Outlining the case study design

With the Māori-centred, critical feminist theoretical paradigm and ethic of care framework of this study now articulated, the next part of this chapter outlines the case study design of this research.

Case Studies

There are divergent views in the methodological literature on what case study research ‘is’. For example, Stake (2005) defines case study research as a choice of what is to be studied, rather than a methodology, whereas Creswell (2013) contends that case study research is a methodology and: “a type of design in qualitative research that may be an object of study, as well as a product of the inquiry” (p. 97).

Case studies come in many forms. They can be positivist or descriptive, interpretive or theory building (Gerring, 2004). Given the wide breadth of case study designs, it is not surprising that those who write about how to undertake case studies have different approaches to their theoretical paradigms, design and methods. Batten (2008) has considered case study approaches on a continuum,

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with positivist psychology research such as that undertaken by Yin (2009) at one end, and case study researchers from education and sociology such as Stake (2006), Creswell (2007, 2011, 2013) and Hamel (1993) at the other.

A case study design was chosen for this research as it was considered the most appropriate strategy for examining the role and potential of community care for Māori with cancer, within a wider system of care. The system of care includes the views of people at different vantage points of care planning, delivery and receipt. Thus, the ethic of care groups (those who care about, care for, give and

receive care) defined by Tronto (1998) lend themselves to identifying the boundaries of the cases in this research.

The case study approach enables the investigation of four different environments within the system of cancer care, facilitating examination of how individuals within these environments connect with each other, and where their views diverge. This importance of identifying different contexts is described by Goodrick (2011) who defines the case study as:“a research approach that facilitates understanding of complex social phenomena where it is difficult to disentangle the phenomena from the context in which it is embedded” (p. 36). In this way, the case study design is consistent with the ethic of care theoretical framework of the study and is most appropriate to answer the research questions posed in this research.

Other study designs would not have provided the same opportunities to examine cancer care for Māori from different perspectives of the system of care. An alternative research strategy for this study, for example, might have been a phenomenological study. Cresswell defines phenomonology research as

“describing the common meaning for several individuals of their lived experiences of a concept or a phenomenon” (Cresswell, 2013, p. 76).

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In this research, ‘cancer’ is a lived experience, whether as a patient, whānau member or person delivering or planning cancer care. However a

phenomenological study combining the views of a plethora of individuals regarding cancer treatment and support services would not assist in examining different parts of the system of care, and how these relate to each other. To return to Goodrick’s definition, the environments (or contexts) in which the research participants inhabit, as cancer patients, care providers, managers or planners cannot be easily “disentangled”from their views of cancer care and services (Goodrick, 2011, p. 36). To attempt this research with a

phenomenological approach would miss potential differences and similarities between groups at different levels of the system of care.

Thus, in choosing a case study approach, the focus of the inquiry is on the views and interactions of clearly established cases, rather than the phenomenological approach which would endeavour to find common meaning from a universal group. The study of cases for this research not only facilitates identification of similarities and differences between various parts of the system of cancer care, but also the reasons why they might exist. Creswell (2013) said that: “case study research begins with the identification of a specific case” (p. 98).

Multiple bounded systems

In establishing the boundaries of the case studies I will first present the

geographical boundaries of the study, second, outline the levels of care, including cancer services available within the bounded context and finally, describe the characteristics of each case.

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The study was based in the lower North Island, predominantly in the Wellington, Lower Hutt and Wairarapa regions (for the purpose of this study, called the greater Wellington region). The cancer co-ordinator was based in Palmerston North. All areas can be seen in Figure 1.

Figure 1: Lower part of Te Ika a Maui (the North Island of Aotearoa)

Primary care

Primary care is usually the first point of contact for people who go on to have a cancer diagnosis (Campbell, Scott & Seneviratne, 2002). Capital and Coast DHB has four PHOs and each of these has up to 53 GP practices, each serving

thousands of patients. As described in our earlier work exploring the cancer care services of Māori health providers, it is difficult to estimate the number of Māori health providers in any area as this information is not publically available (Crengle, 2000; Slater et al, 2016). Participants from four GP clinics and four Māori health provider organisations took part in the study. Due to confidentiality, these health service providers will not be named here, but some of them can be described.

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One of the Māori health providers is based in a marae setting, with kōhanga reo and other whānau services provided. The services are set in a very welcoming environment, with people coming and going, children playing and a large outdoor space. Another Māori health provider organisation operates its services from a modern building with light flooding in from large glass windows. The waiting area is spacious, with whakairo (carvings) at reception, toys for children, fresh flowers, a large television screen and comfortable chairs. Both examples in this study have large reception areas with wāhine Māori behind the desk, greeting whānau who visit the service and making them comfortable. One of the GP clinics is based near the shops of a small urban village. It is surrounded by trees and a playground for children. The building is modest, but houses a large and welcoming waiting room with comfortable chairs, toys for children and is decorated with posters presenting public health messages such as the importance of vaccination and cancer screening. At the time I visited, the consulting rooms were being painted and had a fresh, modern feel. Cheerful women at reception welcomed and chatted to people as they arrived at the clinic.

Cervical and breast screening services are available at GP clinics, and some Māori health providers also provide cervical screening services in homes. In the greater Wellington area, Breastscreen Central, part of Breastscreen Aotearoa, is the lead provider for mammography, with screening units in Lower Hutt,

Wellington and Kenepuru as well as mobile units which are scheduled to serve each area for periods of between one week and two months.

Cancer services

There are three DHBs in the region selected for this study: Capital and Coast, Wairarapa, and Hutt Valley DHBs. Depending on where patients live, the type of cancer, and treatment required for patients, they could be treated at either Masterton, Hutt Valley, Kenepuru or Wellington hospitals. The Wellington Blood

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and Cancer Centre at Wellington Hospital provides medical oncology, radiation oncology, haematology and palliative care services. They also provide outreach services at Masterton, Kenepuru and Hutt hospitals.

There are two hospices in the greater Wellington region: Te Omanga hospice in Lower Hutt and Mary Potter hospice in Newtown. Both provide outreach

services, with Mary Potter serving the Porirua and Kapiti Coast communities and Te Omanga working in conjunction with Kahukura specialist palliative care nursing service in the Wairarapa.

Much of the palliative care work provided by hospices and the hospital is undertaken in the community rather than in inpatient units (Slater et al, 2015). However both Te Omanga and Mary Potter hospices have comfortable and welcoming premises, where patients can have whānau stay with them. The hospices provide services to support whānau and include them in care, as well as caring for the dying patient. Te Omanga hospice is based in an historic convent building with extensive grounds and beautiful gardens. Mary Potter hospice is located next to Wellington hospital and optimises its space with beds for 18 patients, communal spaces for families and a self-contained apartment for larger families. Both hospices have meeting rooms, libraries and chapels available to staff and families.

Supportive care services

The supportive care services provided by the Cancer Society, who are the main providers of supportive care for people with cancer in Aotearoa have previously been described. Other organisations include those focussed on specific cancer types such as the Breast Cancer Foundation, Melanoma New Zealand and the Prostate Cancer Foundation of New Zealand. Free telephone and online information services are provided by the Cancer Society.

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For patient and whānau study participants who were undergoing treatment in Wellington, supportive care services were available at the Cancer Society Wellington Division, which has a large, welcoming building with free parking directly across the road from Wellington hospital. The Wellington Division provides counselling and advocacy services. There are also smaller centres in Masterton and Kapiti.

The Cancer Society runs the ‘Living Well with Cancer Education Programme’ which supports and educates patients about living with cancer. The Living Well programme was first run by the Wellington Division of the Cancer Society in 1991 and consists of 6 weekly sessions of 2-3 hours with the overall aim being to support and educate patients about living with cancer. The specific content of the programme varies according to the particular needs of the group (Jasperse, Herst & Kane, 2012). The Look Good Feel Better charity also offers workshops free of charge to women in the Wellington region who are undergoing cancer treatment.

For Māori in the Hutt Valley, the KOETI programme is also available. This programme was developed by the Wellington Division of the Cancer Society and Kokiri Seaview Marae and provides a safe space for Māori that is marae-based and whānau-centred. Like the Living Well programme, KOETI supports and educates patients about living with cancer. However, KOETI also provides a forum for whānau to support each other in an environment where they are welcomed as integral to the cancer journey.

Parking vouchers are available through hospitals for those undergoing cancer treatment. Some shared driving services are provided by the Lions Club and the Cancer Society. For patients from out of town who must travel to Wellington for treatment, accommodation is available at Margaret Stewart House in Wellington.

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This accommodation has bedrooms for families and shared cooking facilities and is based on the hospital grounds.

Characteristics of the cases

I have taken Tronto’s (1998) ethic of care framework and constructed case boundaries using Creswell’s (2007) multiple bounded systems categories. Cresswell (ibid) has outlined three requirements for defining multiple bounded systems. The first is the necessity to study more than one case (or bounded system). For this research, the four perspectives (care receivers, care givers,

those who care for and care about) from Tronto’s (1998) ethic of care framework

(Table 5) determined the case boundaries. The way that the cases worked as a system of care are further explored in the comparative analysis using Denier and Gastmans’ (2013) Circles of personalist care ethics model, which will be

described later in this chapter.

Cresswell’s (2007) second requirement in studying multiple bounded systems is to collect multiple sources of information from each case. The primary data source for this research was the interview data from participants in each case. Finally, Cresswell’s multiple bounded systems categories include reporting case based themes. The case boundaries defined by Tronto’s (1998) ethic of care framework identify four perspectives from different parts of the system of cancer care, thus allowing examination of the themes through four different lenses.