QUALITATIVE Hardcastle et al.

HEALTH / CRITICAL RESEARCH QUALITATIVE / January RESEARCH 2006 METHOD

ARTICLE 10.1177/1049732305283998

Carspeckens Five-Stage Critical Qualitative Research Method: An Application to Nursing Research

Mary-Ann Hardcastle Kim Usher Colin Holmes

In this article, the authors provide an account of Carspeckens (1996) five-stage approach to doing critical ethnography, or what he has termed critical qualitative research (CQR). They provide the reader with an overview of the concepts presented in Carspeckens book Critical Ethnography in Educational Research and describe how they applied several of his ideas within a research project that explored renal nurses decision making using a critical ethnographic approach. They briefly describe the five stages of CQR and incorporate within the article an example of how they applied the stages. They propose this approach as a useful method for nursing and other health-related research. Keywords: critical ethnography; Carspeckens critical ethnography; critical qualitative research; methods; decision making ritical ethnography is fast becoming a recognized way of researching issues of importance to nursing. This approach, guided by the principles of critical theory, aims to link social phenomena to wider sociohistorical events to expose prevailing systems of domination, hidden assumptions, ideologies, and discourses, so that social situations such as nursing can be redefined. Lodh (1996) explained that critical theory was introduced as a philosophical position with the central tenet of freeing or emancipating people by actively addressing patterns of power and domination. The critically positioned researcher purposefully adopts an action agenda with the purpose of empowering people and transforming political and social realities (Creswell, 2003). Carspecken (1996) has considered critical ethnography to be a form of social activism and has called a researcher who uses the approach a criticalist (p. 3). He prefers the term critical qualitative research (CQR) over critical ethnography, as he believes that the ethnographic approach should not take precedence over other qualitative approaches (Georgiou & Carspecken, 2002). In this article, we introduce the reader to the five-stage CQR approach developed by

AUTHORS NOTE: This project was made possible by a Queensland Nursing Council Scholarship and School of Nursing Scholarship (James Cook University) and by the participation of the nurses and medical staff in the renal unit.
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Carspecken and demonstrate its usefulness to nursing by outlining its application to a study about renal nurses decision making (Hardcastle, 2004).

CARSPECKENS APPROACH TO CRITICAL QUALITATIVE RESEARCH (CQR)

Critical research traditions differ from other forms of research, as they recognize that claims to truth are always discursively situated and implicated in relations of power (Kincheloe & McLaren, 2003). Kincheloe and McLaren explained that truth involves regulatory rules, and for some statements to be deemed to be more meaningful than others, those rules must be met. If these rules are not met, then truth has no meaning, and, as a result, libratory praxis has no purpose. Carspecken (1996), in his book Critical Ethnography in Educational Research, critiqued relativism and traditional truth claims based on perception models. Instead, he proposed that perception itself is structured communicatively (p. 19) and claimed that to construct a socially critical epistemology, critical ethnographers must understand holistic modes of human experience and how they relate to communicative structures. In his opinion, truth and validity are based on holistic modes of human experience and their relationships to communicative structures (p. 19). He believes that CQR seeks to do more than merely reconstruct reality. Rather, he claims it seeks to understand the relationship of culture to social structures, and although these mostly escape the awareness of the actors, they influence how they act (Georgiou & Carspecken, 2002). Carspecken (1996) explained that mutual understanding is about meaningful actions and that every time we act, we presuppose some universal or normative relation to truth that helps us to anchor meaning in our everyday lives (Kincheloe & McLaren, 2003). He proposed that mutual knowledge is gained through all kinds of truth claims and used Habermass (1981) theory of communicative action as a way to examine the plausible range of possible claims to truth actors make (Korth, 2002, p. 383). He also incorporated Giddenss (1979) argument that power accompanies all actions, as all actions have the potential to make a difference, and explained that agents are not forced to act, instead, are influenced by cultural conditions (norms and social conduct), or resource/constraints (law and economics) to act in broadly predictable ways, yet always retain the potential to act otherwise (Carspecken, 1996, pp. 37, 128). However, continuity of social structures might escape peoples awareness, resulting in repetitive and meaningful action expressed as routines that contribute to mutual knowledge production, power structures, and asymmetric relation (Georgiou & Carspecken, 2002). Carspecken (1996) described critical epistemology as an understanding of the relationship between power and thought as well as power and truth claims (Kincheloe & McLaren, 2003). To achieve an understanding between power, thought, and truth claims, he advocated the examination and articulation of researcher bias and the discovery of researcher value orientations (Kincheloe & McLaren, 2003). Communication is an important aspect in CQR because of the importance of communicative structures during interaction, for example, social rules of speech such as turn taking during a conversation and grammatical rules. These form part of any given culture, the shared patterns of belief, thoughts, values,

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TABLE 1: Stage 1

Carspeckens Five Stages of Critical Qualitative Research Description Data Collection Analysis Cultural reconstruction (etic)

2 3

Building a primary etic record: Fieldwork: nonparticipant What is going on? observer, monological, unobtrusive, reflection Researcher interpretation, etic Preliminary reconstructive perspective analysis Dialogical (emic) data genera- Fieldwork: participant tion, collaborative stage observer, interactive, interviews, reflection Describes systems relations to Conducting systems analysis broader context between locales/sites/cultures (discovery) Explains relational systems Links findings to existing macro-level theories (explanation)

Cultural reconstruction (etic) Cultural reconstruction (emic)

System analysis (etic)

System analysis (etic)

and normative expectations of how things should be done (Georgiou, Carspecken, & Willems, 1996). Carspecken also adopted Herbert Meads idea of self-consciousness and its relationship to how we internalize cultural and social expectations during interaction. He explained that even if we observe something alone, we still make use of communicative structures as we symbolize the object in a way that can be communicated to others. For example, everyone perceives objects in different ways yet shares this perception through established language patterns, resulting in an assumed mutual understanding. As a result, Carspecken emphasized the importance of how body language is interpreted in research (Kincheloe & McLaren, 2003) and how truth claims are consistent for a group of people, thus leading to his call for shared understandings (pp. 19-20). It is the consent given by a group that validates shared understandings or truths, yet truth claims are always fallible, because future cultures might find reasons to discard the truths of today (p. 84). To construct a methodological approach that incorporates the basic tenets of critical theory, Carspecken (1996) developed a five-stage model for doing CQR. The first three stages of the framework use critical analytic models to reconstruct cultural structures and themes, whereas the last two stages are designed to discover how routine social actions form and reproduce system relations that coordinate activities across various reaches of space and time (Georgiou & Carspecken, 2002, p. 690). However, Carspecken (1996) warned that even though the method is presented as a five-stage approach, it should be interpreted as comprising loosely cyclical stages, or even portions of the stages, depending on the aim of the research. As a result, the researcher will often move from one stage to another and back again. The five stages are presented in Table 1.

APPLICATION OF CARSPECKENS CQR FRAMEWORK

We were interested in the cultural conditions of nurses decision making during social interaction and how social structures (rules and resources) were generated

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and maintained during social action (Giddens, 1984). The five-stage approach developed by Carspecken (1996) was considered an appropriate framework for the study of renal nurses decision making (Hardcastle, 2004), because it advocates for simultaneous data collection and analysis, identifies cultural structures and themes, and helps to reveal the culturally pragmatic material from which actors mutually construct their worlds (Georgiou & Carspecken, 2002). Critical qualitative research (CQR) involves the use of hermeneutic-reconstructive techniques of dialogue and reflexivity to reconstruct culture and provide meaning about social action with the intent of exposing personal, cultural, and political aspects of nurses decision making. The adopted ethnographic methods in this study were used to illuminate the decision-making culture that raised questions particularly about social organization, cultural rules and regulations (Fetterman, 1998, p. 1). We selected participants purposefully because of what we thought they knew, prompting reflexivity through interview techniques that made the researcher-participant dialogue rarely naturalistic (Carspecken, 1996, p. 154).

The Preliminary Research Plan

We obtained ethical clearance to conduct the study from both university and hospital human ethics experimentation review committees.1 Nurses working in the renal unit were invited to participate in the study. We asked those who volunteered to sign a consent form and reminded them of their right to withdraw from the study at any time. Data were included only from the nurses who consented to participate (n = 21). Prior to entering the field, we developed a research plan (Carspecken, 1996). Carspecken recommended that the researcher make two lists of questions and specific items for study via a preliminary brainstorming approach. The first list should identify issues that can be investigated, whereas the second list outlines information required to address the questions as issues arise. For example, the preliminary list developed for the study to explore renal nurses decision making is outlined in Table 2. It might be possible to address a number of research questions and issues at some point in the study, as such concerns often intersect. This was certainly the case in the renal nurses decision-making study (Hardcastle, 2004). It is also essential that the list remains flexible enough to respond to new data and insights as they arise within the study (Morse, Barrett, Mayan, Olson, & Spiers, 2002). For example, during the data collection phase of this study, observations revealed how nurses used their personal power to avoid making decisions or to take control of decision making, and how they often used charisma, humor, or playfulness to achieve their desired outcome. It was important to remain flexible enough to allow the inclusion of these new insights that had not been part of the original list of questions created by the researcher.

Implementing the Stages

Stages 1 to 3 assisted in the reconstruction of cultural nursing practice addressing nursing actions and how meaning was constituted during interactions in relation to patterned expectations across time and place.

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TABLE 2:

Potential Issues for Preliminary Research Plan Information That Needs to Be Collected to Address These Interests Social routines and rituals in the unit Aims and goals of the unit Knowledge and surveillance of outcomes Rules, written and unwritten Relationships, communication, and power networks The culture of decision making Sociopolitical, economic, and historical aspects of nurses decision making in Australia Factors that enable and constrain decision processes Professional practice and scope of practice Personal and shared understanding Allocation and application of resources Subjective experiences of the nurses Individual versus group dynamics

Potential Interests to Be Investigated Who makes the decisions in the unit? What sort of decisions are made? How are decisions implemented and evaluated? What forces are behind decision-making procedures? What influence does interrelationships have in decision-making? What relationships exist between the unit and hospital locales? How do broader social structures and institutions influence decision making? What factors constrain and enable decision making? What decisions do nurses identify as nurse decisions? What role does trust play in decision making? How does economics influence decision making? How is autonomy perceived in nurses decision making? How do personal and group values, beliefs, and norms influence decision making?

Stage 1: Building a Primary RecordThe Etic Perspective

Spradley (1979) believed that ethnography starts with a conscious attitude of almost complete ignorance (p. 4). Carspecken (1996) promoted this level of ignorance by recommending that the researcher compile thick descriptions to sharpen ones awareness of events that may occur routinely (p. 49); by collecting data as a monological, or etic-outsider, perspective, and by observing social practice in an unobtrusive and passive way. For example, the nurses decision-making practices were described by the researcher from an outsiders, or etic, position, the perspective of an uninvolved observer (p. 42). This requires an attitude of openness and acceptance. The purpose of this outsider perspective is to enable the initial findings to be compared with data that emerge in subsequent stages. This facilitates cultural themes that appear meaningful during interaction, such as interaction patterns, power relations, and roles, to be identified, described, and analyzed during Stage 2. However, Cormack (1991) has questioned the ability of researchers to remain uninvolved with and unreceptive to the people they observe, as the mere presence of the researcher begins to change the dynamics of social interaction, known as the Hawthorne effect. Carspecken (1996) argued, however, that the Hawthorne effect is not damaging to a qualitative study, as alterations in participant behavior usually do not correspond with alterations in the cultural milieu (p. 52). What is important, he claimed, is acknowledging how behaviors have changed (p. 52). In this study, the position of passivity was not always possible or desired, as critical methodology

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encourages participants to engage actively in the research project. The nurses automatically engaged in dialogue, asking questions of the researcher, and, as a result, became actively involved in the outcome of the project. The primary method of data collection applied in the research project involved field notes, journaling, and researcher reflections, in which focused and dense records of daily routines, rituals, and social interaction were constructed in keeping with Carspeckens (1996) approach. Several decision-making locales were included, as the nurses made decisions extending from the renal unit context to include the meeting rooms, intensive care unit, and wards. Carspecken defined locales as patterned activities taking place in areas surrounding a social site (p. 38) (e.g., the renal unit). We assumed that contrasting and comparing how decisions were made in various locales would provide a greater depth of understanding in relation to the nurses decision making. Mutual understanding of how to go about daily practice were observed in terms of how practice could enable and constrain decision making. The nurses drew from implicit, practical know-how structures during decision-making encounters, another reason why the participants in CQR must be studied from the third-person outsider position (Georgiou & Carspecken, 2002, p. 694), as people are rarely conscious of them during interaction. Routinized actions are not usually deliberately produced and maintained; rather, these are unacknowledged and unintended consequences of action (Carspecken, 1996; Giddens, 1984). Deviations from predictable actions and routines were also noted, as these might generate new meanings, albeit in subtle ways.

Stage 2: Preliminary Reconstructive Analysis

Analysis of the data began with a description of the cultural context or site of the renal unit, identifying social interactions, routines, roles, and power relations: Who made decisions? How were decisions made? What constituted a decision? When were decisions made? and Why were decisions made? Our aim in this stage was to tease out themes, key issues, and areas that required further exploration in the proceeding stages. The data were initially entered into the word database of the computer, coded, and categorized so that we could see patterns and themes emerge as recommended by Carspecken (1996). However, as more information was collected and categorized, the database became more difficult to manage. For this reason, analysis became more of a cut-and-paste affair, the floor providing a birds eye view of coded themes that enabled us to be in touch with the data.

Stage 3: Dialogical Data Generation

Unlike Stages 1 and 2, Stage 3 involves an engagement of a dialogical approach to gain an emic or an insiders position with respect to culture (Georgiou & Carspecken, 2002, p. 690). Interactive data collection methods, including interviews, were employed, and the data were checked against themes arising from Stages 1 and 2, assisting in the integrity of the study (Georgiou, Carspecken, et al., 1996, p. 320). Georgiou and Carspecken (2002) referred to the emic position as performative attitude (p. 690); the researchers interact and take positions as participants do rather than objectifying participants. Stage 3 was considered potentially the main catalyst stage to transform social practice through this partnership.

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We compared the initial etic data collected in Stage 1 to the nurse responses during discussions and interviews in Stage 3, illuminating practical understandings through discursive means where explanations could be provided. This takes conditions of action constructed by people at nondiscursive levels to one of awareness and reconstructs them linguistically (Carspecken, 1996, p. 42). Once spoken about, practice has the potential to be changed. Stage 3 was conducted over several months, ranging from 1 to 6 hours per day depending on daily routines, the nurses rostered shifts, time availability, and appropriateness. At the same time, we revisited Stages 1 and 2 in light of new understandings generated through discussions. The interviews were, at times, structured to facilitate cross-checking of findings, observations, and documentation review. At other times, they were open and flexible to encourage the nurses to describe their own experiences. Reviewing the medical records also helped with substantiating, negating, or providing information when cross-checking, although, at times, the documentation was incomplete, which limited the process. We critically examined the data in terms of the context and positioning of each nurse, including the researcher, to address credibility criteria. Carspecken (1996) adopted Guba and Lincolns (1985) validation criteria for assessing rigor and establishing trustworthiness in a qualitative inquirycredibility, transferability, dependability, and confirmabilitybut used them differently and gave them a slightly different rationale. Credibility, for example, can be achieved via triangulation. Triangulation is the expansion of research methods that are applied to study the same phenomenon (e.g., decision making) to provide diverse, rich data (Dootson, 1995; Kushner & Morrow, 2003; Lackey & Gates, 1997; Maggs-Rapport, 2000; Roberts & Taylor, 1998). Carspecken (1996), however, implemented triangulation via the use of multiple recording devices and bodily senses during data collection. The example he gave is I usually take notes with a tape recorder running and, when possible, have another observer take notes with me so that our two records may be compared (p. 88). In this study, we asked many nurses about decision making, at different times and in different contexts, checking what was said at one time with what was said at another, and what was said was checked against what was done (Maloney, 1996, p. 79, emphasis in original). This process required our reasoning to go back and forth, as we linked findings with participants responses, constantly checking and rechecking the information, and in this way creating a solid foundation on which to build rather than making cognitive leaps (Morse et al., 2002, para. 25). Other rigor techniques included variable data collection times, prolonged engagement in the field, peer debriefing by colleagues, and member checks, whereby the field notes were shared with participants. This researcher-participant relationship enabled engagement to be taken beyond a clinical partnership to one of great depth and meaning that facilitated researcher integrity and sincerity (Fontana & Frey, 1998).

Member Checking
Member checking is advocated as an important way to validate data (Carspecken & Apple, 1992). Carspecken (1996) referred to Stage 3 of his approach as an elaborate member check (p. 89), wherein researcher notes are returned to the corresponding participants for further discussion and feedback. Carspecken also recommended

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that participants be brought together for a group discussion from time to time as a method of further revealing dialogical data. In the decision-making study, Hardcastle (2004) casually presented ideas and findings that were emerging from the data at opportune times, for instance, at the nurses station or meeting room, with the purpose of encouraging nurses to make comment in less formal way. This stimulated spontaneous responses from whoever happened to be present and so provided a quick and effective way of evaluating field notes and promoted dialogue between the nurses. When disagreements arose, these were noted for further analysis. In contrast, we assumed agreement to give credibility to the interpretations and considered it to represent a shared understanding of reality. However, the researcher remained aware that this does not necessarily mean the view was correct, merely that is was the accepted view of the group.

Reflexivity
Burns and Grove (2001) stressed how qualitative researchers must be flexible not only in their research design but also in how they view the world. This implies that they must also be ready to change their perspectives as new aspects of the world are unveiled. Therefore, the researcher needs to be open to new ideas. As a result, critical research has an emancipatory intent not only for the researched but also for the researcher (Carspecken, 1996; Street, 1992). Carspecken thus recommended Giddenss (1984) notion of reflexivity as essential to the research process; that is, the chronic monitoring of ones actions and thoughts (internalized actions), which is an inherent feature of human life. Self-reflection assists in the maintenance of critical theory principles, as its purpose is to expose the researchers personal constructions of the world, their values, beliefs, strengths, and weaknesses that mold the research journey and the choices made (Mulhall, Le-May, & Alexander, 1999). Furthermore, a reflexive account increases the plausibility or rigor of ethnographic research (Pellatt, 2003, p. 29). Garson (2003) shared several critical ethnographic assumptions, and these were adopted as reflexive questions throughout the study to assist with conscious reflexivity:
Do I assume to understand the decision-making culture? Are these cultural understandings from a shared or individual perspective? Are group interests being overestimated at the cost of individual interests?

We believed that these questions helped us to maintain consistency throughout the research study.

Stages 4 and 5: Conducting System Analysis

The data collected and analyzed during Stages 1 to 3 were then linked to broader sociopolitical aspects and corresponded to Stages 4 and 5, moving between the etic and emic perspectives. For example, the nurses actions were compared with previous literature and theories about decision-making behavior as part of the overall analysis. Carspecken (1996) linked Stages 4 and 5 to Giddenss (1984) concept of system integration. Integration has been understood by Giddens as involving reciprocity of practices (of autonomy and dependence) between actors [people] or collectivities (p. 28) across time and space. System integration is achieved when a sys-

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tem (patterned relations across time and space) is established, yet human action is separated in time and space, unlike social integration, in which interaction is faceto-face (Carspecken, 1996). Consequently, Stages 4 and 5 involve the adoption of a more objective analytical style and a level of theorizing: The last two stages of a research project are meant to focus entirely on objectively ascertainable behavioral routines locked into system relations (Georgiou, Carspecken, et al., 1996, p. 320). The economy and health organization are examples of system integration. The aim in Stage 4 was to discover system relations between renal nurses decision making and the institution of nursing within the Australian context, linking the social site of the renal unit and locales to other similar sites and locales within the health care system, including political and economic factors. In Stage 5, we attempt to explain the findings by linking them to sociological theory that critically addresses the reproductive circuits of society (Georgiou & Carspecken, 2002, p. 694). Why people act the same over and over again is of interest to CQR, as class structures, gender relations, and asymmetric relations (e.g., doctor-nurse) are all produced by people yet often escape peoples awareness. Consequently, what nurses say they do and what they do are habitually quite different. Carspecken (1996) recommended that key participants within the research project play a role in analysis during Stages 4 and 5. How achievable this is depends on the nature of the study, time availability to conduct participatory analysis, and the participants understanding of the phenomenon of study. In this study, group work was not a viable option because of time constraints and work structures. However, opportunities arose when the researcher was able to discuss issues and findings at a more abstract theoretical level with individual nurses.

CONCLUSION
We found Carspeckens (1996) five-stage approach to CQR to be a particularly useful way to study renal nurses decision making (Hardcastle, 2004). The approach was logical, and the examples provided in Carspeckens book assisted with data collection, organization, and analysis. It also helped the researcher to remain focused on the importance of seeking explanation for social behavior (e.g., nurses decision making) in a holistic way (Georgiou, Carspecken, et al., 1996) by comparing what was observed with what was said, and then comparing what was said with meanings generated during the researcher-participant encounter. This approach further facilitated validation and trustworthiness throughout the research process. The five-stage approach assisted the researcher by providing levels of inquiry and is particularly useful for novice researchers. The first three stages (cultural reconstruction) were used to construct a comprehensive understanding about the renal nurses decision-making practices. The aim in Stage 1 is collecting data from an etic, or outsider, perspective in relation to the social, cultural, and historical context, whereas Stage 2 involves the analysis of these relationships to expose the underlying assumptions that structure meaningful actions. In Stage 3, the dialogical stage, the researcher involves the participants during reconstructive analysis to gain an insiders, or emic, perspective and is guided by Habermass (1981) theory of communicative action. Stages 4 and 5 introduce the researcher to a more theoretical level. In Stage 4, the researcher links the findings from the local

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cultural site to other similar institutions and knowledge in an attempt to discover what these relations might be, whereas at Stage 5, he or she explains these discoveries in broader social theory terms. Carspeckens (1996) CQR five-stage approach is recommended for any interpretative research study, as the framework incorporates the initial stages of research design through to writing and disseminating of the findings. The five-stage CQR provides a comprehensive understanding of how to do research in the field that is easy to follow and flexible enough to be modified to reflect the needs and/or aims of a project. Although the title of the book, Critical Ethnography, is somewhat misleading, the five-stage approach proposed by Carspecken provides a comprehensive guide to CQR that can be used across a variety of disciplines.

NOTE
1. This and subsequent references refer to Hardcastle (2004).

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Mary-Ann Hardcastle, R.N., B.A., Dip.Ed., M.P.H.T.M., Ph.D., is a staff educator for Townsville Health District Services and also holds an adjunct lecturer appointment with the School of Nursing Sciences, James Cook University, Australia. Kim Usher, R.N., R.P.N., D.N.E., D.H.S., B.A., M.Nurs.S., Ph.D., is an associate professor and Head of the School of Nursing Sciences at James Cook University, Australia. Colin Holmes, R.M.H.N., B.A.(Hons.), T.Cert., M.Phil., Ph.D., is an adjunct professor in the School of Nursing Sciences at James Cook University, Australia.