Linking Paradigms and Methodologies in a Qualitative Case Study Focused On Exploring the Operation of Power in Human Actions During the Design of a New Occupational Therapy Intervention

Abstract

A research paradigm represents how a researcher views the nature of reality and guides how they engage in research to generate knowledge from that reality. Power is a construct that impacts on the individual actions of the researcher and the participants, and their interactions with each other, across a range of perspectives of reality. Qualitative researchers select different paradigmatic stances to represent how they consider and work with the influences of power on these human relations. This influences their decisions about which research design and methodology they select. Drawing on my doctoral study, which explored the process by which a group of occupational therapists designed an intervention for caregivers of children on anti-retroviral treatment living in low-income conditions in South Africa, I describe my process of selecting a poststructuralist paradigm, an instrumental case study design, and a co-operative inquiry methodology to illuminate the operation of power in the research process. An overview of the potential offerings and limitations of different paradigms, research designs and methods, as applied to this research example, are presented to support my assertions. In conclusion, I argue for the more consistent consideration and description of the interplay between paradigms, research design and methodology, to ensure the selection of the best suited combination to explore and describe the influences of power in the research process.

Keywords

power research design research methodology research paradigms

Introduction

Research paradigms are essential to producing rigorous research (Brown & Dueñas, 2019). They represent a researcher’s beliefs and understandings of reality, knowledge, and action (Crotty, 2020; Guba & Lincoln, 1994). In qualitative research, a wide variety of paradigms exist and qualitative researchers select paradigms which are theoretically aligned with their views of how power relates to knowledge, and how power operates in the actions of, and between the researcher and the research participants. In this paper I share how my views on the operation of power on the actions of a group of occupational therapists as they collectively designed an intervention, led me to select a poststructuralist paradigm, a case study design and a co-operative inquiry, as summarised in Figure 1. Readers will be provided with insights which will inform their application of paradigm, design, and methodological combinations to guide their research. I begin with reflecting on what led me to focus on this research in South Africa, foregrounding how the foundation for selecting a research paradigm is initiated by unpacking one’s own views on the construct of power in their research context.

Figure 1.

The interface of the paradigm, research design and methodology in the case example (Gretschel, Ramugondo & Galvaan, 2017).

My Considerations of Power in the Context of This Research

The deeply-rooted negative impacts of the Apartheid regime have continued to create vast positional and intersectional identity chasms between White and Black South Africans. I, a White, Christian, English speaking occupational therapist of middle-class socio-economic status, became increasingly aware of my positioning as a member of a largely homogenous racial, socio-economic and socio-cultural grouping of occupational therapists. My observations were supported by statistics which detail that while Black South Africans constitute approximately 81% of the total South African population (Statistics South Africa, 2021), 66% of occupational therapists working in South Africa are White (Ned et al., 2020).

My appreciation of the existence of dominant Discourses in social groups drove my interest in exploring how, in demographically homogenous communities of practice, similar personal values might shape enactments of professional roles which might not respond optimally to the needs of the people we are working with. In particular I wondered how my (our) positioning as priviledged White South Africans might impact on my (our) ability to connect with caregivers and children from different social groups. Given this interest, I embraced the opportunity to explore the process by which we, a group of White, female, middle-income, English speaking occupational therapists designed a new intervention for predominantly Black caregivers living in low-income conditions in South Africa. The new intervention aimed to build on the caregivers' self-efficacy and their ability to use play to promote the engagement of their HIV positive children in their occupations of play and learning.

Our process of designing the new intervention was an exemplar of a common situation in the context of health and rehabilitation in South Africa. Despite concerted efforts to reduce mother-to-child transmission of the virus, childhood HIV continues to be a major health and social concern in South Africa (Levin et al., 2021). Close to a quarter of South African women of reproductive age are HIV positive (Statistics South Africa, 2021) and many factors limit their access to and adherence to medical care for themselves and their children (Levin et al., 2021). Children with HIV/Aids are a vulnerable population and the various studies describing how their occupational engagement is compromised, emphasise that rehabilitation interventions for them and their families must be prioritised (Meissner et al., 2017; Munambah et al., 2020; Ramugondo et al., 2018).

My research question was, What is the process by which a group of occupational therapists negotiate their intersections of identity and positioning when designing and implementing an intervention for caregivers of children on ART living in low-income conditions in South Africa? The question aligned with a qualitative research approach, focused on gaining insights into human actions and the motivations driving these actions (Denzin & Lincoln, 2005).

We formed a community of practice who came together to engage in a series of activities to design an intervention which aimed to improve on the interventions we had provided in the past (Wenger et al., 2002; Wenger, 2006). We entered this community, with specific identities, which would continue to be shaped by our interactions with each other within the socio-cultural context of our activity of designing the intervention (Wenger, 1999). Recognising the persistence of racially linked power-differentials between White and Black South Africans, I was interested in how we would build on connections and navigate tensions between our values, and the values of the caregivers.

Existing health theoretical frameworks are largely nested in a positivist paradigm which is aligned with a structuralist and objective stance (Mann, 2011; Thomas, 2006). When translated into practice, such a stance implies that there is a set way of being healthy and well, and health professionals who draw on evidence informed procedural approaches can help people to achieve this ideal. I was concerned that this paradigm would not give enough attention to individual and collective meaning making, the impact of contextual factors on human action, the agency of people to take action, as well as the nuances associated with these aspects. I wanted to appreciate and delve deeper into the aspects described above, and for this reason I was drawn to the views of implementation science that account for not only the practical aspects of the intervention design process but also our navigation of our professional and personal values in this process (Lenchuca, Kothari & Rouse, 2007; Leykum et al., 2009).

The below stated objectives reflect the broadness of my focus on describing:

1. how the group accessed, evaluated, and implemented knowledge to develop the intervention,

2. the key concepts, values, and approaches of occupational therapy they integrated into the intervention,

3. the central strategies and activities of the intervention design process in practice and how they facilitated the intervention in practice,

4. the contextual, personal, and professional factors influencing the intervention development and implementation processes, and,

5. the key points of tension and success the group met, and how they managed these tensions and drew on their successes as they designed the intervention (Gretschel, Ramugondo & Galvaan, 2017).

I deliberated between situating my study in a constructivist, critical theory or post-structuralist paradigm and eventually decided on poststructuralism. I was drawn to poststructuralism because it acknowledges our potential to recognise and use our own power (Foucault, 1980). In other words, while structures can exert power on us, we can draw on our power to be self-determining and direct our actions to respond to oppressive and limiting strutures (Mozere, 2006). This paradigm represented my worldview in that I believed that despite our homogenous composition, we would be able to be critically reflexive with ourselves and each other, recognising that we could deconstruct our own power and shift our practice, where needed, during our process of designing the intervention. I believed this to be true given that throughout our similar tertiary education journeys, we had been guided and encouraged to engage in reflective practice. In addition, our close connections with academia meant that we could connect with critical companions who would challenge the assumptions we might have, and we could access research and theory to shape new and innovative approaches. In the sections which follow, I share my deliberations about which paradigmatic stance to select and my final decision to position myself in a poststructuralist paradigm.

Selecting Poststructuralism to Capture an Extended View of Power

The first paradigm I considered was constructivism. A constructivist paradigm focuses on how individuals socially construct their reality (Cresswell, 2007; Crotty, 2020; Guba & Lincoln, 1994). I reflected on my own meaning making, and how my current positioning as a lecturer in academia and my past role as an occupational therapist in clinical practice, would shape my beliefs about what the new intervention should look like. This personal reflection shaped my interest in how each member of the group would enter into the intervention design space, as well as their different experiences of this process. While individual meaning making was valued, I was also interested in how professional, socio-cultural, political, economic, and organisational factors would impact on our practice-based process of designing the intervention (Conklin, Kothari, Stolee, Forbes & Le Clair, 2011; Higgs & Titchen, 2001; Whiteford et al., 2005). Constructivism focuses on the cognitive and meta-cognitive processes of meaning making and less on the possible constraints of structure, which might serve to regulate or influence the realities that individuals construct (Crotty, 2020; Zembylas, 2005). Given this, I feared that constructivism would not unpack how our actions would be driven by economic, political, and ideological forces in the structures of the contexts in which we were designing the intervention (Zembylas, 2005). I thus turned my attention to the paradigmatic perspective of critical theory (Habermas & Habermas, 1971).

Critical theory focuses on the ways in which dominant social, political, cultural, economic, ethnic, and gender forces, reproduced by governments and other organisational structures, influence people’s decisions and actions (Guba & Lincoln, 1994). I was drawn to the ways in which a critical theory paradigm would expose the impact of the conventional ideologies and assumptions, enforced by these dominant structures on our individual subjectivity and our engagement in the intervention design process. In South Africa, these dominant structures included the National sectors of health, education, and social development; the National regulatory bodies, the National occupational therapy association and its affiliated groups; higher education institutions training occupational therapists, other factors in the workplaces of the group, and their familial and faith structures. I recognised the potential impacts of these structures but my discomfort with, and resultant decision to shift from critical theory, linked to its association with an emancipatory agenda. We had all been working as independent practitioners for some time, and because of this I assumed that we would not be disempowered or marginalised. I believed that we would consciously engage during the process of designing the intervention. While I strove to build on conscientisation I believed that I would not be the sole director of this process, and that we as a collective would be able to critique where needed, our current practice and strive towards creating new and relevant knowledge to inform a better practice. After much deliberation, I decided that critical theory would not offer sufficient space to address power as emerging in discursive relations. My attention then shifted to poststructuralism as a worldview which would accommodate for shifting positionalities in expressing both individual and collective agency.

Poststructuralism’s extended view of power (Foucault, 1980; Williams, 2005; Zembylas, 2005), acknowledges that power is not limited to the power exercised over others by structures and organisations. People have power to direct their own actions in both positive and negative ways, but human actions cannot always be described by cognitive and rational boundaries (Kinsella, 2005). This paradigm framed my intent to understand the precarious and contradictory nature of our actions, delving into our negotiation of our power, exploring how we evaluated our intervention design practices, and if and how we worked against our established ways of working if these ways were not well suited to address the needs of the caregivers and their children (Agger, 1991). A post-structuralist lens would guide me to consider not only the external influences but also the actions we would take to respond to significant events and obstructive structural influences which would arise in the process of designing the intervention. In this way, this paradigm would help me explore the diverse ways in which we would re-negotiate power relationships embedded in our practices that may privilege specific ways of knowing and in response, change our practices accordingly.

As described earlier, the decision about which research design and methodology to use is informed by the research paradigm the researcher is locating themselves in. The research design describes the specific tenants of how the inquiry will be conducted, while the methodology refers to how the data will be generated. Once I settled on a poststructuralist paradigmatic stance, I began the process of selecting the research design and methodology which aligned with this paradigmatic stance. In the sections below I describe my process of exploring the utility of applying a case study as a research design and co-operative inquiry as a methodology, justifying their links to poststructuralism.

Case Study, a Research Design to Explore Multiple Dimensions of Power

Case study is a research design that strives to generate context-dependent knowledge, knowledge that Flyvjberg (2006) argues is the only form of knowledge that should exist in the study of human action. Robert Stake’s (1995, 2005, 2008) naturalistic qualitative case study design resonated with the qualitative approach adopted in this study. The case, a “specific, a complex and functioning thing” (Stake, 1995, p.2) bounded my focus on our specific activity of designing and implementing the new intervention. Our process of designing the intervention, represented a single, instrumental case (Stake, 1995; 2000) which was an exemplar of a common issue in the context of health and rehabilitation in South Africa.

The use of multiple methods of data collection associated with case study allowed me to explore, from multiple dimensions, our practice-based process of designing this intervention (Stake, 1995; 2000) providing me with insights into our experiences, and the meaning that we assigned to this process, which aligned with the constructivist underpinnings of qualitative case studies (Stake, 1995; Yazan, 2015). Recognising the limitations of a purely constructivist perspective to case study, I maintained alignment with my poststructuralist stance and sought a methodology that would create a platform for us to reflect on and negotiate our power in our actions as clinicians and researchers designing this new intervention. I saw co-operative inquiry as a methodology that held such potential.

Co-operative Inquiry, a Methodology Creating Opportunities to Exercise Power

Post-structuralism purports that all people have power, however how they choose to harness that power is contrasting and divergent. A methodology was needed to create opportunities for power to be exercised by all involved in the research. Cooperative inquiry is a form of participatory action research that supports the abandonment of hierarchical relationships of power and creates a platform which encourages all involved in the research process to contribute to and even lead aspects of the research process (Cockburn & Trentham, 2002; Kielhofner, 2005; Suarez-Balcazar et al., 2005; Taylor, Braveman & Hammel, 2004). Research participants become co-researchers who collectively engage in research work together with the researcher (Heron, 1996; Heron & Reason, 1997, 2007; Reason, 2002). Co-researchers are often chosen because of their comparable background to the researcher in that they are “...people who have similar concerns and interest to the researcher” (Heron & Reason, 2001, p. 179). The group were eager to work with me to understand and make sense of our practice, and respond with actions to change aspects of our practice when needed. Cooperative inquiry facilitated our engagement as research partners (Heron & Reason, 2001; Savin-Baden & Wimpenny, 2007). I supported a participatory approach, joining the group as not only a researcher but also a co-designer of the intervention. My location of myself in the phenomenon I was researching, aimed to dislodge the hierarchical elements of power associated with traditional research approaches (Kemmis & McTaggart, 2005).

While not without its challenges, the cooperative inquiry encouraged conscious observations of our process of designing the intervention (Reason, 2002; Heron, 1996) creating a platform in which we could, as a “self-aware, critical community of inquiry nested within a community of practice” (Reason, 2002, p. 172), unpack the positive and negative impacts of our professional knowledge as well as our personal values and practice experiences on the intervention design process (Whitehead, 1989). Having detailed my process of selecting a research design and methodology aligned with my paradigmatic stance, I now go on to describe the multiple steps I adopted to ensure that we generated trustworthy findings.

I was mindful throughout the research process of strategies to ensure the credibility, dependability, confirmability and, to some extent, the transferability of the study. For the purposes of this paper and its focus on how I navigated selecting a research paradigm, I will focus on describing how I used reflexivity and member checking as key steps to ensuring the trustworthiness of the study. I sought to be reflexive, drawing on various strategies that allowed me to become aware of and represent my subjectivity in the study (Stahl & King, 2020). I maintained an electronic research journal in which I kept an ongoing record of my experiences and my reactions to these experiences. I wrote in my journal after my meetings with my supervisors and after my interactions with the group. I did this to represent and reflect on my biases openly. I also drew on the reflexive strategy of peer debriefing (Morrow & Smith, 2000), sharing my research journal entries with my two research supervisors, so that they could ask questions to further explore my interpretations. I drew on member checking throughout the data collection and data analysis stages to ensure that I represented what took place in the intervention design process and our experiences thereof (Morrow, 2005). I attempted to be diligent in this regard, considering my close relationship with the group and my respect for their role as co-researchers. Email summaries reflecting my interpretations of what had occurred in the meetings, were sent to all group members to allow them the opportunity to add to my recollections and interpretations of the process and outcomes. I encouraged them to add their own accounts in the review section of these documents. At the end of the inquiry, I shared a summary of my analysis of the data via email and face-to-face engagements with each member of the group. This iterative member-checking process was well suited to the combined post-structuralist paradigmatic stance and co-operative inquiry, allowing for the specificity of the case to be explicated.

Summary Reflections

Different paradigms offer different insights into the phenomenon forming the focus of the research. Constructivism, critical theory, and poststructuralism are at odds with each other given their diverse foci on the construct of power linked to the meaning making and actions of individuals. In Table 1., I present a summary of the potential insights and limitations of the three paradigms presented in this paper with application to the study example shared.

Table 1.

Potential insights and limitations of research paradigms (Gretschel, Ramugondo & Galvaan, 2017).

Research Paradigm	Links with Research Designs and Methodologies	Potential Insights and Limitations with Application to the Study Example
Constructivism	Commonly linked to the research designs of phenomenology and ethnography in which individual interviews and participant observations are used to gain insights into the personal perspectives of an individual in relation to a phenomenon.	Constructivism is inherently focused on individual meaning making, respecting how the experiences of an individual shape their perspectives and contributions. The question posed would be “What was your experience of designing the intervention?” The responses to this question would give me insights into our individual contributions to, and experiences of designing the intervention but would not necessarily illuminate the external factors shaping these experiences, our responses to these factors or the actions we would take to address these factors.
Critical Theory	Linked to research designs which researchers use to engage with participants to identify the impact of historically located and shifting social factors on their experiences of a phenomenon.	Critical theory adopts a critical perspective aiming to uncover the negative impact of factors on the experiences and actions of individuals and groups. The question posed would be “What has been the challenges of designing the intervention and how could these challenges be addressed?” This question would focus on the external factors impacting on our process of designing the intervention but the emancipatory agenda commonly associated with critical theory may detract from the potential power we had to work against these factors. In other words, our potential to exert our agency and use our power in positive ways in the process of designing the intervention.
Post- Structuralism	Commonly linked to participatory and collaborative research designs in which the participants are viewed as co-researchers i.e. equal partners in the research process, who together with the researcher reflect on their power and use of power in relation to the phenomenon.	Poststructuralism appreciates the diverse operation of power and its impact on human action. Drawing on this paradigm the question would look to explore our experiences of designing the intervention, the factors that impacted on the process, as well as the actions we took to build on the positive factors and address the negative factors. This paradigm’s specific appreciation of the actions we would take is unique. A possible limitation of this paradigm is the assumption that people can and will exercise their power to change their actions, when they should. This may not also be the case, given that the presence of similar positionalities and identities in homogenous communities of practice, may sustain stasis in our practices.

Implications

This paper aims to raise consciousness amongst all health professionals of the many factors which interact to shape the actions we do or do not take to address the needs of the people we work with. I argue that a poststructuralist paradigm supports our understanding of the complexity of the needs of the diverse people we work with, and nudges us to critically review, and where required revise our practice to attend best to the needs of all the people we work with.

Conclusion

A researcher’s description of their research paradigm is an essential aspect of a rigorous research project as it is their paradigm that shapes their view of the problem they wish to explore, as well as how they plan to explore this problem (Brown & Dueñas, 2019). Researchers should not ignore engaging in a well considered process of determining and foregrounding the paradigms which underpin their research. In this paper, I share how my poststructuralist worldview guided my selection of a cooperative inquiry methodology which I embedded in a case study design to explore and describe the power linked transitions and stagnations in one group’s process of creating and applying knowledge to design and implement a new intervention.

Intended Audience

Health professionals and students who are planning to conduct research, that draws on their reflexivity through the inclusion of paradigms which allow for nuanced understandings of how the construct of power operates and influences interactions between researchers, participants, health professionals and the people they work with.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Medical Research Council South Africa, National Health Scholars Programme.

Ethical Approval

Ethical approval was obtained from the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee HREC 605/2012.

ORCID iD

Pam Gretschel

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