Participants and setting
High level decision-makers at the municipality and county council
level from two counties in Sweden were invited to participate. The HDMs
were elected politicians and appointed civil servants at a planning and
control as well as executive level that had both budget and quality of
elder care responsibilities. The selection of the participants was made
from a compiled list of municipal and county council HDM names from the
two counties. Names were drawn until there were a total of 18 willing
participants. The first 18 asked were willing to participate with the
result being nine politicians and nine civil servants. They ranged in
age from 43 to 66 years, had held their positions between one to 20
years and 13 were female.
Participation was voluntary and all 18 completed their interviews
and could end them at any time without giving a reason. Written consent
was given after both verbal and written information was provided.
Confidentiality was assured and there would be no possibility to trace
the findings to the participants. The Regional Research Ethical
Committees approved this study (99310-17).
The HDMs chose the location for the interviews, which was often their office. They were asked "Please
tell me about one or more of the ethically difficult situations
regarding elder care that you have experienced in your position."
The concept of an ethically difficult situation was not defined, which
allowed the interviewees to discuss what they considered to be
ethically difficult. Allowing the HDMs to make their reflections
without interruption was done so that the narratives would be as rich
as possible in content. Follow-up questions concerning the HDMs'
thoughts, feelings and actions such as "Tell me more about that" or "What do you mean by that" were asked when the interviewer wanted them to elaborate further or give clarification .
The individual interviews were tape-recorded and transcribed verbatim.
Notes were also taken during the interviews to help with orientation
and understanding in the analysis phase and included non-verbal
communication such as laughter and long pauses.
A phenomenological hermeneutic method  was used to analyse and interpret the interview text. Several other authors have used this method [8,12,17,18]
that is useful when attempting to elucidate the meaning of a lived
experience through the interpretation of an individual's narrative. The
phenomenological hermeneutic analysis process consists of three phases:
the naïve reading, one or more structural analyses and a comprehensive understanding.
The analysis process constitutes a dialectal movement between the whole
and the parts of the text and between understanding and explanation .
In the first phase a naïve reading of the transcribed
interviews was done with an open-mind to gain a first impression of the
text as a whole concerning what the HDMs' experienced as being
ethically difficult situations. The naïve reading indicated the
direction for the subsequent analyses. The narratives were shown to
include both illumination of ethical dilemmas and the HDMs' experiences
of being in ethical challenges. In the second phase structural analyses were
performed, which aredetailed analyses of the text in order to explain
the parts and validate or invalidate the initial understanding gained
from the naïve reading. The text was divided into meaning units that
were then condensed, abstracted and structured into sub-themes and
A meaning unit can be a part of a sentence, a whole sentence or a
paragraph. The sub-themes and themes are presented under the heading
Results. A comprehensive understanding was developed in the
third phase in which the authors' pre-understandings, the naïve
reading, the structure analyses and relevant literature were taken into
account. This is addressed under the heading Discussion. All authors
took part in the analyses until agreement over the interpretation and
findings were considered satisfactory.
The interviews with the HDMs were rich and detailed. Early in the
analysis phase it became evident that the HDMs did not differentiate in
their narrations between the action ethics perspective and the
relational ethics perspective previously described .
When telling about ethically difficult situations, it is natural not to
separate between these two perspectives since these type of dilemmas
and the feelings of being in such situations are often expressed at the
same time. This analytic distinction has previously been used in other
studies as a basis for the structure and the presentation of the
We decided to separate the analysis and the presentation of the results
in the same manner since it gives a possibility to reveal the
complexity of the different ethical perspectives in the narratives [9,11].
This separation has resulted in two parts under the heading Results,
where the first part addresses the ethical dilemmas related to elder
care confronted by the HDMs and the second part addresses their
experiences of the meaning of being in ethically difficult situations
related to elder care.