Trustworthiness

Trustworthiness is important in qualitative research. Trustworthiness is often described in terms of credibility, transferability, dependability, and confirmability (Elo et al., 2014; Lincoln & Guba, 1985; Shenton, 2004).

The following subchapters detail how this thesis preserved trustworthiness and the quality of research.

3.9.1 Credibility

Credibility is the overreaching criterion to ensure trustworthiness in qualitative research (Lincoln & Guba, 1985). Credibility reflects the way in which research is carried out to ensure veracity in the data and interpretations of the topic (Elo et al., 2014). Shenton (2004) describes several ways for researchers to ensure credibility. Our first step was to collect data through focus group interviews, individual interviews, and

observation. We used data triangulation to describe the organisations and its intervention process (Yin, 2018). The phenomenon was viewed from the perspective of managers (unit managers, department managers, professional development nurse) and employees (nurses, healthcare workers) in the nursing homes and homecare services. This enriched the data and strengthened the credibility of findings. The SAFE-LEAD project includes multiple researchers and co-researchers. They brought their own perspectives to the data collection and analysis. The co-researchers had the advantage of being familiar with the nursing home and homecare settings and were liaisons between the academic and practice field and recruited organisations for the project. All participation was voluntary. Debriefing sessions were held in the monthly project meeting and discussions with supervisors and co-authors of the papers to ensure an accurate understanding of the organisations and their quality and safety improvement processes. After each workshop, the intervention team had a debriefing session. The author of the thesis has collaborated closely with thesis supervisors who have read transcripts, collaborated in the analysis and the interpretation of the results to strengthen the research process. Context mapping of each organisation was conducted to provide a detailed description and understanding of the organisations under study (Wiig et al., 2019). With several data sources, we could see, for example, a contextual change in one organisation was mentioned in interviews by the participants, talked about in an observation, noted in the context mapping document, and discussed with by managers in the intervention workshops. This contributed to a thorough and rich understanding of the problem.

3.9.2 Transferability

Transferability means that findings can be transferred to and applied to other settings or contexts (Malterud, 2018). Researchers are responsible for providing detailed and thick descriptions of the phenomenon under study (context, recruitment, participants, data collection and analysis), so

other researchers can decide if the results are transferable to other contexts (Malterud, 2017; Malterud, 2018; Shenton, 2004).

In this thesis, transferability was handled through a detailed contextual information that was described of the organisations and municipalities in Papers II and III and in Chapter 3 of the thesis. The descriptions included size of the municipalities and organisation, managerial level, total number of employees and patients. The Norwegian healthcare context was also described to demonstrate how nursing homes and homecare services provide healthcare services. Information about participants was included in line with ethical considerations. The results included rich descriptions and verbal quotation from the participants.

3.9.3 Dependability

Dependability is the consistency of the research process and the stability of data over time (Shenton, 2004). The dependability issue in qualitative research can be addressed by a detailed report of every step of the study process so future researchers can follow the steps and repeat the work, although not necessarily to gain the same results (Shenton, 2004).

Yin (2018) suggests several ways of reporting case studies. This thesis used a linear-analytic structure that included the problem being studied in light of current literature, description of methods used, data collection, data analysis and findings, and conclusion with implications (Yin, 2018).

Sample and recruitment and analysis have been described for each phase and the methodological limitations are presented in the papers and in the discussion section. In this thesis, the study protocol of the SAFE-LEAD project (Wiig et al., 2018) was published in a peer-reviewed journal to ensure transparency of the research phases. All three papers were peer-reviewed by scientific journals before they were published. Furthermore, the author developed a project plan, research questions, and interview guides in close collaboration with thesis supervisors to ensure stability of the research process. The author was active the development,

implementation and evaluation of the intervention, along with researchers from the project.

3.9.4 Confirmability

Confirmability is the objectivity of the relevance and meaning of the data (Shenton, 2004). As the researcher takes an active role in the implementation of the intervention, and the facilitation of the workshops, it is important to be sensitive to potential bias.

Confirmability, in this thesis, was handled by several researchers and co-researchers with different perspectives and affiliations. The workshops, interviews and site visits were conducted by two researchers to ensure quality. The multiple sources and data triangulation supported the findings such as the focus group data combined with observational data (Yin, 2018). The participation of several researchers in the data collection added both nuance and a broad understanding of the topic. The thesis author has worked as a registered nurse in nursing homes and homecare services. However, the implementation was directed at managers, and the data collection was conducted by two researchers at each site. Lastly, awareness of bias is important to discuss and consider through the research process to ensure trust in the data (Malterud, 2017).

3.9.5 The researcher`s role

Reflexivity is about the researcher's pre-conceptions (background, motives, perspectives, and assumptions) and how this is handled through the research process to ensure trustworthiness in qualitative research (Malterud, 2001; Malterud, 2017). In this thesis, this related to my background as a registered nurse with work experience from the nursing home and homecare setting. This could have contributed to me being biased in the meeting with the organisations and based on my own thoughts of how the managers worked with quality and safety.

Collaboration with multiple researchers in data collection and monthly

project meetings ensured a reflective process. The intervention activities required an active role as a researcher (workshops, observation, site visits, interviews), however, most were facilitated by two researchers with complementary perspectives. The thesis supervisors have backgrounds in safety science, health psychology, and health management. Continuous discussions in the research team and supervisory team contributed to avoid risk of bias and influencing management teams beyond the intervention content.