Article 2: This Study was carried out using a convenience sample of 12 palliative care nurses built around social networks (Funnell, Koutoukidis & Lawrence 2005). It is a useful approach when dealing with a clandestine group (Funnell, Koutoukidis & Lawrence 2005). Bias may be introduced by not using a sample population with a range of views. The smaller and more homogenous the sample population the more difficulty there is to generalise the findings. Sampling methods and data collection are important for critiquing the rigour of the study. Benefits include saturation of themes and synchronized data collection and analysis.
- Methodology as related to the problem.
Article 1: Ethnographic approach emphasises the natural environment of participants and a holistic approach to data collection (Maggs-Rapport 2001). The ethnographer is the instrument of research immersing themselves in the participant’s values and beliefs, assisting to develop frames of understanding and mediating between the meanings and differences people give to their cultural world (Maggs-Rapport 2001). This methodology was particularly suited to the theme of euthanasia and the objectives of this study because of the difficulty of exploring a legally, ethically, morally and socially unacceptable act – the termination of a life. An ethnographic approach disclosed viewpoints from participants regarding the justification of active euthanasia from both those who could justify it and those who could not, and the reasoning behind these opinions.
Article 2: Grounded-theory approach gives a saturation of information in the area of the subject being focused on (Chivotti & Piran 2003). Grounded theory includes inquiry processes guided by participants, and this research model addresses credibility, auditability and fittingness of the research (Chivotti & Piran 2003). This methodology was particularly suited to this article’s objective because the researchers were curious what palliative care nurses thought about euthanasia in light of the Belgium debate. This methodology allowed the researchers to gather data that was credible, auditable and trustworthy. Minimal interpretation is placed on participants views by the researchers allowing room for readers to provide their own interpretations of the data (Crookes & Davies 2004). By using this methodology appropriately the researchers were able to ensure the validity of the study. Grounded-theory tries to minimise researcher bias and has a very complex analysis system (Crookes & Davies 2004). Limitations include the difficulty of providing researcher objectivity without conceptual notions (Crookes & Davies 2004).
5. Consistency in relation to Data Collection Method.
Article 1: Ethnography: this study was performed through semi-structured and focused interviewing of participants with four themes. It was pre-tested before use. Analysis started with reading replies, important phrases were gathered and classified into negative/positive/no opinion regarding euthanasia. Reasons for opinions were sought within the data and recorded ‘verbatim’. The researcher conducting the interview was a qualified registered nurse in cancer research who analysed the data securing the researchers immersion in the culture of the study. Ethnographic research must be carried out in the field in the participants’ natural setting and aims to balance the participants viewpoint against the researchers critical perception (Melnyk & Fineout-Overholt 2005). This research article is consistent with an ethnographic methodology (Maggs-Rapport 2001)
Article 2: Grounded-theory: this study was performed through face-to-face interviews over four months. An interview guide was used and data analysis and collection progressed together. Questions were added to the interview guide as different themes arose. Meetings with research supervisors were held regularly to control question quality. Feedback was sought from participants about anything unclear to them. Interviews took one hour at participant’s work place. Open coding and axial coding was used to group the categories of data and make theme connections. Grounded theory categories must be data indicated; relevant to practice; useful in interpreting, explaining or predicting a phenomenon; and adaptable over time to social conditions and change (Melnyk & Fineout-Overholt 2005). The methods used in this study were consistent with a grounded-theory methodology (Webb 2003).
6. Qualitative Methodology and methods used.
In both articles, there were open ended questions which provided the ‘what’, ‘why’ and ‘how’ for the qualitative studies. Methods used allowed researchers to concentrate on the issues being studied and allowed exploration of different perspectives (Barbour 2000). Sample representativeness was important in both studies to ensure the validity of viewpoints (Barbour 2000). Qualitative methodology allows for multiple views and voices with a variety of meanings attached to different events and it provides a means of understanding others views and can give rise to extension of arguments in debates (Barbour 2000). A qualitative methodology was an important choice for researchers when selecting their methods due to the object of their subject, euthanasia viewpoints. Ethnographic methodology was important to article 1 as researchers needed culture immersion to meet their aims and article 2 needed a grounded-theory approach to give their study validity.
7. Rigours of each article.
Standards of rigour address Credibility, Auditability and Fittingness (Crookes & Davies 2004). Rigour addresses how faithfully the researchers have adhered to the chosen methodology and the principles guiding their data collection (Chiovitti & Piran 2003). Credibility addresses faithfulness, auditability ensures transparency, and fittingness is shown in the detailing of supporting literature within the study and the delineation of the scope of the research and subsequent generation of theory. Validity, reliability, triangulation and systematic and self conscious data collection are the tools of rigour for credibility. Parameters are outlined and differences are identified and reported in participants viewpoints. The studies findings must not be generalised and fault finding must be explored by the researchers (Melnyk & Fineout-Overholt 2005). Triangulation shows systematic and self conscious research techniques to confirm or deny the studies findings (Crookes & Davies 2004). Rigour within the sample is indicated in the homogeneity of the population chosen, the orientation of the study, the type of analysis performed and practical considerations for the study sample and subjects (Crookes & Davies 2004).
Article 1: Interviews were taped, and transcribed verbatim with complete answers of participants, themes and coding used. Explanation of participant selection was given, and background of the interviewer provided credibility. The scope of the research fitted the sample and setting. All ethical considerations and methodological rigour were met.
Article 2: A decision and audit trail was set up illustrating dependability and confirmability of data. A systematic process was adopted for the collection of materials and documentation. Frequent discussions and meetings with supervisors confirming coding, categories and interpretations took place. At the end of the study experts challenged the findings of the researcher via a peer debriefing process and unclear points were questioned. This article gives no background information on the interviewer.
8. Comparisons of findings within each article.
Article 1: The most important result from this study was that more than half of the participants could justify active euthanasia. An inductive statement about results providing ‘some’ evidence of greater euthanasia acceptance, is made citing previous studies. Sample size is much bigger than article 2 allowing ‘some’ credibility with narratives supporting this conclusion and the studies main objective. No general recommendations are made and further evidence is needed to show support for this conclusion. Evidence may show different conclusions from different learning experience, and circular arguments are difficult to ensure interconnected reasoning are recorded and alternatives are given (Van Den Brink-Budgen 1996).
Article 2: The most outstanding finding was that participants were not strongly for or against euthanasia. Attitudes were connected with the situation and each individual case.
Both articles found there was no reasonable majority either for or against euthanasia but that acceptance was inextricably linked with the situation and patient condition. Both reported previous findings in literature of small proportions in favour of euthanasia. Reasons given for acceptance or rejection of euthanasia were similar amongst both studies, however, article one found euthanasia was more acceptable in terminally ill patients and article two found it was more acceptable when suffering was visible.
9. Health care practice and incorporation of findings.
Euthanasia immediately evokes feelings of a taboo subject and of clandestine activities, with discussions held in hushed tones. Judgments are made regarding the protection of life and an individual can be caught in a situation of unbearable suffering and loss of autonomy (Doerclx de Casterle, Gastmans & Verpoort 2004). Palliative sedation is considered a less active, but more acceptable way to ethically end a life, and this form of euthanasia already occurs as a ‘double effect’ of pain management (Orr 2001).
A patients right to make decisions should be respected at all times and within the Critical Thinking Analysis Domain of the Australian National Competency Standards for Registered Nurses and codes of conduct there sits a place for patients rights in regards to euthanasia for the future (ANMC item 9.3, 9.4), but until these rights are clarified legally with transparency for all, there can be no place for it, including palliative sedation with the view to hasten death.
Therapeutic nursing is an important component of palliative care (Crisp & Taylor, 2005 & ANMC 2006, item 2.1, 2.4, 3.2, 4.2, 4.4, 7.7, 9.1, and 10.4). It should be actively developed to ensure as much independence and quality of life as possible in all patients ensuring genuineness, empathy, trust and confidentiality (Sheldon 2005 & Hewitt 2006).
Professionals must stay within Competency Standards, legal codes and policies and must interact in debates and research in a way that is objective, non-judgmental and advocating for the rights of all ensuring that personal values are not imposed on others (Horsfall & Stuhlmiller 2000).
Pro-active involvement in research by health professionals improves best practice guidelines (Melnyk & Fineout-Overholt 2005). Active voluntary euthanasia may be the ultimate act of patient self-determination and autonomy, evoking ANMC (2006) item 7.6 and patient independence over own health outcomes (7.2) and therefore Health care professionals need to pay particular heed to patients’ mental well-being and participation in their own care and decisions, especially in a palliative environment (ANMC 2006, item 3.2, 4.2). Holistic care involving patient’s families should be open and available. Work teams need to have good working relations and ethical standards. Heeding the guidelines of the ANMC (2006) provides clear legal, ethical and moral direction for the pathways of perceived need for change.
Uncertainty in health care can be decreased with evidence based care, and optimal clinical care can be achieved (Melnyk & Fineout-Overholt 2005). Evidence from research, patient assessment, healthcare resources, clinical expertise, and information about patient preferences and values and critically appraising, integrating and evaluating leads to Best Practice and quality patient care and outcomes (Melnyk & Fineout-Overholt 2005). Best practice uses quality knowledge that includes certainty gained by credible research maintaining quality, quantity and consistency (Melnyk & Fineout-Overholt 2005). Qualitative research provides rich information on patient preferences and values, an important element of best practice and trustworthiness criteria must be met with credibility of actions, dependability of opinions, transferability to other studies, and confirmability of objectivity. Care cannot be generalised and must be individualised to the needs of each unique patient. Skills, practice and clinical insights for best patient care are never infallible (Melnyk & Fineout-Overholt 2005). Clarification needs to be constantly sought, checked, compared and explored and nursing practice and standards can be improved by research (Funnell, Koutoukidis & Lawrence 2005). Nurses must recognise changing clinical relevance and develop specific knowledge about individual patients to make relevant clinical decisions (Melnyk & Fineout-Overholt 2005). Barriers to optimal patient care must be overcome in open and transparent ways and those who ‘can’ must advocate for those who ‘cannot’. A reflective, inquiring, curious approach to nursing brings about best practice and improves health care (Funnell, Koutoukidis & Lawrence 2005). Through continuing education, debates and dialogue, best practise and guidelines are improved (Funnell, Koutoukidis & Lawrence 2005).
The findings of these studies provide important insights and increased awareness with significance in debates, both professionally and within communities. A body of extensive and dependable research to fill current gaps of current knowledge must first be built within this paradigm to protect all those who may be involved in its processes. Palliative care is an important area of study and due consideration must be given to all aspects of implications for education surrounding euthanasia, all voices must be heard and all literature reviewed before legislation can take place in a dynamic field of constant change.
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