital, North West Province vi LIST OF ACRONYMS ABP Acting on Behalf of Patients ANA American Nursing Association CEO Chief Executive Officer CSJ Championing Social Justice DoH Department of Health HREC Health Research Ethics Committee ICN International Council of Nurses NHREC National Health Research Ethics Council NMC Nursing and Midwifery Council NuMIQ Research to promote quality in Nursing and Midwifery NWP North West Province PI Principal Investigator REC Research Ethics Committee SANC South African Nursing Council SPA Safeguarding Patients' Autonomy SDG Sustainable Development Goals TIE Time-Inconvenience-Expenses WHO World Health Organisation vii TABLE OF CONTENTS PREFACE ........................................................................................................................ i DECLARATION ....................................................................................................................... ii ACKNOWLEDGEMENTS ........................................................................................................ iii ABSTRACT ....................................................................................................................... v LIST OF ACRONYMS .............................................................................................................. vi LIST OF FIGURES AND TABLES .......................................................................................... xii CHAPTER 1: OVERVIEW OF THE STUDY ......................................................................... 1 1.1 INTRODUCTION ........................................................................................... 1 1.2 BACKGROUND TO STUDY .......................................................................... 1 1.3 PROBLEM STATEMENT .............................................................................. 4 1.4 PARADIGMATIC PERSPECTIVE ................................................................. 5 1.4.1. Meta-theoretical assumptions ........................................................................ 5 1.4.1.1 Man/person. ................................................................................................... 5 1.4.1.2 Environment ................................................................................................... 6 1.4.1.3 Health ............................................................................................................ 6 1.4.1.4 Illness............................................................................................................. 7 1.4.2 Theoretical assumptions ................................................................................ 7 1.4.2.1 Applicable theory ........................................................................................... 7 1.4.2.2 Conceptual definitions .................................................................................... 8 1.4.3 Methodological assumptions ........................................................................ 11 1.5 RESEARCH AIMS AND OBJECTIVE ......................................................... 11 1.5.1 Research aim ............................................................................................... 12 1.5.2 Research objective....................................................................................... 12 1.6 STUDY DESIGN .......................................................................................... 12 1.7 RESEARCH METHODOLOGY .................................................................... 12 viii 1.7.1 Study context ............................................................................................. 12 1.7.2 Population and sampling .............................................................................. 13 1.7.2.1 Population .................................................................................................... 13 1.7.2.2 Sampling ...................................................................................................... 13 1.7.2.2.1 Sampling technique ...................................................................................... 13 1.7.2.2.2 Sampling size ............................................................................................... 14 1.7.2.2.3 Inclusion criteria ........................................................................................... 14 1.7.2.2.4 Exclusion criteria .......................................................................................... 15 1.7.3 Data collection: ............................................................................................ 15 1.7.3.1 Data collection tool ....................................................................................... 15 1.7.3.2 Data collection process ................................................................................ 16 1.7.4 Data analysis ............................................................................................... 19 1.8 RIGOUR ...................................................................................................... 22 1.9 ETHICAL CONSIDERATIONS .................................................................... 26 1.9.1 Legal authorisation ....................................................................................... 27 1.9.2 Goodwill Permission ..................................................................................... 27 1.9.3 Probable experience of participants ............................................................. 27 1.9.4 Risk and benefits ......................................................................................... 27 1.9.5 Vulnerability of patients ................................................................................ 31 1.9.6 Respect for participants ............................................................................... 31 1.9.6.1 Privacy and confidentiality. ........................................................................... 31 1.9.6.2 Anonymity .................................................................................................... 32 1.10 EXPERIENCE, SKILLS, AND COMPETENCY OF THE RESEARCHER .... 32 1.11 DATA MANAGEMENT ................................................................................ 33 1.12 DISSEMINATION OF RESEARCH RESULTS ............................................ 33 1.12.1 Dissemination to academia .......................................................................... 33 1.12.2 Dissemination to institutions ......................................................................... 34 1.12.3 Dissemination to participants ....................................................................... 34 ix 1.13 CONFLICT OF INTEREST .......................................................................... 34 1.14 EXECUTIVE SUMMARY ............................................................................. 35 CHAPTER 2: LITERATURE REVIEW OF FACTORS INFLUENCING NURSING ADVOCACY ................................................................................................ 36 2.1 INTRODUCTION ......................................................................................... 36 2.2 METHOD FOR LITERATURE REVIEW ....................................................... 36 2.3 THE CONCEPT OF NURSING ADVOCACY ............................................... 37 2.3.1 Advocacy in general ..................................................................................... 37 2.3.2 Advocacy in nursing care ............................................................................. 38 2.4 ETHICAL CONSIDERATIONS OF THE NURSE'S ROLE AS A PATIENT ADVOCATE ................................................................................. 40 2.5 ATTRIBUTES OF NURSES AS PATIENT ADVOCATES ............................ 43 2.6 NURSE TRAITS THAT INITIATE NURSES' ADVOCACY ROLE FOR PATIENT ADVOCACY ................................................................................ 45 2.7 POSITIVE CONSEQUENCES OF PATIENT ADVOCACY. ......................... 46 2.8 CONCLUSION OF THE LITERATURE REVIEW ......................................... 47 CHAPTER 3: ARTICLE MANUSCRIPT: FACTORS INFLUENCING NURSES' ADVOCACY ROLE IN LEVEL TWO PUBLIC HOSPITALS IN THE NORTH WEST PROVINCE ......................................................................... 48 CHAPTER THREE OUTLINE .................................................................................................. 48 COVER PAGE ..................................................................................................................... 49 ABSTRACT ..................................................................................................................... 50 KEYWORDS: ..................................................................................................................... 51 INTRODUCTION ..................................................................................................................... 52 CONCEPTUAL FRAMEWORK ............................................................................................... 53 AIM AND OBJECTIVE OF THE STUDY. ................................................................................. 53 RESEARCH METHOD AND DESIGN ..................................................................................... 54 x The setting of the study/ study context .................................................................................... 54 Study population and sampling ................................................................................................ 54 Data collection ..................................................................................................................... 55 Data analysis ..................................................................................................................... 55 RIGOUR ..................................................................................................................... 56 ETHICAL CONSIDERATIONS ................................................................................................ 56 RESULTS ..................................................................................................................... 57 DISCUSSION ..................................................................................................................... 65 LIMITATIONS ..................................................................................................................... 67 CONCLUSION ..................................................................................................................... 67 Acknowledgements ................................................................................................................. 69 Competing interest .................................................................................................................. 69 Authors' contribution ................................................................................................................ 69 Funding ..................................................................................................................... 69 Data availability ..................................................................................................................... 69 Disclaimer ..................................................................................................................... 69 LIST OF REFERENCES ......................................................................................................... 70 CHAPTER 4: EVALUATION, LIMITATIONS, AND RECOMMENDATIONS ...................... 73 4.1 INTRODUCTION ......................................................................................... 73 4.2 EVALUATION OF THE STUDY ................................................................... 73 4.3 LIMITATIONS OF THE STUDY ................................................................... 75 4.4 RECOMMENDATIONS ................................................................................ 75 4.4.1 Recommendations for nursing practice ........................................................ 75 4.4.2 Recommendations for nursing research ....................................................... 76 4.4.3 Recommendations for education .................................................................. 77 4.4.4 Recommendations for policy ........................................................................ 77 4.4.5 Recommendations for nursing management ................................................ 78 xi 4.5 CONCLUSION ............................................................................................. 78 REFERENCES ..................................................................................................................... 80 APPENDICES APPENDIX A: ETHICS APPROVAL ................................................................................... 88 APPENDIX B: APPROVAL FROM NWP DEPARTMENT OF HEALTH .............................. 89 APPENDIX C: PERMISSION FROM HOSPITALS .............................................................. 90 APPENDIX D: RECRUITMENT MATERIAL ........................................................................ 92 APPENDIX E: INFORMED CONSENT ............................................................................... 94 APPENDIX F: DATA COLLECTION TOOL ...................................................................... 103 APPENDIX G: COVER LETTER TO THE EDITOR OF CURATIONIS .............................. 105 APPENDIX H: GUIDELINES FOR AUTHORS - CURATIONIS ......................................... 106 APPENDIX I: TURNITIN REPORT .................................................................................. 109 xii LIST OF FIGURES AND TABLES Figure 1. Conceptual model of advocacy categories and interaction ...................... 7 Table 1: Definition of concepts and application to the study .................................. 8 Table 2: Process of data analysis ........................................................................... 19 Table 3: Epistemological standards for rigour as applied .................................... 23 Table 4: Risks and precautions to limit them ......................................................... 28 Table 5: Direct and indirect benefits of the study .................................................. 30 Table 6: The evolvement of the concept of nursing advocacy ............................. 38 Table 7: Attributes of nurses as patient advocates ………………………………...44 1 CHAPTER 1: OVERVIEW OF THE STUDY 1.1 INTRODUCTION Patient advocacy has been a topic of much discussion in the nursing literature for some decades. Advocacy is a key nursing role, yet diverse definitions exist, confusing the purpose of a nurse's advocate role and the factors influencing nurses to advocate, making it challenging to put advocacy into practice (Negarandeh et al., 2008:457). Patient advocacy became a subject of interest to the researcher who aimed to explore the factors influencing nurses to advocate for patients in level two public hospitals in the North West Province. Chapter one will focus on the research background, problem statement, aim and objective of the study, as well as recruitment of participants in order to get data which will be analyzed in chapter three. 1.2 BACKGROUND TO STUDY It remains unclear what patient advocacy entails and what values it ought to embody. Advocacy is alleged to be a means of safeguarding good patient care. Many professionals claim to be best suited for the position, many stating that the role of patient advocates is inherent to their profession. As seen in the early work of Schwartz (2002: 37), numerous role players have different interpretations of and applications for the role of an advocate. The concept of advocacy by a nurse on behalf of patients appears to have gained widespread acceptance in the western world (Breeding, 2002:110). Within an African context, patient advocacy has been identified as a core duty of the nurse (Dadzie et al., 2017:1). Advocacy has become an almost universal catchword among nurses, indicating that this concept has been legitimised within various nursing ethical codes (Breeding, 2002:110). Over the past four decades, patient advocacy has become central to nursing's professional identity. Regulatory and professional nursing organisations explicitly and implicitly include advocacy activities as part of codes of conduct and ethics. The International Council of Nurses (ICN) describes advocacy as central to nurses' contribution to the development of strong and resilient healthcare systems in the United Nations Sustainable Development Goal number 3 (ICN, 2016). Nurses need to advocate for each patient who is vulnerable and at-risk; and contribute to the development of policy that supports SDG goal 3 of ensuring healthy lives and promoting the wellbeing of all patients of all ages (ICN, 2016; Water et al., 2016:696). Furthermore, advocacy is usually employed by someone powerful on behalf of someone who has less or no power (Negarandeh et al., 2006:2). The core condition that demands advocacy action 2 is a patient's vulnerability because of illness and risks inherent in the institutional process to which patients are exposed. The majority of the patients exhibit various degrees of vulnerability due to their disease, culture, economic or educational background, personality, and previous experiences with healthcare. Patients ̓medical conditions such as unconsciousness, cancer, or mental illness can cause vulnerability and compromise their ability to self-determine their health care and protect their best interests. Feelings of powerlessness because of limited knowledge about health care or experiences of being neglected in the health care system can increase a patient's vulnerability. In addition, the negative way that health professionals sometimes relate to patients, specifically the disregarding, dehumanising, controlling, punitive and judgemental practice of biomedicine, can increase patients' vulnerability requiring nurses to assume their role as patient advocates (Negarandeh et al., 2008:457). In addition, the World Health Organisation (2014) report indicates that inaccurate diagnosis, medication errors, inappropriate or unnecessary treatment, inadequate or unsafe clinical facilities or practices, or providers who lack adequate training and expertise, prevail in all countries. These are just some highlights from the Report on Delivering Quality Health Services: A Global Imperative for Universal Health Coverage relevant to nursing advocates. The report also highlights that sickness associated with poor quality health care imposes additional expenditure on families and health systems (WHO, 2018). To add to the report of WHO (2018), Water et al. (2016:698) reported an interesting case in Aotearoa, New Zealand, where a significant shift in power relations within the health care sector occurred during the 1980s. The case had important implications for patient advocacy as many patient issues regarding advocacy came to the fore during the 1987 Commission of Enquiry into allegations concerning the treatment of cervical cancer at a National Women's Hospital, also known as the Cartwright Inquiry. This inquiry led to a significant shift in public attitudes towards the medical profession by directly challenging the medical paternalism that characterised many health professionals' attitudes towards patients. Issues of inadequate patient advocacy were a key concern of the inquiry. Judge Cartwright particularly noted the failure of nurses to advocate for patients in the face of breaches of patients' rights, saying "nurses who most appropriately should be the advocates for the patient feel intimidated by the medical staff". Cartwright's comments on this case highlighted the principles that nurses should act as patients advocates. By not protecting the patients' rights, the nurses have failed in their ethical responsibility. Water et al. (2016:697) pointed out that patient advocacy has seen its rise to prominence within nursing as part of a series of profound changes in Western society/culture in the 1960s and 1970s. Central to these changes were the women's civil rights movements, whose critique of power relations in society that sub-judged women and minority groups were significant for health care and nursing 3 as a profession (Water et al., 2016:697). After the findings of the Cartwright Inquiry, nurses aligned themselves with patients at the rise of consumer movements to signal increased patient power within the health care system (Water et al., 2016:698). Nurses laid claim to this role mainly based on their patient-centred practice facilitating more insight into the needs of the patient than any other health care professional group. Hanks (2008:469) adds that at any given point, the patient exhibits characteristics that stimulate the nurse to advocate. The available literature shows that the advocacy role is more entrusted to the nursing profession than to other health care professionals, primarily because of the intimate nature of the relationships nurses have with their patients (Hanks, 2008:469; Water et al., 2016:697, Negarandeh et al., 2008:457). The Nursing Act no. 33 of 2005 clearly states that it is the nurse s̓ right to advocate for and protect patients and personnel for whom he/she has accepted responsibility (Nursing Act, 33 of 2005:7). The scope of practice of a nurse (Regulation 2598) outlines all the roles of a nurse towards a patient in any health care facility (Department of Health, 2020:3). These duties have an underlying core character of a nurse advocating for the patient by ensuring that they promote, support, and restore the health care of patients and assist health care users in maintaining the basic activities of daily living, maintaining continuity and coordination of health care, and provide a safe and conducive environment for health care. All these nursing duties, as stipulated in Regulation 2598, are achieved through nurses assuming their role as patients' advocates. Studies in a Ghanaian and broader African context (Dadzie et al. 2017; 2018) show possible reasons for inadequate advocacy. The study of Dadzie et al. (2017:2) found that nurses are often overworked and may lack the energy and time to advocate for patients due to insufficient staff on duty and lack of resources at work, and their low level of participation in decision making in the hospital that led to frustration. Nurses may lose compassion and find it challenging to advocate for patients who may show ingratitude. Dadzie et al. (2018:10) investigated patient characteristics that influence the advocacy role of nurses in Ghana. This study found that vulnerable patients show signs of neglect, regardless of their background and social status. The vulnerability of patients is a core condition that demands nursing advocacy; both for personal vulnerability due to illness, and vulnerability due to risks inherent in the institutional process to which clients are exposed (Negarandeh et al., 2008:457) Within a South African context, no studies could be found regarding factors influencing nurses advocacy role, only a newspaper article with a discussion that follows. Health care services vary from primary health care, offered for free by the public sector, to highly specialized, hi-tech health services available in both the public and private sectors. However, the public sector is stretched 4 and under-resourced in places Nt'sekhe, 2018:np), which means that resources are limited, leading to vulnerable patients who need advocacy. While the state contributes about 40% of all expenditure on health, the public health sector is under pressure to deliver services to about 80% of the population (Nt'sekhe, 2018:np). While access has improved, the quality of health care has deteriorated. The situation is compounded by public health challenges, including the burden of HIV and tuberculosis (TB) and a shortage of medical personnel. This situation compounds patients' vulnerability as they have to accept the treatment and care they receive without asking questions. This, in turn, affects the type of nursing offered to vulnerable patients nursed in hospitals with limited resources Nt'sekhe, 2018:np). Patient care remains the nurse's primary responsibility, in particular the professional nurse, as primary caregivers amidst the challenges and shortcomings that the environment imposes on them, such as cost containment, minimised human resources, and the management of these resources. Within a South African context, patient advocacy has been identified as a core duty of the nurse (Dadzie et al., 2017:1). Patients are dependent on nurses as their primary caregivers who are expected to promote the patients’ best interests in their day-to-day activities within a multidisciplinary health care team. The researcher identified a need for nurses to strengthen their role as patients' advocates by understanding what this role entails. This study, therefore, focused on factors that influence nurses to advocate for their patients in level two public hospitals in the North West Province. 1.3 PROBLEM STATEMENT Nurses perform a vital role as patient advocates to ensure that the treatment and care provided are appropriate and safe (Selanders & Crane, 2012; Canadian Association of Critical Care Nurses, 2013). However, the barriers that confront nurses as patient advocates are often problematic and well documented in the literature; thus, nurses do not advocate for patients (Negarandeh, 2007; Zomordodi & Foley, 2009). The literature (Selanders & Crane, 2012; Canadian Association of Critical Care Nurses, 2013, Negarandeh, 2007; Zomordodi & Foley, 2009) shows that the nurse's role as a patient advocate in healthcare settings depends on the patients' autonomy. Thus, when nurses identify patients who cannot make an autonomous decision, they realise that these patients rely on the nurses' advocacy to stand up for their views and beliefs. Vulnerability, lack of information, and neglect are key characteristics that demonstrate the need for patient advocacy (Cole et al., 2014:576; Shah & Garg, 2011:4-7; Dadzie et al., 2018:1). 5 Within a South African context, nursing advocacy is not a subject that nurses are familiar with as the researcher could not find any literature that indicates factors influencing nurses advocacy role. It is either that nurses do not know what is nursing advocacy, how to advocate, and when to advocate, which led the researcher to the following deduction. Deducing from Dadzie et al. (2017:20, Cole et al., 2014:576; Shah & Garg, 2011:4-7; Dadzie et al., 2018:1), quality patient care can be compromised by factors influencing nurses' inability to advocate for patients. In addition, nurses seek to define and clarify their role and position in practice; they search for new interpretations concerning patient advocacy. However, the factors influencing nursing advocacy in practice within a South African context in level two public hospitals are not well known yet. 1.4 PARADIGMATIC PERSPECTIVE De Vos (2005:40) contends that the paradigmatic perspective describes the way in which the researcher views the research material. The paradigmatic perspective of this study guides the research methodology and knowledge and action of nursing (Alligood, 2010:62). The paradigmatic perspective of this study comprises the meta-theoretical, theoretical, and methodological assumptions. The following statements define the paradigmatic perspective and the parameters within which the researcher conducted the research. 1.4.1. Meta-theoretical assumptions Meta-theoretical assumptions refer to the researcher's personal beliefs regarding man and the environment in which they live, and it is not testable. The meta-theoretical assumptions for this study are based on a Christian worldview as well as Roy's theory of adaptation in nursing practice and include beliefs regarding the following concepts: man/person, the environment, health, and illness (De Vos, 2005:40; Alligood, 2010:310). Assumptions regarding a man/person, environment, health, and illness are described as follows: 1.4.1.1. Man/person. The researcher's view of human beings is connected to her view of God. The Almighty God is the creator of the universe, owner, and ruler of creation. He cares for His Creation and is concerned about His creations. Human beings are created as complex, unique, multidimensional beings. God has given man the task of increasing, inhabiting, ruling, cultivating and caring for creation. He has given each human being specific tasks, as well as gifts and talents, time, energy, and means to fulfil these tasks within specific societal relationships and structures (De Vos, 2005:40). Roy's theory of adaptation views a person as an adaptive system in constant interaction with the internal and external environment (Alligood, 2010:310). In this study, the concept, man/person 6 refers to a nurse as a patient advocate. Roy's theory of adaptation in nursing practice considers nursing as a vital service in assisting sick or well individuals in responding to a variety of new stressors, move towards optimal well-being, and improve the quality of their lives through adaptation (Alligood, 2010:309-312). For this study, the term nursing is used to refer to the rendering of quality patient care, including acting as an advocate for patients. The patient is viewed as a person receiving care from the nurse. 1.4.1.2. Environment Roy's theory of adaptation considers the environment as a source of a variety of stimuli that either threaten or promote a person's unique wholeness (Alligood, 2010:310). For this study, the concept environment refers to the nurses' workplace within a hospital environment. Following Roy’s theory of adaptation and the conceptual model of advocacy categories (Figure 1), the environment includes all the social, economic, and legal elements that influence patient advocacy (Dadzie et al., 2017:2). For this study, the researcher will focus on the social environment where the nurse-patient interaction occurs. The social environment is vital as nurses interact with other multidisciplinary team members with whom they have to advocate for patients. The patients' environment is also considered as it influences the nurses’ interaction with the patient and their advocacy for patients. Environmental factors such as poverty, social status, patients' vulnerability, neglect, lack of information, intimidation, and dissatisfaction with healthcare rendered (Dadzie et al., 2018:1) could influence the nurses' ability to advocate. 1.4.1.3. Health Human beings experience health and illness in the totality of their being. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition (World Health Organization (WHO), 2014:3). The WHO defines health as the state of complete physical, mental, sexual, and social well-being and not merely the absence of disease or infirmity. Illness is seen as impairment in health, and health and illness are dynamic states (WHO, 2014:3). A person is in a healthy state when the mind, body and spirit are in a state of being integrated with the process of life (Alligood, 2010:312). For this study, health refers to a state of nurses assuming their advocacy role regardless of the factors that influence their role as advocates. The core condition that demands advocacy action is the patients' vulnerability, in terms of both personal vulnerabilities because of illness and susceptibility to risks inherent in the institutional process to which clients are exposed in the health care system (Negarandeh et al., 2008:457). 7 1.4.1.4. Illness In this research, illness refers to vulnerability if a patient's nurse fails to advocate for the patient. Failure to take on an advocative role could harm the patient. This failure can be due to the nurses' state of mind, such as fear, fatigue, frustration, and burnout (Dadzie et al., 2017:2). 1.4.2. Theoretical assumptions Jackson (2015:10) argues that a pragmatic approach to nursing theory selection implies a humble and inclusive nursing practice. A nurse can critically evaluate a range of theoretical options and determine the most effective and appropriate course of action for a specific client. In the discussion below, the researcher will only introduce one model to address the research question. 1.4.2.1. Applicable theory For this study, the researcher considers the Bu and Jezewsky advocacy model (2006:101) adapted by Dadzie et al. (2017:2) (see Figure 1). This model is relevant to the current study as it addresses patient advocacy and understanding of this role in general. It can be used as a basis for focusing on advocacy in nursing. The mid-range theory developed by Bu and Jezewsky (2006:101) maintains that patient advocacy consists of three core attributes: safe-guarding patients' autonomy (SPA), acting on behalf of patients (ABP), and championing social justice (CSJ) in the provision of health care. Figure 1. Conceptual model of advocacy categories and interaction (Dadzie et al. 2017:2) 8 The model clarifies how nurses view their advocacy role and the circumstances under which they perform this role. In this model, three interdependent categories help to determine when, if and how nurses practise patient advocacy, namely, the "client", "nurse", and "environment". According to this model, the client’s (or patient’s) characteristics consist of neglect, vulnerability, being uninformed, intimidated, complaining and being disinterested. The nurses' characteristics are described in terms of traits and states. The relevant traits include being empathetic, nurturing, ethical, assertive, objective, and persistent. The nurse’s states affecting her performance of her advocacy role are fear, fatigue, frustration, and burnout. The model then indicates the environment in which the nurse and the patient interact, comprising job security, staffing rules and regulations, administration, time constraints, multidisciplinary team traditional role, consumerism, managed care, and presence of physicians (Dadzie et al., 2017:2). The researcher chose Bu and Jezewski's (2006:101) model because it suits the research topic and appropriately matches the problem statement. This model guided the study as a lens through which the researcher viewed the study. 1.4.2.2. Conceptual definitions With the following conceptual definitions, the researcher aimed to clarify how these concepts were applied in the current study. Table 1: Definition of concepts and application to the study CONCEPT DEFINITION APPLICATION TO THE CURRENT STUDY Patient A patient is a person who is physically or mentally ill or who is undergoing treatment for physical or mental illness (Freshwater & Maslin-Prothero, 2007:440). In the current study, a patient refers to any person who meets the nurse in their professional capacity and exhibits vulnerability, neglect, lack of information, intimidation, distress, or complaining about the type of care received (Dadzie et al., 2017:2). Nurse A nurse is a person who is registered in a category under section 31(1) to practise nursing or midwifery in South Africa. In the current study, a nurse is a professional nurse who cares for patients and advocates for them. Professional nurses have the authority to advocate for all hospitalised patients with whom they come into contact. 9 CONCEPT DEFINITION APPLICATION TO THE CURRENT STUDY A professional nurse means a person registered as such in terms of section 31. (South Africa, Nursing Act 33 of 2005:6). Nursing Nursing is the activity involved in providing physical care and emotional support to the sick, wounded, and helpless. Nursing includes all the activities performed by a nurse and is concerned with the restoration and maintenance of individual physical and mental health (Freshwater & Maslin-Prothero, 2007:362.) Nursing is practised by a person registered under section 31, which supports, cares for and treats a health care user to achieve or maintain health and where this is not possible, cares for a healthcare user so that he or she lives in comfort and with dignity until death the (Nursing Act 33 of 2005:6). In the current study, nursing refers to the act of providing quality patient care and being able to identify and act as a patient advocate. Advocacy Advocacy means the process of providing support, referral, liaison while representing and protecting the interest of individuals and families who may or may not be aware of the need or are unable to coordinate or arrange health care for In this study, advocacy is the ability and activity of the nurse to identify the need and act accordingly on behalf of the patient by always representing the patients' best interests. Advocacy has been described as specific actions such as helping the patient obtain the needed health care, assuring the quality of 10 CONCEPT DEFINITION APPLICATION TO THE CURRENT STUDY themselves (Nursing Act 33 of 2005:1). care, defending the patient's rights, and serving as a liaison between the patient and the health care system. When a patient does not obtain the needed health care, the nurse should step in to advocate for the patient (Negarandeh et al., 2006:2). Advocate An advocate acts for or defends the rights of another person who is unable or unwilling to act for him/herself (Freshwater & Maslin-Prothero, 2007:363). For this study, the nurse assumes the role of an advocate as she/he represents the patients' best interests, ensuring that quality patient care for the patient. The nurse talks for the patient, and advocates on behalf of the patient due to their vulnerable position when hospitalised. Nursing advocacy The process of providing support, referral, liaison, representation, and protection of the interest of individuals and families who may or may not be aware of the need for, or are unable to coordinate or arrange, health care for themselves (Nursing Act 33 of 2005:4). For this study's purpose, the researcher will apply the definition as it is relevant and applicable to nursing and the advocacy role of a nurse. In the context of typical nursing practice such as the hospital, patients need nursing care that involves nurse advocacy because they are vulnerable or debilitated by illness or injury (Kalaitzidis & Jewel, 2020:77). Level two hospitals Level two hospitals are defined as providing secondary level of care. This type of care is highly differentiated by function with 5 to 10 clinical specialties. These hospitals size range from 200 to 800 beds. (Jamison et al., 2006:79) For this study, level two hospitals are provincial hospitals providing secondary care within the North West Province of South Africa. 11 CONCEPT DEFINITION APPLICATION TO THE CURRENT STUDY In addition to that Torrey, (2020:np) explains that secondary care is when your primary care provider refers the patient to a specialist that is reachable within the same premise of care. When a patient is referred for level two or secondary care, it means the health care provider transferred the care to someone who has more specific expertise in whatever health issue. 1.4.3. Methodological assumptions Botma et al. (2015:287) define methodology, which includes the research design and methods of how researchers study whatever they believe can be made known. For this study, the researcher followed a qualitative approach to explore the factors influencing nurses to advocate for their patients. Qualitative research is well suited for "why", "how", and "what" questions about human behaviour, motives, views, and barriers (Neergaard et al., 2009:2). 1.5. RESEARCH AIMS AND OBJECTIVE In the following section, the aim and objective of this study are discussed. The researcher was interested in contributing to quality patient care by contributing to the body of knowledge on how to perform their role as patient advocates despite the challenges currently facing the health sector in South Africa. From the problem statement, the following question arose: What are the factors influencing nurses' patient advocacy role in level two public hospitals in the North West Province of South Africa? 12 1.5.1. Research aim This study aims to contribute towards the promotion of nursing advocacy by exploring and describing factors that influence nurses' performance of their patient advocacy roles. 1.5.2. Research objective A research objective is a concrete, measurable end towards which effort or ambition is directed. It is defined as a clear, concise, declarative statement written in the present tense (Brink et al., 2016:85). To reach the aim, the following objective was formulated: To explore and describe factors that influence nurses' performance of their patient advocacy roles at level-two public hospitals in the North West Province. 1.6 STUDY DESIGN The study followed a qualitative descriptive research design. Qualitative description is widely used to investigate health care and nursing-related phenomena (Kim et al., 2017:1). A qualitative descriptive design follows an empirical method of investigation, aiming to describe the participants' perceptions of experiences of the world. The study is also interpretative, as Sandelowski (2010:79) clearly states that all research has an interpretative component when the researcher analyses the data. For this study, the researcher followed the qualitative descriptive design to produce qualitative findings from the data, also referred to as a thematic survey (Sandelowski, 2010:78). 1.7 RESEARCH METHODOLOGY A descriptive qualitative framework was used for this study to answer the research question and to understand the phenomenon within its specific context (Negarandeh, 2008:549; Sandelowski, 2010:7). 1.7.1. Study context The study was carried out at all four level two public hospitals in the North West Province as they serve as secondary referral hospitals and are main referral hospitals within the province. These hospitals have a more comprehensive service provision than level one district hospitals. The participating hospitals were initially four, namely: Klerksdorp Hospital, Joe-Morolong Hospital, Job Shimankane-Tabane Hospital and Mafikeng Provincial Hospital. Klerksdorp/Tshepong hospital 13 has two complexes, the initial plan considered using only one complex from that hospital. However, the second complex was later included to obtain data saturation. Each hospital had a minimum of 100 nurses to a maximum of 300 nurses. The hospital had speciality services varying from neonatal wards, ante natal wards, dialysis units and oncology wards. Although the number of wards was not the same in each hospital, the researcher applied randomisation (Brink et al., 2016:123) when selecting wards for participants to be recruited from. Wards in the hospitals were randomly selected to allow all the wards an equal chance to be included in the study. 1.7.2. Population and sampling The population is all the elements, the participants, persons, and events from which the sample is drawn. Sampling is done to obtain a picture of the phenomenon under investigation, and more practical than to include all the population elements (Brink et al., 2016:123). 1.7.2.1. Population Brink et al. (2016:1230) define the population as the entire group of persons or objects of interest to the researcher, in other words, those that meet the criteria that the researcher is interested in studying (Brink et al., 2016:126). The target population (N=34) was the professional nurses who worked in the identified level two public hospitals in the North West Province. The number of professional nurses in each hospital varied from a hundred to three hundred. 1.7.2.2. Sampling Sampling is the process of selecting the subset or portion of the population to represent the accessible population (Botma et al., 2015:124). Botma et al. (2015:200) further explain that sampling involves selecting participants or artefacts to be included in the study. Sampling is done because the target population might be too large for the researcher to include the entire population. 1.7.2.2.1. Sampling technique A multi-level sampling technique was used in this study – for hospital wards and individual participants. For this study, the researcher adopted both probability sampling and non-probability (purposive) sampling methods (Brink et al., 2016:139). With the probability sampling method, simple random sampling was used to select wards as each unit or element of the study had an equal chance to be selected (Botma et al., 2015:127). The 14 researcher randomly selected the wards in each institution by putting ward indicators in a container and randomly drawing the required number of ward indicators. Purposive sampling as a non-probability method was used to select the professional nurses who participated in the study. Though non-probability sampling may not accurately represent the population, it is often used in qualitative research and is suitable for this research. The quality of the data obtained from non-probability samples, such as purposively selected samples, can potentially be high when the researcher is dealing with willing and able subjects (Brink et al., 2016:139). 1.7.2.2.2. Sampling size There is no simple formula to guide the researcher to determine the sample size, which was determined by data saturation (Brink et al., 2016:129). Participants were recruited from the randomly selected wards for the focus groups. Each focus group consisted of six to eight participants. The researcher planned at least one focus group at each hospital. Data-saturation occurred when the researcher became very familiar with the settings, routine, or data being collected, perhaps even feeling bored and if one has heard it all (Botma et al., 2015:200). Five focus groups were conducted with a total of thirty-four participants. (details in Chapter three where participants demographics will be outlined). 1.7.2.2.3. Inclusion criteria An inclusion criterion is defined as eligibility or distinguishing descriptors, which will form the basis for deciding whether an individual qualify as a member of the population in question (Brink et al., 2016:125). The following inclusion criteria were used: (1). Registered as a professional nurse with the South African Nursing Council. (2). Professional nurses with two years or more of full-time experience because such nurses have established social and work relations with other multidisciplinary health team members and have been exposed to patients who need advocacy. (3). Professional nurses who work shifts as they interact with different professional groups and have contact with patients during weekends when most members of the management are not available. They need to take responsibility for decision-making and patients' advocacy. 15 1.7.2.2.4. Exclusion criteria Exclusion criteria should be based on sound reasons. Inclusion and exclusion criteria have ethical implications (such as fairness of selection) and are not just of scientific relevance. (1). Nurses who have just graduated and are doing community service or probation were not included because they rotate around the various units in the hospitals as part of their community service and do not have prolonged encounters with patients. 1.7.3. Data collection: Data were collected during five focus group interviews. Focus group interviewing is a qualitative data-gathering technique used to obtain general background information and the participants' perceptions about a focused theme in a setting that is permissive and nonthreatening (Burns & Grove, 2009:513). A focus group interview is an open conversation on a specific topic in which participants make comments, ask questions, and in which there is good interaction between the researcher, co-facilitator, and the participants (Botma et al., 2015:360) 1.7.3.1. Data collection tool An interview schedule was used as a data collection tool. (See Annexure F). The interview schedule, also known as an interview protocol or topic guide, is a set of pre-determined open- ended questions that guide but does not dictate the interview. This schedule was based on the research question as it was more likely to generate valid answers in the study context. There were six questions in total, with the first question, an introductory question. Participants introduced themselves and gave biographic information with this first question. The researcher requested biographic information such as participants' age, sex, years of nursing experience, and educational qualifications as the first part of the interview schedule. The biographic question served as an introduction to relieve the potential tension between participants and researcher (Hanks, 2008:471. The follow-up questions were based on the interview schedule (See Annexure F) and were supplemented with supporting questions. For this study, the researcher will not be discussing results found on the study conducted by Hanks as it was an old study but was more interested in how the researcher could develop the interview schedule. Hanks (2008:471) designed a pilot study for nurses' advocacy roles used as a phenomenological inquiry about a particular phenomenon. The study was found to be like the current research study as it aimed to understand the essence of factors influencing nurses to advocate for patients (Hanks, 2008:471). The researcher amended the questions to fit her study. 16 The researcher also collected field notes that assisted in obtaining a thick description of data (Botma et al., 2015:219). The field notes formed part of the data collected and focused on aspects that participants did not verbalise, such as non-verbal cues or reactions to what other participants had said. Field notes will be saved with the collected data for storage according to the POPI Act, Act, 4 of 2013. These were very important as they assisted the researcher in obtaining an in- depth meaning of participants' feelings and behaviours accompanying what they have said during the interviews. The researcher also noted field notes such as the sitting arrangements, the order in which people speak, non-verbal behaviour such as eye contact, posture, gestures between group members, crying, fidgeting, and themes that are striking as well as specific group dynamics (Botma et al., 2015:219). 1.7.3.2. Data collection process Data were collected according to a pre-established plan. Firstly, the researcher ensured that permission was obtained at different levels, such as ethics approval from the NWU (see Annexure A) and approval for the research from the North West Province Department of Health. The permission obtained from the provincial Department of Health (Annexure B), the chief executive officers of the various hospitals (Annexure C) and the unit managers of the randomly selected units granted the researcher access to recruit professional nurses for the study. The participants were recruited as follows with information sessions and a recruitment pamphlet. The language used in the brochure was simple, written in English, and at the potential participants' level of understanding (Botma et al., 201514). The researcher selected a mediator such as the training officer at each hospital. They have a prior relationship with the potential participants and therefore know the appropriate people to approach and invite to participate in the study. The mediator was responsible for introducing the study to the potential participants in the relevant wards. The researcher ensured that the mediator was well trained and informed about the research study beforehand. The mediators at the various hospitals were asked to arrange information sessions where the researcher could tell the potential participants about the study. The researcher gave a brief presentation during these sessions at the wards during shift changes after report taking. Participants were able to ask the researcher questions regarding the study. After the information sessions, the recruitment pamphlets were distributed for potential participants to read during their own time to understand the study before they decided if they wanted to participate (Botma et al., 2015:145) (See Annexure D). The following information was provided in the informed consent documentation (Annexure E): • The title of the research project. 17 • An introduction to the research activities, extending the invitation to the nurses to participate in the study. • The researcher's title and position to enhance the credibility of the study. • The purpose of the project, including the long-term aim. • The selection of the study population and sample to indicate the population to be studied as well as how and why they were selected as potential participants. • An explanation of methods and procedures of data collection. • A description of any risk and discomfort (be it physical, psychological, emotional, economic, or social) involved as well as the benefits. • Confirmation of anonymity and confidentiality. • The voluntary nature of participation. The participant must sign a non-coercive disclaimer, as a statement that his/her participation is voluntary and that refusal to participate will not involve any penalty or loss of benefits. The participants were made aware that they may withdraw at any time, without the risk of the researcher withholding some of the information deliberately. • Participants were informed of the offers of the researcher to answer any questions they may have. • The contact person's name if a participant needed to talk to someone regarding his/her participation. • A delineated place for the signatures of the researcher, participant, and a witness (Brink et al., 2016:39). The researcher ensured that the participants were not unduly influenced or coerced to participate, as this was unethical. All participants were allowed to voluntarily decide whether they wanted to participate. During the process of obtaining informed consent, participants were made comfortable and told that a refusal to participate would not have been prejudice to them in any way. (Brink et al., 2016:37). Participants had 24 hours to decide if they wanted to participate. Participants were informed to bring back the unsigned consent form. After demonstrating their understanding of the essential information on the informed consent form, they signed it in the presence of the independent person who signed as a witness. The collected informed consent forms were stored in a sealed box to maintain the confidentiality of the participants. This box was kept in a locked cupboard for the duration of the research, with the plan to scan later and store the contents at the university for five years (see Annexure E for informed consent form). 18 After at least six to eight participants per hospital had signed and submitted their informed consent forms, the independent person (an administration clerk) informed the researcher. The independent person further arranged a suitable date for the focus group interviews. The time of the focus group interviews was set according to the participants' preference, and the researcher accommodated their choice, whether during day-duty, off-duty or night-duty time. A comfortable venue with enough room and privacy was selected to ensure no disturbance during the focus group interview (Brink et al., 2016:54, 143), for example, an office or meeting room. After the time, date and venue had been confirmed, the participants were informed of the final arrangements. They were also told that snacks and beverages would be served and that they did not need to bring food or spend from their pockets. Focus group interviews were conducted on the days as confirmed with the participants. The researcher conducted at least one focus group interview at each hospital. More groups would be added if data saturation were not reached with the first four groups. A fifth focus group was eventually conducted with participants from the second complex of Klerksdorp/Tshepong hospital. On the day of the focus group (all these interviews occurred before lockdown in March, thus no mention of Covid-19 lockdown), the researcher checked the room and its conduciveness to conduct a focus group interview an hour before the arranged time. The chairs were placed in a circle so that everybody in the group could see one another. Air conditioning for the room was available and set according to the participants' preferences. Snacks were available during the interviews. An audio recorder and a voice-recorder of a cell phone were used to record the data collected during the focus group interviews. Participants gave their consent to record the interviews. The researcher asked the questions and took the field notes. She has good communication skills as she was specially trained and is a qualified educator who could facilitate interactive and meaningful group discussions. The researcher and participants met behind closed doors to prevent the interviewees from being overheard by passers-by. " Do not Disturb" notice was placed on the door. Ground rules for the group were set before the focus group interview started, for example, allowing other participants to finish talking before someone else talked. The consent form was re- read as a reminder of what they consented to; also as a means of ensuring that participants still want to participate in the study. A critical ground rule was that participants would have to agree not to divulge the information shared during the focus group interview to ensure shared confidentiality amongst the participants and the researcher. 19 The focus group interviews lasted 40-60 minutes per group (Negarandeh et al., 2008:549). 1.7.4. Data analysis Qualitative data analysis involves integrating and synthesising non-numeric data that are reduced to themes and categories with the aid of a coding procedure (Brink et al., 2016:57). Before starting to analyse or process the data, the researcher examined the data for completeness and accuracy. The researcher followed Creswell ҆s (2014:209) thematic data analysis method and Tesch's eight steps to identify common codes. Data were analysed manually. The researcher communicated with the co-coder via email due to the Covid-19 lockdown. There were no differences in the themes identified between the co-coder and the researcher. Creswell refers to a generic qualitative analysis approach in which the researcher collects the qualitative data, analyses it for themes or perspectives, and reports four to five themes. The researcher interpreted data using thematic analysis by grouping information in themes as the study followed a qualitative descriptive design (Creswell, 2014:209; Sandelowski, 2010:79). Table 2: Process of data analysis STEPS DESCRIPTION OF STEPS SUB-DESCRIPTION OF STEPS Step 1 Organising and preparing data The first step was to prepare and organise the data for analysis. This involved transcribing the interview audiotapes and typing up the field notes. The researcher was aware that transcribing focus group interviews is time-consuming; accordingly, time was allocated for this process. A transcriber was hired and instructed to transcribe the audio into written form. This transcriber had to sign a confidentiality form. The transcriber used a template with enough space on both the left and the right margins to allow the researcher to make notes during the analysis. One margin was used for personal notes, and the other for identified categories. During transcription, additional data such as 20 STEPS DESCRIPTION OF STEPS SUB-DESCRIPTION OF STEPS field notes were added to the transcription to enrich the depth and context of transcription (Botma et al., 2015:214). Step 2 Developing a general sense The second step was to develop a general sense of the data by reading through the data (transcriptions and field notes) obtained during focus group interviews and reflecting on the overall meaning (Botma et al., 2015:214) Step 3 Data coding During the third step, the data were coded, according to the eight steps of data coding (Botma et al., 2015:22). Coding is the process of organising the material into chunks or segments of text before bringing meaning to the information. It involved taking text data, gathered during data gathering, segmenting (words, phrases), sentences, or paragraphs, into categories, and labelling those categories with a term based on the participants' language (Botma et al., 2015:225, Creswell, 2014:209). This step is important as it was used to find patterns and produce explanations using both deductive and inductive reasoning to categorise data into segments. This step is called coding; it is a process used to organise data collected during interviews or from other types of documents. Tesch's eight steps of Coding according to Botma et al. (2015:224): The researcher got a sense of the whole data by reading through it. She picked one document, went through it to create meaning by writing on the margins. After completing this task of coding all five documents, the researcher identified topics and clustered them together; these topics were then put into columns. The researcher then used this list to go back to the data and abbreviate the topics into codes. This was done to determine if preliminary themes could emerge; fortunately, such themes emerged. Descriptive wording was used to turn the codes into categories. 21 STEPS DESCRIPTION OF STEPS SUB-DESCRIPTION OF STEPS A final decision of each category was then made regarding the abbreviations of the codes. Data was then assembled in each category to make a preliminary analysis. There was no need for re-coding. (Creswell 2014:198) Step 4 Describing and identifying themes The fourth step was to describe and identify the themes by using the coding process to generate a description of the setting or people as well as themes from the categories Step 5 Representing the findings Step number five entailed representing the findings. This included a detailed discussion with the co-coder about the various themes identified (Creswell, 2014:209). Verbatim quotations were used when data findings were presented. Step 6 Interpreting the data A final step in data analysis involved interpreting the meaning of the data. Support of literature was used during the data interpretation. Source: Botma et al., 2015:224. The co-coder was an experienced qualitative researcher who signed a confidentiality agreement that all identifiable information she came across would be kept in confidence. The co-coder was instructed to follow the coding process described by Creswell, which incorporates the eight steps of data coding (Botma et al., 2015:224; Creswell, 2014:209). 22 1.8 RIGOUR Validity and reliability are not relevant, as qualitative research methods do not lend themselves to statistical calculations of validity. However, this does not imply that qualitative researchers are not concerned with the quality of their data collection techniques (Brink et al., 2016:163). Rigour in qualitative research refers to openness, relevance, epistemological and methodological congruence, thoroughness in data collection and data analysis processes, and the researcher's self-understanding (Brink et al., 2016:126). For any missed or misunderstood information during the focus group interview, the researcher asked follow-up questions or repeated after the participants to verify what the participants had just said. The researcher used an audio recorder and a cell phone used for backup for data collection, which ensured accuracy for data to be transcribed from the recording done (Botma et al., 2015:214). The recording made it feasible for the transcriber to transcribe the data using the latest software and technology that assisted in the transcription of data and allowed the transcriber to listen to sounds that may have been missed. The transcriber also signed a confidentiality agreement. Rigour in a qualitative study deals with trustworthiness or measures put in place to ensure the quality of the research (Creswell, 2014). The authors employed measures to ensure credibility through the purposeful selection of study participants, member checking, and peer review (Creswell, 2014; Polit & Beck, 2008:509). Confirmability and transferability were also ensured. In Table 2, the researcher presents the epistemological standards to promote rigour that was applied in this study. 23 Table 3: Epistemological standards for rigour as applied EPISTEMOLOGICAL STANDARD STRATEGY TECHNIQUE Truth value Credibility: this criterion was met by using accurate descriptions and interpretations of participants’ ̓ experiences. In addition, the participants were allowed to verify their own experiences and interpretations during the focus group sessions. The researcher reported all the participants' perspectives as clearly as possible (Botma et al., 2015:292). Credibility was ensured by using accurate descriptions and interpretations of participants' experiences (Hanks, 2008:472). Applicability Transferability is met if a professional nurse in another hospital who must advocate for a patient is influenced by similar factors found in this study. The reader should have enough information to decide if the findings will yield the same results within their setting. The researcher applied purposive sampling of participants, a thick description and data, and data saturation. Polit & Beck describes thick description as a rich, thorough, and vivid description of the research context, this includes the people who participated in the study, and the experiences and processes observed during the inquiry. Thick description of this study looked into explaining the prevailing sentiment is that if findings are to be transferable by applying theme in a different province in order to yield the same results. From the study participants, also contribute to other quality criteria, including the authenticity and vividness of a qualitative study. The researcher can also share an oral report at different provinces for 24 describing the findings of this study (Polit & Beck The researcher wrote her field notes as part of a thick description; these field notes added value to the description of data. The focus group interviews were conducted at all four level two public hospitals in the North West Province to get in-depth information through carefully selected questions and thorough probing. The participants were encouraged to give a detailed account of their knowledge regarding the research question (thick data), as they were telling the researcher about their personal experiences regarding the research phenomenon. Data saturation was reached when the same themes repeated themselves within the focus group interviews. The researcher gathered the data from the six to eight participants per focus group in each hospital; this was done until the researcher no longer received new information from the focus group interviews (Fusch & Ness, 2015:1413). If data saturation was not obtained after the first round of focus group interviews, more focus group interviews would have been conducted until there was saturation of data. 25 EPISTEMOLOGICAL STANDARD STRATEGY TECHNIQUE Consistency Dependability: this was maintained if an external reviewer was able to reach the same conclusions using the raw data and analytical documents should a similar study be conducted. For this study, the external reviewer can be an external examiner or another researcher The researcher used peer debriefing as credibility in the research methodology class when she presented her research project during her studies. This allowed the researcher an opportunity to receive criticism and to justify the study. The researcher wrote her reflections regarding these peer reviews and debriefing to see if they could be used to build her argument. Dependability and credibility were further promoted when an external reviewer (the co-coder) reached the same conclusions using the raw data and analytical documents as the researcher. Confirmability is also supported if a reviewer of the published study reaches the same conclusions. Confirmability was supported by maintaining a verifiable audit trail of movement through the data, including field notes, the interview schedule used during the focus group interviews, and methodological notes. Applicability was promoted as a reader can apply the findings to similar samples in other public hospitals settings (Hanks, 2008:472). Source: adapted from Burns & Grove (2009:375-376, 215-219). 26 1.9 ETHICAL CONSIDERATIONS For this study, the researcher accepted the responsibility of conducting high-quality research and following the general ethical principles outlined by Brink et al. (2016:30-43) and the Department of Health (DoH, 2015:7). Throughout the study, these standards were followed regarding the planning, implementation, and reporting of the research. The supervisor and the scientific committee of the research entity thoroughly scrutinized the research proposal. The researcher was also committed to scientific honesty and ensured that this was maintained by highlighting the opposing and supporting viewpoints identified. The researcher acknowledged other individuals' ideas and work by accepting the plagiarism policy of the North-West University. An extensive audit trail was kept of each step of the research process to facilitate peer review of the entire research process. The NWU Health Research Ethics Committee executed an ethics review according to the Ethics in Research: principles, process, and structures (South Africa, 2015:7, The National Health Act (NHA), 61 of 2003 (NHA 72(1):9). The Department of Health (2015:7) requires that proposals to conduct health research must undergo an independent ethics review before the research commences. This review of proposed 'health research must be conducted by a REC (Research Ethics Committee) or AREC (Animal Research Ethics Committee) that is registered with the NHREC (73(2) of the NHA. RECs must review health research proposals and protocols to ensure that the research promotes health, contribute to the prevention of communicable or non- communicable diseases or disability, or result in cures or alleviation of suffering caused by communicable or non-communicable diseases or disability (NHA s 73(2)(a)). RECs must ensure that research proposals stand up to scientific and ethical scrutiny appropriate to the disciplines concerned. RECs must review research proposals and protocols prospectively to ensure that they meet the accepted ethical norms and standards before research commences, using these guidelines as a minimum benchmark (NHA s 73(2)(b) (DoH. 2015:7). According to Tracy (2010:847), the researcher ensured procedural and situational ethics. As a method of procedural ethics, the researcher safeguarded participants from undue exposure by securing all personal data in a locked office or drawer (Tracy, 2010:847). Situational ethics implies that each circumstance is different and that the researcher repeatedly reflected on these differences, critiqued, and questioned her ethical decisions. In short, this ethical consideration suggested that ethical considerations should be based on the particularities of a specific scene (Tracy, 2010:847). 27 1.9.1. Legal authorisation According to Section 72 of the National Health Act 61 of 2003, the National Health Research Ethics Council (NHREC), National Health Act, 61 of 2003 (NHA), the Health Research Ethics Committee (HREC) of the North-West University gave legal authorisation for the research to take place after it has approved the research protocol (see Ethics Approval Certificate, Annexure A). The researcher received official permission to access facilities from the Department of Health of the North West Province after ethics approval. The Planning, Policy, Research, Monitoring and Evaluation Office at the Department of Health of North West Province also gave legal authorisation for the level two public hospitals in the province to be used for this research project (see Annexure B). 1.9.2. Goodwill Permission The researcher requested goodwill permission from the gatekeepers at different levels. The CEO of the four level two hospitals in the province were requested to approve that their employees may be asked to participate in the research process. The deputy nursing director of each hospital was asked to grant goodwill permission for the hospital's nurses to be interviewed. Finally, the different unit managers were also asked to grant permission for the nurses from their units to participate in focus group interviews (See Annexure C for permission from the hospitals). 1.9.3. Probable experience of participants Participants were informed that they were expected to participate in semi-structured focus group interviews. They will be asked to discuss their viewpoints, perceptions, opinions, and experiences on the factors that influence their role as patient advocates. They were also notified that while the discussion may be uncomfortable initially, it will likely become more comfortable during the ice- breaking and introduction session. Participants may have experienced uneasiness at the beginning of a focus group as this research aimed to understand nurses' emotions concerning factors that influence their role as patients' advocates. Some participants may have been uncomfortable due to emotions attached to past experiences with patients who needed advocacy. 1.9.4. Risk and benefits Before beginning the study, the researcher and reviewers from the Health Research Ethics committee (HREC) examined the ratio between the benefits and risks involved. The general guideline was that the risks must not exceed the study's potential benefits. When the risk is high, the researcher must ensure every effort to reduce it and maximise the benefits as a precautionary measure (Brink et al., 2016:42). In this study, the benefits were more than the risks. 28 Risk equates to harm or injury and implies something detrimental that may occur in the future (Botma et al., 2016:21-22). There are six types of harm, namely physical, psychological, social, economic, legal, and dignitary harm. No legal or dignitary risks were foreseen or experienced in this study (Botma et al., 2016:21-22). The researcher was on the lookout for any risks that may occur because of the research, and the necessary and relevant referrals would then be made. Table 4: Risks and precautions to limit them RISKS PRECAUTIONS Physical risk: There was no physical harm or risks encountered by the participants as this study did not include any bodily contact or harm For physical comfort, the researcher ensured that the room was not too cold or too warm and clean and well ventilated. The data were gathered before the COVID-19 pandemic with its associated risks. Psychological risk: Participants in the study may encounter psychological risks as they may experience doubt about their ability to advocate for hospitalised patients. If any participant becomes emotional such as being upset during a focus group interview, the researcher requests a break, offers a glass of water, and allows re-grouping. She also asked the participants if they wanted to continue or if the interview should be postponed to a better time when the participants would be able to provide information. For this study, a counsellor (an experienced psychiatric nurse) was available to counsel participants who might need counselling because of the emotions experienced during the focus group interviews. Social risk: There is a risk of loss of confidentiality – especially in a focus group. Work can be viewed as a social environment; the participants might fear to be a social outcast at work or to be labelled as a "snitch" by other health care professionals as they were discussing factors that they have seen in Only the participants and members of the research team know the venue where the interview took place to avoid unannounced visitors or unnecessary movements during the interview process. The venue was private to ensure that no one overhears the discussion and to limit disruptions. 29 RISKS PRECAUTIONS their working environment that influenced them and/or other nurses to advocate for their patients. This may be uncomfortable to some nurses and viewed negatively. All the participants were requested to introduce themselves before the commencement of the focus group interview so that all those who wanted could withdraw should they feel uncomfortable. The researcher emphasised ground rules such as not divulging information gathered during the focus group interview. Complete confidentiality could not be guaranteed as it depended on the cooperation of all, only shared confidentiality. The participants were reassured that anonymity would be maintained when the research report was presented and published. Economic risk: Participants who must travel specifically for the interviews may have travel expenses The Time-Inconvenience-Expenses (TIE) principle must be considered for those who would have travelled; however, the focus groups were conducted during the participants' working hours or lunchtime according to their preference. Participants were not reimbursed by the researcher for time or inconvenience. Benefits are positive values of the research, while risk refers to the possibility that the participants may be harmed during the research process. As in most aspects of daily life, all research involves a certain amount of risk (Brink et al.,2016:42). Direct benefits to participants are only applicable in studies where participants receive specific therapeutic interventions. There was no intervention in the current study, and therefore, participants did not receive any direct benefits. Significant benefits included the following: • An increase in knowledge about health care practices regarding nurses' performance of patient advocacy. 30 • An improvement in the participants' understanding of health care delivery and nurses' perceptions regarding their role as patients' advocates. • The enhancement of the participants' self-esteem, as nurses learn and understand what advocacy entails and what guiding principles there are to use as they advocate for patients, thereby enhancing self-esteem. • Improved assessment of health needs of vulnerable patients who need advocacy. Table 5: Direct and indirect benefits of the study DIRECT BENEFITS FOR PARTICIPANTS: INDIRECT BENEFITS FOR SOCIETY AT LARGE OR THE RESEARCHERS/INSTITUTIONS: There are no direct benefits as there is no therapeutic intervention. Patient care It will improve because nurses will be able to understand that all patients are vulnerable when they are in hospital and that they all need advocacy (Negarandeh et al., 2008:457). Self-esteem Participants will discuss the factors which have influenced them to advocate for patients. This will allow them to explore ways to improve this role, thereby improving their self-esteem and interpersonal relations with other health care providers; they would know how to approach issues regarding patients and assume the role of a patient advocate. Role clarity Nurses who understand their role as patient advocates can perform this role within the multidisciplinary health team more efficiently and effectively, not as subordinates to other health care providers. Source: Department of Health (South Africa), 2015:16. Tables 4 and 5 indicate that there are more benefits than risks. 31 1.9.5. Vulnerability of patients There were no vulnerable participants as all were adult professional nurses with at least two years’ experience at the participating hospitals. 1.9.6. Respect for participants Section 12(2) of the Bill of Rights in the South Africa Constitution (South Africa, 1996) protects against research abuse by providing that: “Everyone has the right to bodily and psychological integrity, which includes the right: (a) to make decisions concerning reproduction; (b) to security in and control over their body; and (c) not to be subjected to medical or scientific experiments without their informed consent, (Department of Health [South Africa], 2015:6)”. All participants were treated with respect and courtesy. Permission was asked from participants concerning participation and publication of the research findings. 1.9.6.1. Privacy and confidentiality. Privacy is concerned with who has access to participants’ personal information during data- collection, and ‘confidentiality’ ensures that appropriate measures are implemented to prevent disclosure of information that might identify the participant (inadvertently or not) either during the research or afterwards. The Protection of Personal Information Act, 4 of 2013 (Bangani & Moyo, 2019:3-4), has increased the need to ensure computer safety, locked record storage facilities, and careful gatekeeping about access to raw data, including completed informed consent documents. Complete confidentiality could not be guaranteed as it depended on everybody's cooperation; only shared confidentiality is possible. Participants were urged to keep the information they became aware of during the study confidential. Instead of the actual names of the participants, pseudonyms were used during the focus groups. A voice recorder and a cell phone as backup were used for data collection. Participants were ensured that confidentiality would be maintained by deleting recordings from the device immediately after they had been transferred to a password- protected computer. After that, only the transcriber who had signed a confidentiality agreement was able to hear it. This procedure prevented any unauthorised person from having access to the recordings. During data analysis, the transcriptions were shared with the co-coder in a password- protected folder. The co-coder was instructed to delete all information after data analysis had been completed. 32 All paper documents (informed consent forms) were stored in a locked cupboard in the locked office of the director of NuMIQ for five years. All the printed and electronic documentation, such as consent forms and transcripts of the interviews, were kept securely (DOH, 2015:22). After the research had been finalised, the electronic documents (transcriptions and analysis documents) would first be saved on an external storage drive and then deleted from all computers. The external device was stored with the paper documents for five years. Confidentiality agreements were entered into by the mediator, transcriber, and co-coder. 1.9.6.2. Anonymity Anonymity means namelessness. Anonymity cannot be maintained in a focus group, as participants were known to each other. For the participant's anonymity to be maintained when data is interpreted and analysed, codes were used instead of names. The process of ensuring anonymity refers to the researcher’s act of keeping the participant’s identities a secret concerning their participation in the research study. Even the researcher should not link any participant and hospitals to specific findings. The researcher assured participants about safeguarding their identities when the results of the research study were published. As focus group interviews were used, participants were made aware that absolute anonymity would not be possible as they know each other. However, the researcher processed the data anonymously (Brink et al., 2016:37), and the hospitals and participants’ names do not appear in the research report as only codes were used. 1.10 EXPERIENCE, SKILLS, AND COMPETENCY OF THE RESEARCHER Researchers must be suitably qualified and technically competent to carry out the proposed research. The principal investigator (PI) or research leader has the primary responsibility to ensure participants' safety and well-being, the scientific integrity of the protocol and is responsible for the implementation of that protocol. Competence was demonstrated mainly by academic qualifications, credentials, scientific and technical competence. Competence includes research competence, which is assessed in terms of education, knowledge, certification, and experience. In addition, researchers should produce evidence of appropriate research ethics training within the previous three years. The student researcher has undergone ethics training and has passed the required ethics assessment to be able to apply and conform to ethical considerations for the duration of the research process. The researcher has also undergone additional training to conduct focus group interviews before conducting the focus group interviews. Qualifications and relevant experience 33 of the supervisor/principal investigator were considered as the researcher is supervised by an experienced researcher with a doctoral qualification in nursing. 1.11 DATA MANAGEMENT The following key areas were addressed to maintain the confidentiality of the research data: 1. Personal information and identifying essential information were captured on a datasheet. The master list of the participants’ details was kept in a locked-up place away from the data. Informed consent forms were not being stapled to data collection sheets. 2. Access to confidential information was limited to those who were directly involved with the research, which was: the researcher, the supervisor, and the co-coder. No information was shared with a person who is not officially and directly involved in the research. Participants also had to agree to keep shared information from the focus group interview confidential. 3. All printed copies of data were safely and securely stored in a locked cabinet. 4. Data were anonymised and stored on a computer that was password protected (Botma et al., 2015:18). 5. An audio recorder and cell phone recordings were deleted as soon as it was saved on a password-protected computer. Data captured from the participants was only shared for analysis. 1.12 DISSEMINATION OF RESEARCH RESULTS Dissemination of research results is the communication phase or the phase of writing the research report and is done not only for publication but also for knowledge translation (Brink et al., 2016: 53). Dissemination will be done to academia, the institutions where the research was done, and the participants. 1.12.1. Dissemination to academia Dissemination to academia will be done in the following way: An article will be submitted to a peer-reviewed journal with the assistance of and under the guidance of the study’s supervisor. The article will communicate each step of the study process 34 and will indicate the findings. The researcher will ensure compliance with the publisher’s policies, and corrections will be made according to the journal’s policies. The results will also be presented at a suitable conference, addressing the improvement of quality patient care (Brink et al., 2016:58). 1.12.2. Dissemination to institutions A research report will be sent to all the institutions that were involved in the research to inform them about the outcome of the study. The hospitals’ chief executive officers and deputy directors of nursing who have given goodwill permission for the researcher to access the hospital will receive the reports. 1.12.3. Dissemination to participants As some participants may not have access to platforms in which the findings will be published, a presentation of the results will be done during the provincial Department of Health research day, where nurses are usually gathered in large numbers, or at mass nursing meetings commonly held at hospitals. The researcher will request permission to do the presentation to disseminate findings to participants. The findings of the research could also be communicated to participants from the reports sent to the institutions and read out during patient hand-over in the wards when shifts change. 1.13 CONFLICT OF INTEREST Quote ”Conflict of interest represents circumstances in which professional judgements or actions regarding a primary interest, such as the responsibilities of a researcher, may be at risk of being unduly influenced by a secondary interest, such as financial gain or career advancement. The secondary interest may be