Datacollection

The interviews were conducted in the period from September 2007 to April 2008.

The very first interviews made it clear that it was essential to ask the physicians and nurses questions about their professional reasoning with regard to their practices, since they

50 described actions that were somewhat controversial in terms of ethics, but without giving any reasons. The hospitalisation of terminal nursing-home patients was one example.

From the very start I became aware that it was essential for coherence that I concentrated on the interviewing without too many other tasks to divert my attention. Furthermore, it was important to establish an interviewing frequency that could allow one interview to be transcribed and reviewed before I would go on to do the next one. A main purpose of the reviews was to include new questions in the interview guide if new topics came up (Pope, Ziebland et al. 2000).

To obtain the maximum benefit from a composite total sample of relatives, physicians and nurses I chose to mix the sequencing of the interviews. For example, when I had heard the statements from the relatives I could follow up on these in the interviews with the physicians and nurses in the same nursing home. In the same manner I could follow up on topics internally in the sub-samples (Kvale and Brinkmann 2009). As an example I followed up on an interview with one doctor from a small rural nursing home in an interview with a physician in a city nursing home. This gave some valuable data based on the impact of community differences and the physicians` familiarity with the patients and their families in the decision-making process.

The respective processes of interviewing medical professionals on the one hand, and the relatives of patients who had passed away on the other, were highly dissimilar. In order to learn about the medical professionals’ experience while also seeking to shed light on their norms and values (grounds for action), it was important to accommodate reflection without posing questions that were too critical in order to make sure the interviewees did not take a defensive stance. Interviews with relatives were coloured by the fact that they had a genuine wish to share their experience with me as a researcher who was interested in listening to their experiences and post-event reflections. It was a challenge in these situations to ask questions which in addition to eliciting a description of their experiences, would uncover their reflections and their understanding of the decision-making processes.

4.3.1.1 The interview situation

The relatives were free to choose where to conduct the interview. In light of their recent bereavement, many respondents wished to be interviewed outside the nursing home.

Physicians and nurses were interviewed at the nursing home in their working hours.

51 Prior to each interview I spent some time on focusing before meeting the interviewee. I retrieved the project description (with new comments added) and “calibrated” the focus for the interview. I also checked the updated interview guide.

Before switching on the digital recorder (in accordance with “written informed consent”), we would discuss the topic to establish a reasonably joint focus and I informed the participant that he or she was free to discontinue the interview at any time. I started the recorded interviews by asking the participants to describe their experiences. All the interviewees (physicians, nurses and relatives) started to give their descriptions. There were only two instances where these initial narratives diverted from the interview focus, “end-of-life decision-making processes”. In these situations I drew attention to previous statements to bring the interview back on track. In all other situations I refrained from interrupting with further questions. The interview guide was used to keep the interview focused. I followed up by asking questions that had not been fully described in the initial phase. The objective of the interview guide was to follow up participants with more elaborate questions wherever this felt natural, and also to ensure that the participants would describe topics that were central to my interest.

The atmosphere that prevails during the interview is important to enable the participants to come up with additional material and good descriptions rather than “censoring” their own statements thanks to a negative judgmental attitude, which would be reflected in the way the questions are asked (Kvale and Brinkmann 2009, Fog 2004). This is a part of the researcher’s important role in research interviews to secure the possible meeting of the interviewee participant’s horizon (Thornquist 2003).

Leading questions - were used deliberately in a number of different situations. In terms of methodology, this is a tool used to provoke the interviewee to elaborate on his or her own views. According to Kvale and Brinkmann (2009), deliberately leading questions are underused, since they can be utilised as a tool to increase the reliability of the respondents’

answers. The criticism raised against leading questions tends to emphasise that they may push the interviewee in a particular direction, although this is unlikely to be a problem in an in-depth interview, where knowledge and information are exchanged in an intersubjective relationship. Examples of leading questions that I asked the relatives with a view to obtaining

52 more detailed information included querying why one family had wanted to continue the intravenous hydration of their dying father:

Researcher: Your assessment after the hydration had been removed was that he needed it, then? That he would be thirsty, perhaps?

Relative: Sure, we had these infamous sponges, then – so we dipped them and moistened his mouth, and – we could see that he had saliva in his mouth, and – so we tended to his mouth and washed it, and he appeared to be very dry. So that was done, anyway, he was given some fluids. I cannot say whether he noticed, but we felt the need to do it (AS01P).

On other occasions I would receive negative/repudiating answers. Criticism of the use of leading questions is far more relevant with regard to questionnaires, in particular when pre-defined response categories are used.

Balancing the questions

In my interviews with physicians and nurses on topics such as competence to provide consent I was careful not to use leading questions. This could have induced them to answer “by the book”, and give a not entirely accurate description of their own practices. My assessment was that my oral and written presentation of the project would serve as sufficient introduction to the theoretical aspects of the research question. I was also aware that some interviewees might hold back some information or deliberately provide the answers that I expected. I assessed it to be ethically defensible to make an attempt to overcome these restrictions. I tried to focus on the use of different interview techniques. This involved, for example, maintaining a balance between being overly cautious so as not to offend the participant and ending up just

“scratching the surface”, and asking more inquisitive questions in order to obtain more elaborate answers (Fog 2004).

The use of pauses - or waiting some moments before proceeding - could provide space for reflections that possibly could result in more elaborate answers. This is effective, but can be difficult when facing a stranger. The qualitative research interview is a “craft”, and awareness of this as well as of the need to conduct several interviews in order to develop the proper skills is required (Kvale and Brinkmann 2009).

I have discussed the content and the technique of the dialogue in the interviews (the process of collecting data) with one of my supervisors, who has also reviewed the full body of data in order to secure the necessary depth in the interviews.

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