Design and Settings

The research process in this dissertation involves the search to understand when theoretical statements represent changeable dependent relationships that are often taken for granted (Habermas, 1999). Habermas (2015) describes this as “a kind of methodological inner view”:

From the circumstance that theories of the critical type themselves reflect on their (structural) constitutive context and their (potential) context of

application, results a changed relation to empirical practice, as a kind of methodological inner view of the relation of theory to practice. (Habermas, 2015, p. 14)

Critical hermeneutics influence the aims and research questions in this dissertation when a search for and critically discussion of participants’ experiences are asked. As a result, the studies are designed with qualitative methods (Kvale & Brinkmann, 2015).

Habermas’s (1999) central concept of communicative action - understood as interaction coordinated by speech actions - informs the data gathering and an

abductive critical hermeneutic approach. Abduction is a suggested approach when studying complex situations. It includes observing what we do not understand and critically reflecting on data to suggest what occurs, and whether other data supports this assumption (Kvale & Brinkmann, 2015). The abductive approach indicates a dialogical design that searches for contrasts between HMMs’ lifeworld and system-world, and which facilitates critical reflection in a participatory and interacting dialogue around the participants’ experiences (Habermas, 2015). This dissertation can therefore be understood in the context of triple hermeneutics: while simple hermeneutics is based on the individual’s own interpretation and double hermeneutics is based on the researcher’s interpretation, triple hermeneutics consider unconscious processes, ideologies, and power dimensions (Alvesson &

Sköldberg, 2008). The research design comprises a comprehensive systematic review and meta-synthesis (Study I), two primary studies (Studies II and III), and a synthesis of the results from Studies I-III.

As a part of the PhD program in Professional Praxis at Nord University, it is pre-required to raise awareness and further develop professional practice and experience-based knowledge. Research should contribute to the theoretical and empirical development of professions and provide a scientific understanding of action-based knowledge (Nord University, 2016). This is consistent with the practical purpose of critical hermeneutics (Habermas, 1999). From its starting point in

professional practice, the experience-based data gathered as part of Study II delivers valuable critical insights, before pursuing a more international scientific

understanding from the systematic review and meta-synthesis in Study I. Study I ensures a scientific overview to Studies II and III. Study II contributes empirical results to Study I, and critical reflection to Study III. Study III influences Studies I and II by contributing contrasting experiences from HMMs’ professional practice.

As a result of the critical hermeneutic process, the timeline of this dissertation is non- linear. Study II begins in December 2014 with data gathering from the critical

reflection of experience-based knowledge in a learning network. This data is

transcribed in 2015 and inspires the project outline of the dissertation. A protocol for the systematic review and meta-synthesis in Study I is developed in 2016, when Study II reaches the analysis phase. Studies I and II then inform the design of Study III in the same year. The protocol for Study I is published in 2017; hence it’s numbering in this dissertation. Study II is published in 2018. The search strategy for Study I is completed between October 2017 and February 2019, and the article is published in 2019. Data for Study III is gathered in April-May 2019, and the study is published in 2020. The three studies and the synthesis form a continuous critical whole, where the results from each study inform and influence each other. As a result of this process, themes that emerge in one study are highlighted and elaborated in another. This back-and-forth process includes the writing of this dissertation, completed in 2020.

Studies I-III are interconnected as they aim to identify and critically discuss experiences of HMMs’ development of capacity and capability for leadership from different perspectives. Study I has a macro-level perspective, summarising and synthesising knowledge of HMMs’ experiences of development of capacity and capability for leadership in public hospitals and municipal healthcare in an

international context. This comprehensive systematic review and meta-synthesis is planned and completed in close cooperation with a university librarian and an experienced research team (my supervisors), as suggested by Ludvigsen et al. (2016) and Sandelowski & Barroso (2006).

Study II has a meso-level perspective, based on focus groups with HMMs and a user representative from a learning network spanning organisational and structural levels.

This learning network is located in rural northern Norway and concern the

participants’ development of capacity and capability for quality improvement (QI).

The network is supervised by the Norwegian Institute of Public Health and meets three to four times a year in sessions supported by a transformative learning model (Illeris, 2014). It has 54 participants from public healthcare across four municipalities and one local hospital (41 HMMs, one user representative, and 12 healthcare

professionals with a special interest in QI). Four different perspectives are represented from this network. HMMs working in: (a) hospital, (b) municipal long-term care, and (c) municipal homecare, and (d) user representative. It is important to note that this recruitment is about increasing breadth and depth of representation and not to compare perspectives.

Study III has a micro-level perspective, designed as a multimethod study of how HMMs’ development of capacity and capability for leadership influences QI (as a central part of HMMs’ leadership) in nursing homes (as a specific complex context). A study is considered multimethod when data gathering is completed using two or more methods, and the results are triangulated into a whole (Morse, 2015). The main method used here is focus groups, supported by one individual interview and

participative observations. These methods are considered complementary (Alvesson

& Kärreman, 2012). Study III is designed in collaboration with a senior manager in a rural northern municipality of Norway. The HMMs in this municipality participate in the learning network in Study II and in workshops and process guidance connected to this municipality's commitment to systematic QI based on PDSA (Plan-Do-Study-Act) (Taylor et al., 2014 ) and Lean (refers to slim) (Mason, Nicolay, & Darzi, 2015) working structures. Systematic QI isintroduced to the HMMs in 2014-16 and implemented as a mandatory part of their leadership in 2016. The setting in this study is the two nursing homes located in this municipality. The multimethod study includes focus groups with HMMs and volunteer relatives, an individual interview with one HMM, and participative observations of HMMs during their regular workdays.

Data is analysed separately for each study. The results from Studies I-III are then synthesised to constitute part 1 of this dissertation, along with previous research and the theoretical landscape. The synthesis is multimethod in that the three studies use different methods separately, and the results are synthesised into a whole. The synthesis is an analysis of how the two primary studies (Studies II and III) inform and add knowledge to Study I, the comprehensive systematic review and meta-synthesis,

and vice versa. Figure 1 illustrates the interconnection of the three studies and synthesis, the rationale and overall design.

Figure 1. Rationale and Overall Design