Interviews/focus groups

The interview/focus group process is detailed to enable an understanding of the procedures employed. A total of 42 people participated in this study: 10 individual interviewees and 32 nurses in the five focus groups that took place over a 20 week time period. Semi-structured questions were used for both the interviews and focus groups; these were well suited to case study research. Using a semi-structured approach allowed predetermined questions to be asked while allowing the flexibility to probe more deeply into issues of interest when the researcher has a list of topics or broad questions that need to be addressed (Polit & Tatano Beck, 2006). At the same time, participants are able to express themselves openly and freely and define the world from their own perspectives (Hancock & Algozzine, 2006).

The case study researcher should be able to ask ‘good’ questions, be a “good” listener and not be trapped by their own ideologies or preconceptions (Yin,

2003). Being a “good” listener means assimilating large amounts of new information that captures the mood of the participants and enables an understanding of the context from which the interviewees perceive their world. Questions in this study prompted discussion on the Primary Health Care Strategy specifically around participant perceptions of the Strategy, the changes that had taken place, and how and why those changes occurred. Individual interview and focus group prompts are included in Appendices Eight and Nine.

With the exception of the focus groups held at existing primary health care nursing forums, participants themselves selected the venues where the interviews and focus groups took place. This encouraged a feeling of ease and stimulated the conversation. Participants were seated around a table to facilitate discussion. The table also provided an object on which the audio- taping equipment was placed, and while suitable for the participants, the venues were not always appropriate for audio-taping. Two audio-tapes recorded each interview/focus group to ensure all information was captured clearly. The scheduled time for each interview/focus group was 60 minutes with an extra 30 minutes allowed for introductions and conclusions. Refreshments were offered at the end of each interview/focus group and allowed participants the opportunity to debrief.

5.6.1 Individual interviews

Individual interviews were conducted with key stakeholders and decision- makers at middle and senior management levels of TDH and two PHOs. I used purposive sampling to select participants for the individual interviews. In purposeful sampling there is no random selection process (Ezzy, 2002; McGivern, 2006; Silverman, 2005, 2009). Individual participants were selected on the basis of their perceived knowledge of and ability to influence implementation of the Strategy in Tairawhiti and subsequent nursing contribution. They were considered key players in the implementation of the Primary Health Care Strategy in Tairawhiti. Chief executives, representatives from planning and funding, as well as senior nurses and a doctor were

I chose individual interviews for these participants as they had different levels of responsibility and I wanted them to speak freely without concern. I was also aware of the commercial sensitivity of the given information as the managers were employed by different organisations. Individual interviews also allowed increased flexibility in setting the date and times for the interviews to occur. From the managers, I sought information on the implementation of the Primary Health Care Strategy in Tairawhiti at a more strategic level. I also wanted middle and senior management perspectives on where primary health care nursing sits within the Strategy.

5.6.2 Focus groups

Focus groups were chosen as the preferred technique for the primary health care nurses as they offered a way to listen to the multiple voices of others while significantly reducing the risk of any threats of intimidation from my nurse leader position. Focus groups provide a powerful means to explore the variation, diversity and consensus of both ideas and beliefs on a given topic within a social context (Hennink, 2007; Liamputtong, 2011). This was considered especially important for making audible the voices of people who are rarely heard (Liamputtong, 2011).

Some diversity in the composition of the group aids discussion, but too much can inhibit it. Participants tend to feel safer and prefer being with others who share similar characteristics (Finch & Lewis 2003). A very heterogeneous group can feel threatened and can inhibit disclosure. The focus groups in this study were relatively homogenous and this facilitated disclosure. Conversely, the conversation can become too easy and the researcher might need to work hard to tease out the differences in views.

Focus groups produce a concentrated amount of data on precisely the topic of interest and in a shorter time frame than if the individual interviews were held with the same number of participants (Hennink, 2007; Liamputtong, 2011). The hallmark is the explicit use of group interaction to produce data and insights which would be less accessible without the interaction found in a group situation. Interaction is actively encouraged to maximise the spontaneity

that arises from the stronger social context (Barbour, 2007; Finch & Lewis 2003; Hennink, 2007).

The comments made are dependent upon the context and group member’s responses to contributions from others as well as the dynamics of the group (Hennink, 2007). The language they use, the emphasis they give, and their general framework of understanding, all emerge from the discussion. The group context in this research allowed participants to ask questions of each other, and comment on what they had heard while prompting others to reveal more. The discussion was less influenced by interaction with the researcher than it might otherwise be in an individual interview, although researchers do take an active role in creating the discussion.

Focus groups have the advantage of being stimulating to respondents and aid recall and elaboration. Focus groups facilitate participant recognition and awareness of their own subjugation which may lead to participant involvement as change agents for their cause (Madriz, 2003). The person conducting the focus group must be objective, empathic and persuasive while encouraging all respondents to participate to ensure the fullest possible coverage of the topic (Finch & Lewis 2003; Liamputtong, 2011).

The disadvantage of this form of data collection is that less information is obtained from each respondent at the individual level (Hennink, 2007). There is also the potential for psychological factors and group dynamics to affect the group. The greatest threat is “groupthink” wherein stronger participants influence responses from other group members (Boateng, 2012). This can severely limit the self-expression of members and limit the conversation. Had this occurred it would have been managed by allowing each participant to challenge ideas and present objections as well reining in participants that attempted to “steamroll” their opponents.

The study population identified for the focus groups included all primary health care nurses in Tairawhiti; this numbered approximately 100 potential participants. I sought representation from most primary health care nursing

groups including practice nurses, public health nurses, occupational health nurses, district nurses, plunket nurses, tamariki ora nurses, rural nurses, sexual health nurses, Iwi based nurses and community mental health nurses.

The majority of focus group nurse participants were between 40-55 years of age. The high number of Māori nurses (just over half) is noteworthy and reflective of strong Iwi organisation participation in this study. European, two Pacifica nurses and one other made up the remaining ethnicities. A significant proportion of participants were tertiary educated and overall represented many years of nursing experience and practice between them. Less than a third had commenced or completed post graduate qualifications. It is acknowledged there was no representation from district nurses, occupational health nurses or nurses employed in the smaller NGOs and therefore the sample is not representative of all primary health care nursing groups in Tairawhiti.