**2. Methodological approach**

#### **2.1. Research design**

Constructivist grounded theory (conGT) was adopted in this project. This approach was inspired by Rodwell's [28] constructivism approach to research and Charmaz's [29] work on 'Constructing grounded theory: A practical guide through qualitative analysis'. Their writing provided a methodological map in clarifying the strategies and perspectives for understanding the phenomenon on decision-making in residential care homes for older people. In the research process, knowledge was co-created through the reciprocal relationship that was formed between the researcher and participants as they worked towards exploring an interpretative understanding of the participants' experiences and acknowledging they created multiple meanings of their worlds in which they live in [30].

#### **2.2. Sampling and setting**

**1.3. Defining the issues at play**

224 Gerontology

degree of involvement in making decisions.

**2. Methodological approach**

**2.1. Research design**

In HK, the maintenance of family harmony and filial piety is still very much the core value of the Confucius Chinese traditional practice, despite evidence suggesting that the practice of filial duties has weakened [22–23]. Policy reforms have continued to affirm the view of the 'warm, supportive and stable families are what counts in nurturing the healthy development of individuals' ([24] p. 28). Potentially, there is an expectation that Chinese families still have an important role to play as providers of care, even after older people are admitted into the homes. However, there is very scant information available to understand the respective roles of families and their influences on the care of older people following entry into residential care homes in HK. Despite efforts to involve older people and their significant others in making decisions that affect their care, participation and involvement remain generally minimal and decisions are mainly made by staff based on what they consider to be in the older persons best interests [25]. This is further supported by work undertaken in HK which found that residents became dependent much earlier than needed [26]. It was found that staff acted on behalf of all residents, even for those who did not need their assistance, and perceived the tasks to be within their capabilities. Indeed, there is a need to develop mutual understanding about how to provide care which can truly reflect the competence of older people and minimize unnecessary dependence [27].

Growing old and living in residential care homes need not mean that making decisions becomes a thing of the past. Rather, being able to make informed decisions about personal choices and preferences continues to be important and should be promoted regardless of mental and physical frailty. If the ethos of caring is about understanding what is wanted from older people, merely getting things done for them will not enhance their satisfaction or quality of life. Identifying older people's preferences and values on how care needs ought to be met and their capacity and capability to continue to make decisions about daily living will help to inform appropriate care decisions. Such information will enable staff to re-prioritize and re-organize their work patterns by responding to the older person's expectations of care, and thereby involve those older people who wish to participate in decisions that directly concern their welfare. It is with this intention that this study was undertaken to explore the decision-making experiences and processes taking place in residential care homes from older residents, their families and staff, particularly how residents' needs were met, and their

Constructivist grounded theory (conGT) was adopted in this project. This approach was inspired by Rodwell's [28] constructivism approach to research and Charmaz's [29] work on 'Constructing grounded theory: A practical guide through qualitative analysis'. Their writing provided a methodological map in clarifying the strategies and perspectives for understanding the phenomenon on decision-making in residential care homes for older people. In the research process, knowledge was co-created through the reciprocal relationship that **Table 1** depicts the participants and study settings. Purposive sampling was used to recruit the initial sample and to identify participants who were most likely to provide rich information about the experiences or phenomena of interest [31]. As data collection progressed I recruited people with diverse backgrounds to achieve maximum variation and ensure multiple perspectives [28]. Theoretical sampling followed to sample people, activities and events as guided by the emerging codes and categories. The selection criteria were:


Data collection used a 3 × 3 design with three datasets from residents, families and staff in the three distinct homes. Data collection in home one was completed before commencing concurrent data collection in the second and third homes. In home one, data were collected to provide an orientation and overview of the research problem from the three participant groups. These data informed the selection of another two homes and participants. Homes two and three moved from general discovery of issues to more targeted probing among the participants [28]. The emerging categories were refined to focus on the (co-) constructions that emerged in the data. Data collection terminated when in-depth information, with maximum


**Table 1.** Overview of participants in the three study homes.

variation in participants' views, and a high degree of consensus about the categories and constructions was achieved.

collapsed into broader categories [29]. Similar coded data were compared against the existing extensive data, and the incoming data from other transcripts. The identified sub-categories were compared with the verbatim data and codes to ensure that the 'emergent set of categories and their properties fit the data, work, and were relevant for integrating into a theory' ([35] p. 56). The researcher moved from specific incidents to abstraction, by comparing incidents to incidents and incidents to concepts to determine similarities and differences in an iterative process [33]. Once the codes were all collapsed to form categories, possible relationships among and between the categories were examined to establish a conceptual link between them [29] to theoretically explain decision-making experiences among the stakeholder groups.

Decision-Making Experiences and Patterns in Residential Care Homes for Older Residents…

http://dx.doi.org/10.5772/intechopen.74267

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Ethical approval was obtained from the Survey and Behavioral Research Ethics Committee of the University to conduct this study. The superintendents of the homes gave me permission to conduct the study. In upholding the ethical principle to respect autonomy, participants were wellinformed about the inquiry, and were given time to ask questions before agreeing to consent to participate. The provision of informed information safeguarded the rights and respects the participant's choice to participate. All participants signed the consent form before being interviewed. They were informed of their rights to stop the interviews, refuse to answer questions and withdraw from the study at any time. They were advised that consenting to the inquiry was entirely voluntary and withdrawing from the study did not influence the care provided by the homes.

Based on the case analyses of the three homes, distinct patterns of decision-making and the influences on the residents' approach to decision-making could be delineated. The processes by which residents were facilitated or hindered from decision-making were strongly influenced by the pattern of decision-making that predominated in the homes. **Table 2** summarizes the three processes and six elements that were identified to capture the subtleties of the process of decision-making for residents that unfolded from entry into the homes to how they

Residents proceeded through a fairly logical approach and had varying degrees of involvement in decision-making. These processes demonstrated how residents settled into the home by becoming familiar with it and then becoming more involved in the decisions that influenced their lives. As residents moved through these decision-making processes that were practiced in the homes, the degree of negotiation that was possible determined the extent to which they were able to negotiate successful, less successful and unsuccessful decisions. As residents engaged in these processes the extent to which the family and staff ensured that decisions were successfully negotiated to meet needs or needs were not met were also highlighted. In comparing the similarities and differences in these processes across the three homes, three decision-making patterns were identified as negotiated, partially-flexible and constrained patterns of decision-making. Through the interactions between the participant groups, negotiations and/or compromises occurred that either facilitated or hindered residents' involvement

**3. Patterns of decision-making and influences on residents**

continued to make decisions to adjust to the living environment.

**2.5. Ethical considerations**

#### **2.3. Interview procedure**

Interviews were the main data collection method used. The main emphasis of interviewing pointed to what, why and how questions were asked, and being able to listen to the participants answering the questions in order to understand the experiences, and deriving interpretations from it [32]. Interviews therefore provided a tentative impetus to make decisions about 'where to go', 'what to look for', 'from whom', and 'how to ask questions' ([28], p. 21). The intention was not to impose a rigid order to the interviews by following each question in a particular sequence, but to allow the interview content to unfold by following the lead of the participants who were telling the story [33]. In fact, the researcher and participants were allowed to go 'beneath the surface of ordinary conversation and examine earlier events, views and feelings' ([29] p. 26–27). The participants were asked to reflect deeply on their experiences and encouraged to talk more. Clarifying and encouraging more information helped to articulate intentions and meanings. Therefore, only a few broad, open-ended semi-structured questions were needed to focus the interviews. A guiding principle in framing the questions was to 'direct questions to collective practices first and then attend to the individual's participation in and views of those practices' ([34] p. 679).

Family and staff members were interviewed once, and residents were interviewed twice (at 2 weeks and between 2 and 3 months after admission). As the study examined how residents made decisions with the support from staff, residents' first interviews and staff interviews were conducted almost simultaneously. Families were interviewed after the residents' second interview. This allowed me to hear the residents' experiences and how staff responded to them before comparing the accounts of residents and staff with the families' to gain fuller perspectives of those experiences.

#### **2.4. Analysis strategy**

Simultaneous data analysis and data collection occurred as far as possible. Constant comparative analysis was the method of data analysis used to generate concepts and to develop the theory through an inductive process of defining, categorizing, comparing data and, explaining and seeking relationships in the data [29]. Each interview was transcribed verbatim as soon as possible after each interview. Once the transcripts were checked for accuracy, the data were subjected to initial and focused coding. Initial coding enabled me to examine the fragments of data (words, lines, segments and incidents) and to give them a label that best summarized and described the data [29], using the participants' words to help me stay close to the data. A table of codes was compiled for each participant group, to which constant comparison of data was undertaken to check whether participants from each care home had identified similar concepts. The idea was to keep or reword existing codes, and only add new codes when new information was forthcoming [33]. The table was updated after changes were made to the coding scheme. The table at a glance helped to identify convergent and divergent opinions, and find gaps in the coded data to direct subsequent data collection [29]. Focused coding synthesized larger segments in the data by examining which significant initial codes could be collapsed into broader categories [29]. Similar coded data were compared against the existing extensive data, and the incoming data from other transcripts. The identified sub-categories were compared with the verbatim data and codes to ensure that the 'emergent set of categories and their properties fit the data, work, and were relevant for integrating into a theory' ([35] p. 56). The researcher moved from specific incidents to abstraction, by comparing incidents to incidents and incidents to concepts to determine similarities and differences in an iterative process [33]. Once the codes were all collapsed to form categories, possible relationships among and between the categories were examined to establish a conceptual link between them [29] to theoretically explain decision-making experiences among the stakeholder groups.

#### **2.5. Ethical considerations**

variation in participants' views, and a high degree of consensus about the categories and

Interviews were the main data collection method used. The main emphasis of interviewing pointed to what, why and how questions were asked, and being able to listen to the participants answering the questions in order to understand the experiences, and deriving interpretations from it [32]. Interviews therefore provided a tentative impetus to make decisions about 'where to go', 'what to look for', 'from whom', and 'how to ask questions' ([28], p. 21). The intention was not to impose a rigid order to the interviews by following each question in a particular sequence, but to allow the interview content to unfold by following the lead of the participants who were telling the story [33]. In fact, the researcher and participants were allowed to go 'beneath the surface of ordinary conversation and examine earlier events, views and feelings' ([29] p. 26–27). The participants were asked to reflect deeply on their experiences and encouraged to talk more. Clarifying and encouraging more information helped to articulate intentions and meanings. Therefore, only a few broad, open-ended semi-structured questions were needed to focus the interviews. A guiding principle in framing the questions was to 'direct questions to collective practices first and then attend to the individual's participation

Family and staff members were interviewed once, and residents were interviewed twice (at 2 weeks and between 2 and 3 months after admission). As the study examined how residents made decisions with the support from staff, residents' first interviews and staff interviews were conducted almost simultaneously. Families were interviewed after the residents' second interview. This allowed me to hear the residents' experiences and how staff responded to them before comparing the accounts of residents and staff with the families' to gain fuller

Simultaneous data analysis and data collection occurred as far as possible. Constant comparative analysis was the method of data analysis used to generate concepts and to develop the theory through an inductive process of defining, categorizing, comparing data and, explaining and seeking relationships in the data [29]. Each interview was transcribed verbatim as soon as possible after each interview. Once the transcripts were checked for accuracy, the data were subjected to initial and focused coding. Initial coding enabled me to examine the fragments of data (words, lines, segments and incidents) and to give them a label that best summarized and described the data [29], using the participants' words to help me stay close to the data. A table of codes was compiled for each participant group, to which constant comparison of data was undertaken to check whether participants from each care home had identified similar concepts. The idea was to keep or reword existing codes, and only add new codes when new information was forthcoming [33]. The table was updated after changes were made to the coding scheme. The table at a glance helped to identify convergent and divergent opinions, and find gaps in the coded data to direct subsequent data collection [29]. Focused coding synthesized larger segments in the data by examining which significant initial codes could be

constructions was achieved.

in and views of those practices' ([34] p. 679).

perspectives of those experiences.

**2.4. Analysis strategy**

**2.3. Interview procedure**

226 Gerontology

Ethical approval was obtained from the Survey and Behavioral Research Ethics Committee of the University to conduct this study. The superintendents of the homes gave me permission to conduct the study. In upholding the ethical principle to respect autonomy, participants were wellinformed about the inquiry, and were given time to ask questions before agreeing to consent to participate. The provision of informed information safeguarded the rights and respects the participant's choice to participate. All participants signed the consent form before being interviewed. They were informed of their rights to stop the interviews, refuse to answer questions and withdraw from the study at any time. They were advised that consenting to the inquiry was entirely voluntary and withdrawing from the study did not influence the care provided by the homes.
