Reflective review of Article 2

This section presents a reflective review of article 2 post-publication and provides additional detail that it was not possible to include in the publication due to the scope of the author's guidelines of the journal.

Critical commentary

The article was reviewed using the NICE Quality appraisal checklist - qualitative studies (2012) (See Appendix 5 for the details of the review). The article was shown to be of good quality. Less strong areas included the limited level of detail of the recruitment procedure, the lack of justification for the research methods chosen and no examination of the relationship

between the participant and the researcher. These omissions are addressed below but were largely due to the limited word count and the focus of the journal.

Recruitment

Women were approached by clinical / research staff in the breast clinics. These staff reported that they had discussed the study with a number of women and given them a study pack including a reply form, but the number of and which women were not recorded. Therefore, it was not possible to know how many were women approached or to send reminders about the study. Therefore only details about the participants who actually volunteered were available.

It is unfortunate the number of women approached and their demographics were not available as this would have provided information about the sample and the women who decided not to volunteer. Tetley, Grant & Davies (2009) highlights how older people are often excluded from research activities. It is only in recent times that older people have been invited to participate in studies, and there appears to be a nervousness and suspicion surrounding the word 'research'. This was evidenced in some of the interviews where women confessed to being worried about what was expected of them or that they what they had to say was not helpful. There is still work to do to make research more transparent and appealing to older women.

114

Rationale for the choice of data collection method

The rationale for the choice of interviews stems from the qualitative methodology used in this study. Qualitative research aims to provide a

detailed description of the topic under exploration from the perspective of the participants. This method of data collection ensures the concepts and/or theories are grounded in data.

Semi-structured interviews are ideally suited to fulfil these aims. The

conversational style interviews used in this study allows the participant to tell their story using the familiar act of talking, and the researcher attempts to make the interview a comfortable and non-pressurised event. Story telling during interviews also triggers memories and provides a richer description of the topic (Davidson 2004). A more detailed examination of interviewing as a method of data collection was given in chapter four of this thesis.

Acknowledging the position of the researcher

Detailing the role of the researcher within a qualitative study is difficult to achieve within the permissible word count of the journal Psycho-Oncology. An important aspect of rigor in qualitative interviews is that the researcher acknowledges and makes public his or her perspectives or 'biases' so that their influence on the interpretations of the data can be judged (Frank 1997). This process is termed reflexivity that has been described as

"…….. an integral process in qualitative research whereby

researchers reflect continuously on how their own actions, values and perceptions impact upon the research setting and can affect data collection and analysis"

(Gerrish & Lacey, 2006 pg 346).

The making public of the researcher's reflexive position is done through providing an account that reflects on the process of the data generation and analysis. Throughout the interviews I was very conscious of how my

demeanour and attitude could affect the interviews. It is key that researchers are organised and prepared for the interview (Legard et al. 2013) and I feel

115

that this was the case. Each interview added to the next in terms of how to raise questions and probe issues raised without 'grilling' the participant. The qualitative approach to uncover the multi-layered realities of the social world made it important for me not to be rigid in my approach to interviewing. This meant there was sometimes a tension between being flexible with the questioning and straying away from the point. I am aware this did happen on occasions, but I also found that this often triggered memories and allowed the participant to provide greater insight. Allowing the women to speak 'off track' provided space to talk to someone who was interested in their illness and let them enjoy it as a social occasion. As the interviews progressed I learned to say less, control my natural instinct to convey agreement or overly encourage a statement. I did however use information, anonymously, from other interviews or create imaginary scenarios to encourage thinking about a topic, particularly when the interview was stalling. Despite some, from a more positivist perspective, considering such practice inappropriate, it is seen as a legitimate way to conduct qualitative semi-structured interviews (Kvale 2007). As a HCP it is a natural reaction to try to help or provide guidance about a problem a woman might raise (Tod 2006). Women in the interview would sometimes raise a problem with the prosthesis or with the side effects of the drugs or the lack of movement they have in the shoulder, and I naturally wanted to offer support or direct them to appropriate services. It is

recommended that roles are strictly separated and I continued throughout trying to remain within the researcher role (Tod 2006). However, it is

important to show genuine interest and a degree of reciprocity of information to develop a good interview relationship, and I felt my open, flexible

approach assisted in achieving these things.

I acknowledge that my gender, maturity and extensive experience as a HCP and as a researcher were a factor in interviewing the women in this study, and feel that they were advantageous (Stevens, Abrams, Brazier, Fitzpatrick & Lilford 2001) I have a great deal of experience of talking to patients in the hospital setting and from previous research with older people. I feel my age conveyed a sense of credibility and of someone with experience of the world,

116

and this, including being a woman, allowed an easy rapport to develop with these older women who arguably could feel more comfortable talking on this topic with someone of the same sex. Gaining an understanding of breast cancer services and attending clinics where women were given a diagnosis and the treatment options discussed gave me very valuable insight into the experience of the women and gave me confidence to conduct the interviews. The interview findings reported in this chapter informed the development of the questionnaire and the also contributed to two further papers, 'The

balance of clinician and patient input into treatment decision-making in older women with operable breast cancer' and 'Understanding older women’s decision-making and coping in the context of breast cancer treatment'.

The following chapter is the third article that forms part of this Article-based PhD and was published in Psycho-Oncology. It reports the findings from the questionnaire phase of the study.

117

118