I'm a novice research student planning a qualitative study augmenting a questionnaire from Sleep Review Magazine that uses a Likert scale for 6 questions with 4 open-ended response questions. I am adding a few questions to this questionnaire regarding application of guidelines and recommendations from professional organizations.  I am using this questionnaire for a pre test, then presenting guideline educational material, then following with post test to assess influence for behavior change of physicians after reading guidelines. The last 4 questions are open-ended for setting theme for 3 focus groups. Is this qualitative if I use a Likert scale or is it mixed? My topic is new and only 1 article from 1/2016 is found. Any ideas for increasing validity?  Research question: What are the reasons why sleep medicine practitioners do not recommend oral appliance therapy to their patients as first-line treatment modality in patients diagnosed with mild to moderate obstructive sleep apnea (OSA), or for those who are severe, are CPAP intolerant thus refusing CPAP, or for those patients who refuse CPAP therapy altogether?

Problem Statement

            Sleep physicians diagnosing patients with mild-moderate obstructive sleep apnea (OSA) often do not discuss, prescribe or allow their patients to be involved in patient-centered first-line choice of therapy between continuous positive airway pressure (CPAP) and oral appliance therapy (OT) despite clinical guidelines and recommendation of the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (ADSM).

Sampling Plan

            The sampling population is sleep medicine practitioners.  It is inclusive of sleep medicine specialists and sub-groups who are board certified in sleep medicine and will also include ANPs and PAs trained in sleep medicine. The sampling frame will select the representative sample from sleep medicine practitioners who practice sleep medicine for at least 50% of their work schedule or a minimum of 20 hours per week.  The sample population will be obtained from sleep practitioners who have professional membership status with the AASM. The random purposeful sampling population is inclusive of sleep medicine practitioners described.  The sampling strategy is to use random purposeful sampling which is a strategy in qualitative research that allows the researcher to “select information rich cases that can teach them a great deal about the central focus or purpose of the study” (Gray, Grove & Burns, p 365, 2013) and (Robert Woods Johnson Foundation, 2008).             

Sampling identified to problem or purpose statement

            The sample population described represents the diagnosticians and prescribers who have patient contact, order diagnostic baseline testing and titration sleep testing (for CPAP), and order durable medical equipment or prescribe for such i.e. CPAP or OAT.  Each member practitioner is considered an element of the population and the elements will represent the larger population. They relate to the problem statement because they are the practitioners who determine if the guidelines and recommendations will be followed when determining their therapeutic modality choice with patient involvement.

Sampling size appropriateness and reasoning

In order to be inclusive of practice philosophies of sleep medicine across the entire United States, a sample frame would include 10 elements from each state for a total of 500 elements.  As surveys are returned, they will not be opened until all states have been represented by 10 responses. This requires sending enough questionnaires to obtain adequate response.  The AASM has the member list divided by state and the elements to survey would be selected randomly from that list until adequate responses were received. The initial ‘n’ would be 30 per state with rationale that the editorial staff of Sleep Magazine had a 30% response on their same questionnaire (Roy, 2016) & (Gray, Grove & Burns, 2013). 

 The sample groups

            The sample groups are selected by the identical criteria of professional training previously described. The focus group will be selected from amongst the group of respondents who answered open-ended questions.  Those who respond will be selected by invitation only and will be pre-informed of this opportunity.  We would utilize 3 open discussions, consisting of 8-10 persons, using tele-technology.  This should allow for one sample and focus discussion would allow for additional insight not identified in the questionnaire.

Population affected by generalized findings

            The primary population affected would be the sleep medicine providers who have the opportunity to adapt guidelines and recommendations into their practice routine through behavior change.  The primary population that will also be affected by the general findings is the sleep apnea patient. 

Affect upon other population entities

            It will also affect the income of sleep medicine practitioners, will decrease frequency of PAP titrations thus affecting sleep lab technologist and directors, will enhance production by dental sleep laboratories and will enhance productivity of dentists.  It will decrease sales of products by durable medical equipment providers.  It will save patients and insurance companies money.

Limitations of population generalizability

            Considering the population of practitioners surveyed, varying scopes of practice and practice law exist between states particularly for dentists, thus may influence feedback from a physician’s perception. The questionnaires may present an unequal distribution between specialists. Sleep practitioners may have minimal access to experienced dental sleep medicine providers and their perception may be affected by bias secondary to specific experience.  Interpretation of the questionnaire and focus group responses may be limited by researcher expectations (Melnyk & Fineout-Overholt, 2015).

Research Design

            The study design is a qualitative research design using an exploratory-descriptive philosophical approach with interpretive and naturalistic perspectives (Madrigal & McClain, 2012).  The design is “multimethod in focus, involving an interpretive, naturalistic approach to its subject matter. Research study things in their natural settings, attempting to make sense of, or interpret phenomena in terms of the meaning people bring to them” (Robert Woods Jones, 2016).  The research utilizes a variety of materials such as “case study, personal experience, introspective, life story, interview, observational, historical, interaction and visual texts that describe routine and problematic moments and meanings in individuals’ lives (RWJF, 2016, & Denzin, NK & Lincoln, 2004, p. 2). This effort generates information regarding perceptions, attitudes and practices of sleep medicine physicians as well as encourages intuitive response towards dental sleep medicine practice. 

            The theoretical framework used to assess behavior change utilizes the trans-theoretical model of behavior change by assessing comparative responses between pre and post presentation of guidelines and recommendations of each practitioner.  The literature review supports use of the TTM in assessing the behavior change in physician learning experience from continued education as well as the evidence behind concepts that is depicted in the survey questionnaires (Johnson et al., 2015).

Hypothesis

            Interdisciplinary barriers and concerns between sleep medicine and dental sleep medicine practitioners may prevent the application of AASM/AADSM guidelines and recommendations for OAT as a first-line therapeutic modality in the treatment of mild-moderate OSA.

Design Flow

The design flows from the problem statement recognizing practitioners not utilizing guidelines and recommendations, to the design for qualitative research with an exploratory-descriptive philosophy to design a questionnaire that will identify perceptions across the US. Once perceptions are identified, the theoretical framework utilizing the education from the presentation of the guidelines and recommendations presented after the pre-test and before the post-test will indicate need to utilize the TTM theory for behavior change. The results of the findings will provide knowledge if behavior change did or did not occur or if in contemplation phase.

Summary:

The research design: Qualitative.

Approach: Exploratory –descriptive research through interpretive and naturalistic perspectives (Gray, Burns & Grove, 2013).

Research method: Questionnaire and focus groups (to further discuss open-ended question responses)

Sampling of subjects: Random purposeful sampling

Subjects: Sleep medicine practitioners

Thanks for your input!  I greatly appreciate it!

Dr. Shelley Shults