Theoretical framework and methodology of the mixed methods research study

While previous studies have utilised written questionnaires and surveys (Patrick et al., 2001), such as the ‘Quality of death and dying questionnaire’ (Curtis et al., 2000), in- depth qualitative interviews are more appropriate to investigate the participants’ perspectives and viewpoints on the ‘good death’ as:

One of the great advantages of qualitative methods is that they enhance the capacity not only to describe events but to understand how and why the same events are often interpreted in a different, sometimes even conflicting manner, by different stakeholders (Sofaer, 1999, p. 1106).

The secondary aims of this research were to determine the influence of PoD, and rural residency on the concept of the good death, and to explore the meaning behind the PoD preferences and decision-making process. Again, this information is best captured in open-ended interviews. To complement the fieldwork, and to place the interview data into context, I also completed a descriptive study of current practice, addressing the questions ‘Where do Snowy Monaro residents die?’ and ‘What factors influence place of death in this rural setting?’ My research therefore, used a mixed methods approach, combining ethnography methods (detailed in Section 4.4), to gain a deeper

understanding of, and the reasoning behind the actual or preferred PoD, with descriptive analyses from the survey data (detailed in Section 4.5).

The theoretical perspective, or philosophical stance, informing the methodology and epistemology (the theory of knowledge embedded in the theoretical perspective, and thereby in the methodology) is symbolic interactionism, developed by Herbert Mead (1863 -1931), in which people create meaning based on their interactions with others. The meaning of events and behaviours arises from an individual’s interpretation. Behaviour, therefore, is not necessarily based on objective truth, but on what a person believes to be true. Interpretations of the same event can vary from person to person (Crotty, 1998). Symbolic interactionism, in turn, reflects the fundamental

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Truth or meaning comes into existence in and out of our engagement with the realities in our world…. meaning is not discovered, but constructed…different people may construct meaning in different ways(Crotty, 1998, pp. 8-9).

Constructionism is based on the view that reality is based on knowledge. Knowledge is formulated through social context, and it is this context that dictates the way people view or construct ‘their world’. Interactions between people and ‘their world’ constructs meaningful reality. Therefore, there is no single or true interpretation of events, only meaningful or useful interpretations. Social constructionism infers that ‘without culture we could not function…. We depend on culture to direct our behaviour and organise our experience’ (Crotty, 1998, p. 53). The theoretical framework is illustrated in Figure 4.4.

Figure 4.4: Theoretical framework and methods underpinning the complete research study.

4.3.1 Ethnography

Qualitative research, utilising interviews and observation, is interpretative and studies ‘things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meaning people bring to them’ (Denzin and Lincoln, 2005, as cited in

Epistemology Theoretical Framework Methodology Social Constructionism Symbolic interactionism Methods 1. Literature review 2. In-depth interviews

3. Survey data descriptive analysis Mixed methods

 Systematic and scoping literature reviews

 Ethnography

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Grbich, 2015, p.40). There are perceived differences between rural and urban cultures, and the influence of rural culture on the ‘good death’ and place of care/place of death is best explored through an ethnographic study. Ethnography specifically ‘deepens the understandings of cultures and culturally based concepts’ (Wilson et al., 2009a, p. 21). In this study, ethnography provided deep insight into the participants’ perspectives on the rural ‘good death’, the meaning behind PoD preferences and decision making, and the influence of rural culture and values on the ‘good death’ and PoD within the Snowy Monaro region.

Ethnography, a research method developed by anthropologists to describe and

understand foreign cultures, is used to understand groups of people living within society (e.g. the marginalised or invisible). As summarised by Patton (2002, p. 81), ‘The

primary method of ethnographers is participant observation… [along with] extensive fieldwork in which the investigator is immersed in the culture under study.’ Variations in cultures are recognised by gaining and describing‘the understandings and meanings constructed by people as they undertake daily activities’(Grbich, 1999, p. 159).

Becker et al. (2004, p. 269) suggest that traditional ethnography defines ‘social problems that have either not been recognised or have fallen off the radar

screen…because the presence of this problem contradicts cultural norm.’ In this study ‘cultural norm’ is the culture of palliative care, as studied from an urban perspective, where urban residents requiring EoLC usually have access to a specialist

multidisciplinary palliative care team. Becker et al. (2004, p. 271) also argue that:

Ethnography has the capacity to develop different ways of thinking about a social universe that is often taken for granted, to explore and make real the experience of people who have gone through hardship, through loss…and possibly even a triumph against all expectations.

Within qualitative research there are two main schools of thought regarding the positioning of the researcher. Grbich (1999, p. 5) suggests some would say ‘the researcher can participate in, and document, the ‘outer’ world with minimal intrusion’ while others believe ‘the perceptions of the researcher and other participants in the ‘socially constructed’ world are intricately interwoven’. Ethnographic researchers are

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conscious of the potential for bias in all research, as every aspect, starting from the research question, design, methodology, selection, analysis, conclusions and responses to ‘ethically important moments’ (Guillemin, 2004), are influenced by our values and beliefs, background and motives, and are open to subjective interpretation (Ulin et al., 2005). Essential components of ethnography are transparency and reflexivity (Rice et al., 1999). Reflexivity is a process of critical reflection by the researcher. It is important that the researcher is able to stand back, at every stage of the research, and take a critical look at their own role in the whole research process.

Researcher influence is not just limited to my personal world view, but my very presence within the study, and my personal framing. ‘Rigorous qualitative research is honest about the role of the researcher in the project’ (Rice et al., 1999, p. 41); however, despite all attempts, no researcher can be totally unbiased. Steps (described later) were taken in my research, starting at recruitment through to the final writing, to minimise my potential bias in collecting, analysing and reporting the research results.