Informed consent, anticipatory regulation and ethnographic practice

Improving the Ethics Review of Qualitative Health Research: A Comparison of Review Practices and Suggestions for Improvement by Researchers and Members of Research Ethics Committees

Most qualitative health research is subject to ethics review and approval by a research ethics committee (REC). While many studies have identified the challenges that current ethics review practices pose to qualitative health research, there is currently a call to move the research focus from the shortcomings of ethics review practices to the possibilities for improvement. The aim of this grounded theory study was to identify possibilities for improvement of current ethics review practices which can count on endorsement from qualitative health researchers and members of REC alike. To this end, we developed interventions for improving review practices through a comparative analysis of qualitative health researchers' experiences with review practices and REC members' discussions about how their review practices operate. Data collection proceeded by means of problem-centered interviews with seven qualitative health researchers and three focus group discussions with 14 REC members in Germany. Our analysis shows two overarching dimensions in the ethics review practice related to the distribution of responsibility for ethically legitimate research and the reasons for ethical concerns about qualitative health research studies. While there was disagreement about concrete suggestions for improvement, our analysis shows that researchers and REC members pursue three shared overarching aims: increasing expertise in qualitative methods among REC members and researchers, improving communication between researchers and RECs, and tailoring ethics review procedures to qualitative health research. We conclude that researchers and REC members need to promote collaboration and collegiality to ensure ethically appropriate review practices for qualitative health research.

Ethical and Epistemological Implications of Conducting Ethnographic Fieldwork as a Researcher-cum-Clinician in Brussels, Belgium

We draw on ethnographic fieldwork conducted in Brussels (Belgium) on the health care experiences of undocumented migrants. We explore the implications of the double position of the ethnographer, who is both a researcher and a practicing doctor. We describe how the intimate knowledge the ethnographer-cum-clinician holds about the health care system influenced and shaped the data collection, analysis and subsequent policy recommendations. We examine the ethical dilemmas in conducting research from an engaged position about care practices toward vulnerable populations in one's own professional field. We conclude with recommendations on how to challenge and interrupt complexities faced by multi-positioned ethnographers.

Ethics and the impossibility of the consent form: Ethnography in a Danish nursing home

Based on ethnographic fieldwork in a nursing home in northern Denmark, this article addresses challenges experienced in putting formal ethics requirements into practice. We consider how to unite procedural ethics with actual, lived ethics, when researching with vulnerable participants who live with a cognitively impairing condition. The article centers on the story of one resident, who wanted to share her experiences with what she had perceived as inadequate care, but who baulked once the wordy consent form was produced. The resident panicked that her words could now be used against her, that talking with the researcher would (further) compromise her care. She was caught in a bind, on the one hand she had a deep desire to tell her story, on the other the piece of paper in her hand threatened to trigger her anxiety and depression. In this article we therefore approach the consent form as an agent. By mapping out these unintended consequences of the consent form, we wish to draw attention to the complexities of ethical research conduct in practice, ultimately arguing that the concept of appropriate informed consent should be broadened so that it is sensitive to the lifeworld of participants.

Experiencias etnográficas y preocupaciones éticas en espacios de atención a la salud en México

En México, la integración de estudiantes-investigadores de antropología en salud a espacios de atención a la salud es muy reciente, por lo que resulta relevante conocer el proceso histórico y de la misma forma problematizar la interacción de estos con los prestadores de salud, así como con sus usuarios, a fin de discutir sobre la posibilidad de acceso para realizar indagaciones sobre las prácticas etnográficas, funciones y consecuencias de la presencia del investigador social en dicho espacio, desde la visión del estudiante de posgrado. Por lo anterior, se realizaron grupos focales con diez alumnos del área de antropología en salud, en los que se averiguó sobre la experiencia de sus investigaciones en los ámbitos anteriormente mencionados, llegando a la conclusión de que son de relevancia tres ejes: en primer lugar, la preparación de trabajo antropológico para y en la institución, seguido de la performatividad en la institución y, por último, los conflictos tanto administrativos, como operativos en la práctica etnográfica. Estos ejes se desarrollaron en este trabajo, y a través de ellos se plantearon y describieron las tensiones de la práctica profesional antropológica en instituciones de salud, con base en el hecho de que la etnografía en estos espacios confronta a dos disciplinas y lógicas institucionales diferentes. Finalmente, se realizó una reflexión desde las implicaciones éticas del desarrollo de la etnografía en estos espacios, al abrigo de los derechos humanos del usuario-paciente.

Ethical tensions surrounding 'third-party disclosure' by participants: Lessons from participatory health research in Eswatini

Third-party disclosure by participants is inherent to much global health research. It presents ethical tensions with respecting the autonomy and privacy of non-consenting individuals whose data are disclosed but is neglected in ethics guidelines. Our aim was to describe and ethically reflect on, third party disclosure in a community-participatory demographic and health survey (DHS) implemented within participatory health research (PHR) about community-based care of children affected by AIDS in Eswatini. We collected DHS data and analysed it statistically. We studied the PHR process and outcomes ethnographically and analysed the data interpretively, using theories that conceptualise secrecy as relational and power-laden. We found that third parties' data were disclosed by DHS respondents (typically women), including data about health conditions, abuse perpetration and being a caregiving burden. Ethnographic findings suggested that some third parties may not have consented to us collecting their data. However, respecting third parties' autonomy and privacy presents ethical tensions related to silencing survey respondents and impairing knowledge creation. To minimise the ethical tensions surrounding third-party disclosure researchers can analyse risks, benefits and power dynamics and extend their ethical responsibilities to protect participants to also protect non-participants, and from data collection to also include reporting.

“I’m Often Alone”: An Ethnographic Study of School Loneliness and Bullying in a Swedish Elementary School

Background

Despite extensive work to prevent and reduce bullying interactions, bullying is still a prevalent problem in many schools. Children and youth also report that they feel involuntarily left out in school. While research has demonstrated the ways in which school bullying is connected to risk factors across different ecological layers or contexts, relatively little consideration has been given to aspects beyond the individuals directly involved in bullying situations, such as the exo, and macrosystem layers.

Objective

The aim of this study was to examine three pupils’ experiences of school loneliness and bullying. The following questions guided the study: (1) What are the pupils’ experiences of school loneliness and bullying? (2) How can the pupils’ experiences of school loneliness and bullying be understood beyond the individuals directly involved in the bullying situations?

Method

The research is based on ethnographic fieldwork conducted at one Swedish elementary school including 34 pupils and 7 teachers in two sixth-grade classes (i.e., ages 11–12). The findings presented in this article are based on a group interview with three pupils about their experiences of school loneliness and bullying. The interview responses are put into perspective using findings from the ethnographic fieldwork. The findings were analysed using methods from constructivist grounded theory and through the lens of Bronfenbrenner’s ecological theory of human development as well as critical bullying studies.

Results

The findings of this study demonstrate the ways bullying interactions are tied to the different layers, or “settings”, of the bullying ecology as the pupils draw from a range of differential points of reference so as to socially evaluate themselves, their classmates, and their peers.

Conclusions

An important conclusion of the study is for principals, teachers, and other school personnel to consider more thoroughly the interdependent interplay of the bullying ecology.

A Study of Environmental Factors in Low Vision Rehabilitation

Healthcare has the past decades shifted from a narrow medical perspective to a more holistic, biopsychosocial perspective. Disability understood as a contextual condition constituted by the relation of the individual to their social and physical context. The disability model of the International Classification of Functions (ICF) contextualizes activity, participation, body functions and structure by including environmental and personal factors. However, illustrated by the consideration of the environmental factors as a neutral dimension, the dynamic interrelation of the individual parts of the system is rather unchartered. In 2017-2019, a lighting assessment was developed and tested on 60 participants in low vision rehabilitation. An action research project accompanied the pilot study from 2018. Ethnographic participatory observations of the low vision consultants in 15 consultations, semi-structured interviews, and a document analysis of the project material of the pilot project has been analyzed using the theoretical framework of science and technology studies. Mapping the physical environment showed a range of factors from spatial organization to luminaires and light bulbs. Moreover, in relation to specific activities, relevant factors were identified and assessed, and in the intervention adjusted to relevant personal and social factors. Identifying overlapping personal, environmental, and professional spheres illustrates the complexity of practicing rehabilitation in people's everyday lives. Acknowledging and coordinating different versions of lighting enabled low vision consultants to work across these spheres relationally. ICF was embedded in the practice of low vision consultants as a frame of reference, however, implementing this framework occurred through an assemblage of tools from different fields. The focus on lighting as an active element in low vision rehabilitation demonstrated a way to work across the personal and environmental to reduce the gap that caused disability. In everyday life, the physical environment was pivotal in the person-environment relationship and in enabling or disabling the individual. However, the physical environment was also key to the rehabilitation process, facilitating the individual's learning and change processes and reconfiguring their understanding and use of the environment. Consequently, the physical environment was not a neutral background to the other factors but rather enabling the rehabilitation and recovery processes.

Data protection, information governance and the potential erosion of ethnographic methods in health care?

With the most recent developments to the European General Data Protection Regulations (GDPR) introduced in May 2018, the resulting legislation meant a new set of considerations for study approvers and health-care researchers. Compared with previous legislation in the UK (The Data Protection Act, 1998), it introduced more extensive and directive principles, requiring anybody 'processing' personal data to specifically define how this data will be obtained, stored, used and destroyed. Importantly, it also emphasised the principle of accountability, which meant that data controllers and processors could no longer just state that they planned to adhere to lawful data protection principles, they also had to demonstrate compliance. New questions and concerns around accountability now appear to have increased levels of scrutiny in all areas of information governance (IG), especially with regards to processing confidential patient information. This article explores our experiences of gaining required ethical and regulatory approvals for an ethnographic study in a UK health-care setting, the implications that the common law duty of confidentiality had for this research, and the ways in which IG challenges were overcome. The purpose of this article was to equip researchers embarking on similar projects to be able to navigate the potentially problematic and complex journey to approval.

The Use of Ethnography in Maternity Care

While the value of ethnography in health research is recognized, the extent to which it is used is unclear. The aim of this review was to map the use of ethnography in maternity care, and identify the extent to which the key principles of ethnographies were used or reported. We systematically searched the literature over a 10-year period. Following exclusions we analyzed 39 studies. Results showed the level of detail between studies varied greatly, highlighting the inconsistencies, and poor reporting of ethnographies in maternity care. Over half provided no justification as to why ethnography was used. Only one study described the ethnographic approach used in detail, and covered the key features of ethnography. Only three studies made reference to the underpinning theoretical framework of ethnography as seeking to understand and capture social meanings. There is a need to develop reporting guidelines to guide researchers undertaking and reporting on ethnographic research.

Participant compensation in global health research: a case study

Background

Compensation for research participants can be provided for reasons including reimbursement of costs; compensation for time lost, discomfort or inconvenience; or expression of appreciation for participation. This compensation involves numerous ethical complexities, at times entailing competing risks. In the context of transnational research, often incorporating contexts of economic inequality, power differentials and post-colonialism, these issues extend into wider questions of ethical research conduct.

Methods

We describe experiences of conducting a community-based study of air pollution in southern Malawi incorporating ethnographic, participatory and air quality monitoring elements. Decisions surrounding participant compensation evolved in response to changing circumstances in the field.

Results

Attention to careful researcher–participant relationships and responsiveness to community perspectives allowed dynamic, contextualised decision-making around participant compensation. Despite widely cited risks, including but not restricted to undue influence of monetary compensation on participation, we learned that failure to adequately recognise and compensate participants has its own risks, notably the possibility of ‘ethics dumping’.

Conclusions

We recommend active engagement with research participants and communities with integration of contextual insights throughout, including participant compensation, as for all elements of research conduct. Equitable research relationships encompass four central values: fairness, care, honesty and respect.

Critical ethnography in maternity care research: bridging creativity and rigour - a discussion paper

Ethnography is a useful research method for maternity care research, because it can identify elements of actual practice that may be missed using non-observational research. However, because of the relative creative freedom of writing ethnography, it can be difficult for novice researchers, because there is no particular set of steps to follow. Much of the work of an ethnography is actually just watching, thinking and writing. In this paper we discuss our three individual doctoral research projects- all variations of critical ethnography-in order to present some of the creative variety of ethnography in maternity care research and to promote discussion within this field about how to maintain robust ethnographic research while keeping hold of its creative aspects. Attempts to standardise ethnographic research have the potential to curtail a very flexible methodology and constrain the knowledge generating work of the researcher. We encourage fellow maternity researchers to contribute to literature on ethnographic methodology in order to expand and refine use of this methodology in maternity care settings.

'Where have all the doctors gone?' A protocol for an ethnographic study of the retention problem in emergency medicine in the UK

INTRODUCTION

'Emergency medicine (EM) in the UK has a medical staffing crisis.' Inadequate staffing, in EM and across healthcare, is a problem that affects the quality of patient care globally. Retention of doctors in EM is a particularly acute problem in the UK's National Health Service. Sustainable careers in healthcare are gaining increasing attention at a national and international policy level, but research to understand the factors that facilitate retention is lacking.This study aims to develop understanding of what drives retention of doctors in EM by focusing on those who remain in these careers, where previous research has targeted those who have left. By addressing the problem of retention in a different way, using innovative methods in this context, we aim to develop a deeper and more nuanced understanding of sustainable careers in EM.

METHODS AND ANALYSIS

This is an ethnographic study combining participant observation in two emergency departments, interviews with doctors from these departments, from organisations with influence or interest at a policy level and with doctors who have left EM. The analyses will integrate detailed workplace observation alongside key academic and policy documents using reflexive thematic analysis.

ETHICS AND DISSEMINATION

Approvals have been obtained from Lancaster University via the Faculty of Health and Medicine Research Ethics Committee (FHMREC18058) and the Health Research Authority (IRAS number 256306). The findings will inform understanding of sustainable careers in EM that may be transferable to other settings, professions, and locations that share key characteristics with EM such as paediatrics, emergency nursing and general practice. Findings will be disseminated through a series of academic publications and presentations, through local and specialty research engagement, and through targeted policy statements.

Constructing classification boundaries in the memory clinic: negotiating risk and uncertainty in constituting mild cognitive impairment

Determining the boundaries around processes of 'normal' ageing and pathological cognitive deterioration associated with Alzheimer's disease (AD) is a difficult process, complicated further by the expansion of the disease category to include mild cognitive impairment (MCI). MCI is a label used to identify individuals with the symptoms of cognitive deterioration not attributable to 'normal ageing' but deemed to be 'at risk' of developing AD despite clinical uncertainty around whether individuals will go on to develop the condition in the future. Drawing on qualitative data gathered across an out-patient memory service, this article examines practitioners' accounts of the complexity associated with constructing the boundaries around MCI, AD and age in the clinic. Practitioners utilise uncertainty by classifying patients with MCI to keep them on for review to account for the possibility that patients may go on to develop AD but they also recognise the difficulty in predicting future progression to AD. Negotiating classification boundaries in the clinic is, however, not only about managing uncertainty regarding potential future risk but also about navigating the wider social and political context in which ageing and cognitive deterioration intersect, and are constructed and managed.

Palliative care in its own discourse: a focused ethnography of professional messaging in palliative care

Background

Despite 50 years of modern palliative care (PC), a misunderstanding of its purpose persists. The original message that PC is focused on total care, helping to live until the person dies, is being replaced and linked to feelings of fear, anxiety and death, instead of compassion, support or appropriate care. Society is still afraid to speak its name, and specialized units are identified as “places of death” as opposed to “places of life” meant to treat suffering. This issue is prohibitive to the implementation and development of PC policies worldwide. It is imperative to identify what message PC professionals are relaying to patients and other health care specialists and how that message may condition understandings of the right to access PC.

Methods

A qualitative study, employing focused ethnography and participant observation (PO) of the daily interaction of PC professionals with patients and family members in three different PC services. Two researchers independently conducted a thematic analysis, followed by member checking with participants.

Results

A total of 242 h of participant observation revealed the following messages sent by PC professionals in their daily interaction with patients and families: i) We are focused on your wellbeing; ii) You matter: we want to get to know you; iii) Your family is important to us.

Conclusion

The complexity of PC discourses contributes to the difficulty of identifying a clear universal message between PC professionals, patients and families. The PC professionals observed transmit a simple message focused on their actions rather than their identity, which may perpetuate some social/cultural misunderstandings of PC. It seems there is a common culture, based on the same values and attitudes, within the messages that PC professionals transmit to patients and their families. PC teams are characterised by their availability.

Ethnography in health professions education: Slowing down and thinking deeply

CONTEXT

Ethnography has been gaining appreciation in the field of health professions education (HPE) research, yet it remains misunderstood. Our article contributes to this growing literature by describing some of the key tensions with which both aspiring and seasoned ethnographers should productively struggle.

METHODS

We respond to the injunction made by Varpio et al (2017) that HPE researchers should ground their methodological ventures in their historical and philosophical tenets. To do so, we first review core ethnographic texts that provide a background for ethnographic research in HPE, then provide an orienting definition to bind the specificities of ethnographic research. Finally, we review core theoretical and practical considerations for ethnographic research.

RESULTS

Ethnography is a slow and deep approach to knowledge production, and as such it requires careful engagement with theory and deliberate choice of methods. Core theoretical tensions include the ontological, epistemological and axiological dimensions of ethnography, and concerns with quality and rigour. Practical tensions include the scope and remit of ethnography, the importance of observing naturally occurring behaviour and the crafting of rich field notes.

CONCLUSIONS

We encourage ethnographers to pursue scholarship that challenges the status quo. Ethnographers should favour deep encounters with research participants, dig deep into the cultural and structural aspects of HPE and be reflexive about knowledge outputs. At a time in HPE when the pressures to publish are high, using ethnography as a research methodology offers an opportunity to slow down and think deeply.

Commentary 1: The Role of Ethical Reflexivity in Conducting Ethically Challenging Qualitative Research

This paper is a commentary on Herzog et al.'s vignette drawn from their experience of conducting ethically challenging qualitative research. They describe an encounter with a family in which an older child has acted as a sibling donor to a sick younger sibling. It is evident that the process has taken its toll on the well-being of the older child and has created tensions within the family. What then are the ethical boundaries and responsibilities of researchers who enter the private domain of the family? This commentary responds with a model of "ethical reflexivity" which shows how a reflexive researcher can incorporate moral reflection at the different stages of the research process. Reflexivity works differently at different points, upstream it allows for anticipation and planning, incorporating ethical strategies into the methodology. Midstream reflexivity allows for evaluation, reflection and strategic response as the research unfolds and downstream it allows for a critical evaluation of how the research played out. Although it is a vital resource for any society to allow a wide degree of freedom for social scientists to research the social life, this freedom also brings responsibilities. Participation in research both creates and reveals the vulnerabilities of participants and since the researcher is entangled in these complexities they must also be prepared to respond and act. At times it may be necessary to step out of the role of researcher in order to offer support or take more decisive action especially when the well-being of vulnerable participants is at stake.

Managing food insecurity through informal networks of care: an ethnography of youth practices in the North of England

Food insecurity in the UK is a pressing concern that is associated with poor health outcomes. Research to date has focused on the challenges for adults in providing food for families. However, there is little evidence showing how children and young people experience food insecurity, particularly outside of the home and school. This paper, drawing on 14 months of ethnography in a youth club in the North of England, explores how young people manage food insecurity. In this youth club, the circulation of takeaway food is part of an informal network where boys purchase, share and receive food. This practice allows the boys to participate meaningfully within their peer groups whilst also providing stable access to food. This peer practice, however, was not available to everyone. This was a gendered practice that for the girls held little benefit due to their concerns about eating and pressure to provide for others. Instead, some girls depend on romantic relationships for food provision that is equated with affection and care. The findings will be discussed through a 'materialities of care' perspective to explore the complex ways in which food as a practice of care is part of everyday routines embedded within local places.

Walking the Plank: An Experimental Paradigm to Investigate Safety Voice

The investigation of people raising or withholding safety concerns, termed safety voice, has relied on report-based methodologies, with few experiments. Generalisable findings have been limited because: the behavioural nature of safety voice is rarely operationalised; the reliance on memory and recall has well-established biases; and determining causality requires experimentation. Across three studies, we introduce, evaluate and make available the first experimental paradigm for studying safety voice: the “Walking the plank” paradigm. This paradigm presents participants with an apparent hazard (walking across a weak wooden plank) to elicit safety voice behaviours, and it addresses the methodological shortfalls of report-based methodologies. Study 1 (n = 129) demonstrated that the paradigm can elicit observable safety voice behaviours in a safe, controlled and randomised laboratory environment. Study 2 (n = 69) indicated it is possible to elicit safety silence for a single hazard when safety concerns are assessed and alternative ways to address the hazard are absent. Study 3 (n = 75) revealed that manipulating risk perceptions results in changes to safety voice behaviours. We propose a distinction between two independent dimensions (concerned-unconcerned and voice-silence) which yields a 2 × 2 safety voice typology. Demonstrating the need for experimental investigations of safety voice, the results found a consistent mismatch between self-reported and observed safety voice. The discussion examines insights on conceptualising and operationalising safety voice behaviours in relationship to safety concerns, and suggests new areas for research: replicating empirical studies, understanding the behavioural nature of safety voice, clarifying the personal relevance of physical harm, and integrating safety voice with other harm-prevention behaviours. Our article adds to the conceptual strength of the safety voice literature and provides a methodology and typology for experimentally examining people raising safety concerns.

Making infection prevention and control everyone's business? Hospital staff views on patient involvement

CONTEXT

Ensuring an infection-free environment is increasingly seen as requiring the contribution of staff, patients and visitors. There is limited evidence, however, about how staff feel about collaborating with patients and relatives to co-produce that environment.

AIMS

This study aims to understand how hospital staff perceive the involvement of patients and relatives in infection prevention and control (IPC) and the main challenges for staff in working together with patients and relatives to reduce the threat of infection.

METHODS

Qualitative semi-structured interviews were conducted with 35 frontline health-care professionals and four executive staff, from two hospital trusts.

FINDINGS

We found that staff were more supportive of approaches that encourage co-operation from patients and relatives, than of interventions that invoked confrontation. We identified challenges to involvement arising from staff concerns about shifting responsibility for IPC onto patients. Staff were not always able to work with patients to control infection risks as some patients themselves created and perpetuated those risks.

CONCLUSIONS

Our work highlights that IPC has particular features that impact on the possibilities for involving patients and relatives at the point of care. Staff acknowledge tensions between the drive to involve patients and respect their autonomy, and their duty to protect patients from risk of unseen harm. The role that patients and relatives can play in IPC is fluctuating and context dependent. Staff responsibility for protecting patients from the risk of infection may sometimes need to take priority over prerogatives to involve patients and relatives in the co-production of IPC.

Under repair: A publication ethics and research record in the making

Based on fieldwork in the Committee on Publication Ethics, this paper offers an analysis of the forms of doings that publication ethics in action can take during what is called the 'Forum', a space where allegations of dubious research conduct get aired and debated between editors and publishers. This article examines recurring motifs within the review of publication practices whose ethics are called into. These motifs include: the shaping of publication ethics as an expertise that can be standardized across locations and disciplines, the separation of the research record from relations that produce it, and the divisibility of the scientific paper. Together these institute an ethics of repair at the centre of the curative enterprise of the Committee on Publication Ethics. Under the language of correcting the literature the members are working out, along with authors, what the research record should be and, inevitably, what it is. In turn, this article elicits new analytical objects that re-describe publication ethics as a form of expertise, beyond (and despite) the rehearsed axioms of this now well-established professional field.

'Text-work' in Research Ethics Review: The significance of documents in and beyond committee meetings

This article analyzes how a formal text (the Ethics Review Form) available at National Health Service Research Ethics Committees (NHSRECs) in the United Kingdom was used in meetings. Derived from the work of Dorothy Smith on incorporating texts into institutional ethnography (IE), it proposes the concept of "text work" as a way into understanding more about decision-making in ethics review and describes the extent to which this formal text shaped and influenced review work. The research study used observations of committee meetings, field-notes and interviews to produce an ethnographic mapping of Research Ethics Committees' (RECs) work. This article draws on one aspect of the research which was the process of isolating a particular, ubiquitous text and analyzing how it worked and was worked on in the meetings. The analysis contributes to contemporary discussion offering an alternative to ongoing debates about idealized ways of conducting ethics review. Finally, some tentative suggestions are made about improving training, based on and starting from the work which reviewers undertake.

Managing clinical uncertainty: An ethnographic study of the impact of critical care outreach on end-of-life transitions in ward-based critically ill patients with a life-limiting illness

Rapid response teams, such as critical care outreach teams, have prominent roles in managing end-of-life transitions in critical illness, often questioning appropriateness of treatment escalation. Clinical uncertainty presents clinicians with dilemmas in how and when to escalate or de-escalate treatment.

AIMS AND OBJECTIVES

To explore how critical care outreach team decision-making processes affect the management of transition points for critically ill, ward-based patients with a life-limiting illness.

METHODS

An ethnographic study across two hospitals observed transition points and decisions to de-escalate treatment, through the lens of critical care outreach. In-depth interviews were carried out to elucidate rationales for practices witnessed in observations. Detailed field notes were taken and placed in a descriptive account. Ethnographic data were analysed, categorised and organised into themes using thematic analysis.

FINDINGS

Data were collected over 74 weeks, encompassing 32 observation periods with 20 staff, totalling more than 150 hr. Ten formal staff interviews and 20 informal staff interviews were undertaken. Three main themes emerged: early decision-making and the role of critical care outreach; communicating end-of-life transitions; end-of-life care and the input of critical care outreach. Findings suggest there is a negotiation to achieve smooth transitions for individual patients, between critical care outreach, and parent or ward medical teams. This process of negotiation is subject to many factors that either hinder or facilitate timely transitions.

CONCLUSIONS

Critical care outreach teams have an important role in shared decision-making. Associated emotional costs relate to conflict with parent medical teams, and working as lone practitioners. The cultural contexts in which teams work have a significant effect on their interactions and agency.

RELEVANCE TO PRACTICE

There needs to be a cultural shift towards early and open discussion of treatment goals and limitations of medical treatment, particularly when facing serious illness. With training and competencies, outreach nurses are well placed to facilitate these discussions.

Ethical dilemmas and reflexivity in qualitative research

CONTEXT

For medical education researchers, a key concern may be the practicalities of gaining ethical approval where this is a national or local requirement. However, in qualitative studies, where the dynamics of human interaction pervade, ethical considerations are an ongoing process which continues long after approval has been granted. Responding to ethical dilemmas arising 'in the moment' requires a reflexive approach whereby the researcher questions his/her own motivations, assumptions and interests. Drawing on empirical studies and their experiences in academic and clinical research practice, the authors share their reflections on adhering to ethical principles throughout the research process to illustrate the complexities and nuances involved.

OBJECTIVES AND FINDINGS

These reflections offer critical insights into dilemmas arising in view of the ethical principles driving good conduct, and through domains which distinguish between procedural ethics, situational ethics, ethical relationships and ethical issues in exiting the study. The accounts consider integrity and altruism in research, gatekeeping and negotiating access, consent and confidentiality, power dynamics and role conflict, and challenges in dissemination of findings. The experiences are based on a range of examples of research in a UK context from managing difficult conversations in the classroom to video-ethnography in the operating theatre.

DISCUSSION AND CONCLUSIONS

These critical reflections make visible the challenges encountered and decisions that must be taken in the moment and on reflection after the event. Through sharing our experiences and debating the decisions we made, we offer insights into reflexivity in qualitative research which will be of value to others.

Informed consent in veterinary medicine: Ethical implications for the profession and the animal 'patient'

Informed consent processes are a vital component of both human and veterinary medicine. Current practice encourages veterinarians to learn from insights in the human medical field about how best to achieve valid consent. However, drawing on published literature in veterinary and medical ethics, this paper identifies considerable differences between the purposes of veterinary and human medical consent. Crucially, it is argued that the legal status of animal patients as 'property' has implications for the ethical role of veterinary informed consent and the protection of the animal 'patient'. It is suggested that veterinary informed consent should be viewed as an ethical pivot point where the multiple responsibilities of a veterinary professional converge. In practice, balancing these responsibilities creates considerable ethical challenges. As an example, the paper discusses the renewed call for UK veterinarians to make animal welfare their first priority; we predict that this imperative may increasingly cause veterinary informed consent to become an ethical pressure point due to tensions caused by the often conflicting interests of animals, owners and the veterinary profession. In conclusion, the paper argues that whilst gaining informed consent can often be presented as a robust ethical justification in human medicine, the same cannot be said in veterinary medicine. If the veterinary profession wish to prioritise animal welfare, there is an urgent need to re-evaluate the nature of authority gained through owner informed consent and to consider whether animal patients might need to be better protected outside the consent process in certain circumstances.

Researching victimisation using auto-ethnography: Wearing the Muslim veil in public

This article reflects upon my personal experiences of undertaking auto-ethnography on victimisation through wearing the Muslim veil in public. Wearing the veil was suggested by some of my respondents as a way to get insider knowledge of their own day-to-day experiences of victimisation. Here, I explore the emotional, psychological and physical impacts of being targeted because of my (perceived/adopted) Muslim identity. I discuss the advantages and disadvantages of covert auto-ethnographic research and consider the ethical challenges and practical difficulties of performing auto-ethnography. Also, I discuss the theoretical and methodological issues that arise from undertaking auto-ethnography as an insider/outsider when researching the targeted victimisation of veiled Muslim women. Finally, I discuss the usefulness and limitations of auto-ethnography as a method for understanding victimisation. I conclude that auto-ethnographic research into victimisation has great potential, although researchers need to be aware of some risks inherent in this approach and, thus, proceed with caution.

Case Study Observational Research: A Framework for Conducting Case Study Research Where Observation Data Are the Focus

Case study research is a comprehensive method that incorporates multiple sources of data to provide detailed accounts of complex research phenomena in real-life contexts. However, current models of case study research do not particularly distinguish the unique contribution observation data can make. Observation methods have the potential to reach beyond other methods that rely largely or solely on self-report. This article describes the distinctive characteristics of case study observational research, a modified form of Yin's 2014 model of case study research the authors used in a study exploring interprofessional collaboration in primary care. In this approach, observation data are positioned as the central component of the research design. Case study observational research offers a promising approach for researchers in a wide range of health care settings seeking more complete understandings of complex topics, where contextual influences are of primary concern. Future research is needed to refine and evaluate the approach.

Expectant futures and an early diagnosis of Alzheimer's disease: Knowing and its consequences

Efforts to diagnose Alzheimer's disease (AD) at earlier stages as a means to managing the risks of an ageing population, dominate scientific research and healthcare policy in the UK. It is anticipated that early diagnosis will maximise treatment options and enable patients to 'prepare for their future' in terms of care. Drawing on qualitative data gathered across an out-patient memory service and in-patient hospital in the UK, the purpose of this paper is to examine the ways in which the hopeful promissory claims of early diagnosis as it maintains the dominant biomedical model for managing AD, are negotiated by healthcare practitioners. Developing the analytical standpoint of the sociology of expectations, this paper demonstrates that early diagnosis has the potential to 'close off' hopeful promissory visions of the future in two ways. Firstly, it (re)produces the fearful anticipations of AD built around expectations concerning the ageing future 'self', and secondly it produces uncertainty in terms of the availability of care as material resource. Whilst practitioners account for the uncertainties and anxieties it produces for patients and their families, they also convey a sense of ambivalence concerning early diagnosis. This article captures the internal conflicts and contradictions inherent to practitioners' perspectives regarding the repercussions of early diagnosis and concludes by arguing that it effaces the uncertainties and anxieties that it produces in practice as it restricts the co-existence of narratives for making sense of memory loss beyond 'loss of self', and fails to recognise care as a viable alternative for managing AD.

Ethnographic methods for process evaluations of complex health behaviour interventions

This article outlines the contribution that ethnography could make to process evaluations for trials of complex health-behaviour interventions. Process evaluations are increasingly used to examine how health-behaviour interventions operate to produce outcomes and often employ qualitative methods to do this. Ethnography shares commonalities with the qualitative methods currently used in health-behaviour evaluations but has a distinctive approach over and above these methods. It is an overlooked methodology in trials of complex health-behaviour interventions that has much to contribute to the understanding of how interventions work. These benefits are discussed here with respect to three strengths of ethnographic methodology: (1) producing valid data, (2) understanding data within social contexts, and (3) building theory productively. The limitations of ethnography within the context of process evaluations are also discussed.

'Mum never loved me.' How structural factors influence adolescent sexual and reproductive health through parent-child connectedness: a qualitative study in rural Tanzania

Research in high income countries shows parent–child connectedness to be protective against undesirable sexual and reproductive health (SRH) outcomes among young people. Little has been done to understand the nature of parent–child connectedness, the structural factors that impact on connectedness and parents’ understanding of how connectedness affects their children's sexual behaviour in sub-Saharan Africa and Tanzania in particular. Ethnographic research involved 30 days of observation in 10 households, 9 focus group discussions and 60 in-depth interviews. Thematic analysis was conducted using NVIVO qualitative data analysis software.

The structural factors with greatest influence on connectedness were economic circumstances, gender, social status, state education, and globalisation. Economic circumstances impacted on parent–child connectedness through parents’ ability to provide for their children's material needs, and the time their occupation allowed for them to spend with their children and monitor their activities. Appropriate parent–child interactions were shaped by gender norms and by social status in the form of respectability, adolescents’ adherence to norms of respect/ obedience shaping their parents’ affection. State education affected parents’ preferences between children but also undermined parental authority, as did broader globalisation. Connectedness was related to SRH in a bi-directional way: lack of connectedness was linked to young people's low self-esteem and risky sexual behaviour while unplanned pregnancies seriously undermined young women's connectedness with their parents. Since material provision was perceived to be a central element of parent–child connectedness, structural factors limiting provision made transactional sex more likely both through direct material pathways and emotional ones. Motives for transactional sex were said to be material needs and to feel loved and cared for.

An important pathway by which structural factors shape adolescent SRH outcomes is through parent–child connectedness, especially parents’ ability to spend time with their children and provide for their economic needs. Modifying these structural factors should facilitate parent–child connectedness, which may help delay early sexual intercourse, protect young people against unplanned pregnancy through encouraging communication on contraception use and, overall, promote healthy adolescent development.

Gaining access to a research site and participants in medical and nursing research: a synthesis of accounts

OBJECTIVES

The literature contains few accounts of how access to a research site and participants in medical and nursing research is gained, and few efforts to synthesise the existing accounts. Therefore, this article has two main goals: (i) to synthesise our own account of access with others in the medical and nursing literature, and (ii) to derive from this synthesis considerations of access and implications for health professions education.

METHODS

Based on field notes from a study conducted in an orthopaedic surgical section of a Norwegian university hospital, we provide an account of how access to the operating theatre (research site) and surgical teams (participants) was achieved. We synthesise the findings by comparing our account with existing accounts on access.

RESULTS

Our synthesis translates into a number of considerations related to the gaining of access to a research site and participants in medical and nursing research. These include conducting continuous negotiations to ensure the agreement and consent of participants and gatekeepers, and demonstrating transparency regarding the researcher's identity and the nature of the particular project and findings. These considerations can raise awareness and preparedness for the process of gaining access, which will benefit health professions education researchers planning or undertaking studies in educational or clinical settings. Health professions educators can also include the considerations in structured educational programmes, specifically methods courses, to instil similar awareness and preparedness in students.

CONCLUSIONS

We suggest that future medical and nursing research should emphasise a detailed, unvarnished documentation of the access process that incorporates existing accounts of the process.

Victims' voices and victims' choices in three IPV courts

Critics of mandatory interventions for intimate partner violence (IPV) propose that the justice system disempowers victims by denying them voice and choice in legal proceedings. This exploratory study examines this claim through observations of three criminal courts. Findings show that victims are offered voice and a degree of choice in only one of the three courts. Court procedures that enhance victim voice and choice include a specialized IPV court, victim advocates trained in victims' rights issues, and a lead judge who models respectful treatment of victims. The author proposes that voice and choice are distinct aspects of victim empowerment and that the provision of voice may have benefits to IPV victims that are distinct from the benefits of choice.

Research ethics in global mental health: advancing culturally responsive mental health research

Global mental health research is needed to inform effective and efficient services and policy interventions within and between countries. Ethical reflection should accompany all GMHR and human resource capacity endeavors to ensure high standards of respect for participants and communities and to raise public debate leading to changes in policies and regulations. The views and circumstances of ethno-cultural and disadvantaged communities in the Majority and Minority world need to be considered to enhance scientific merit, public awareness, and social justice. The same applies to people with vulnerabilities yet who are simultaneously capable, such as children and youth. The ethical principles of respect for persons or autonomy, beneficence/non-maleficence, justice, and relationality require careful contextualization for research involving human beings. Building on the work of Fisher and colleagues (2002), this article highlights some strategies to stimulate the ethical conduct of global mental health research and to guide decision-making for culturally responsible research, such as developing culturally sensitive informed consent and disclosure policies and procedures; paying special attention to socioeconomic, cultural, and environmental risks and benefits; and ensuring meaningful community and individual participation. Research and capacity-building partnerships, political will, and access to resources are needed to stimulate global mental health research and consolidate ethical practice.

Enacting Occupation-Based Practice: Exploring the Disjuncture between the Daily Lives of Mothers with Rheumatoid Arthritis and Institutional Processes

Introduction:

Occupation-based approaches are a hallmark of excellence in occupational therapy practice. This article focuses on the disjuncture between how women with rheumatoid arthritis go about their daily lives, that is to say their occupations, and what is addressed during routine visits at a specialized rheumatology outpatient clinic.

Method:

Institutional ethnography was employed as a method of inquiry to identify the occupations and related issues that were or were not accounted for in health records and addressed within institutional processes. Interviews and participant observations were conducted with seven women with rheumatoid arthritis who were mothers. Hospital records were analysed as texts mediating between the women's daily lives and the rheumatology outpatient clinic.

Findings:

The analysis revealed that despite the diversity in the ways that the women managed their daily lives, the things that they did were viewed, understood, and addressed only within the boundaries of the standardizing relations that ruled practice in this clinical setting. Institutional processes grounded in biomedical concepts such as functional status or disease activity, as well as clinical assessments that depict these concepts, both shape and limit opportunities for occupational therapists to advance and enact occupation-based practice.

Conclusion:

In this setting, the complexity of the participants' daily lives and the occupations they engage in remain unaddressed.

"Dying a hero": parents' and young people's discourses on concurrent sexual partnerships in rural Tanzania

Background

Concurrent sexual partnerships (CSPs) have been speculated to drive the HIV pandemic in many sub-Saharan African countries. We have limited understanding of how people think and talk about CSPs, how beliefs are transmitted across generations, and how this might affect the practice. This paper explores these issues to understand how CSPs are perpetuated and help identify opportunities for interventions to modify them.

Methods

The study employed an ethnographic research design involving: participant observation in 10 households, 60 in-depth interviews (IDIs), and nine participatory focus group discussions (FGDs). Participants were young people aged 14-24 and parents/carers of young people within this age group. The 60 IDIs were conducted with: 17 fathers, 13 mothers, 13 young men and 17 young women (six of whom had had unplanned pregnancies and 11 had no children). The nine FGDs were conducted with groups of: fathers (2), mothers (2), young women (2), and young men (3). A discourse analysis was carried out with all the transcripts. Data were analysed with the aid of NVIVO 8 software.

Results

Six distinct discourses were identified from the way participants talked about CSPs and the norms driving the practice: 1) predatory masculine sexuality; 2) masculine respectability; 3) feminine respectability; 4) empowered modern women; 5) traditional health beliefs; 6) public health. Discourses legitimating CSPs were drawn on and reproduced primarily by young people and the media and only indirectly by parents. Discourses discouraging CSPs were used primarily by parents, religious leaders and learning institutions and only indirectly by young people themselves.

Conclusion

Better knowledge of the discourses through which young people CSPs, and how these discourses are transmitted across generations, might help develop “culturally compelling” interventions that modify these discourses to enhance sexual health.

The case for ethics review in the social sciences: Drawing from practice at Queen Mary University of London

This article responds directly to an article published in Research Ethics in 2011 where Schrag argued against ethics review for social science and humanities research. He argued that review committees offer solutions in search of a problem, impose silly restrictions and apply inappropriate principles. He suggests that review committees typically lack appropriate expertise and argued that the process harms the innocent. This article refutes these claims and offers a case study of the ethical review process at Queen Mary University of London (QMUL) to offer counter claims. The discussion highlights the way in which the QMUL process is sensitized to the challenges posed by social science and humanities research and is a process that, rather than focusing upon avoiding harm, emphasizes notions of care to both participants and researchers.

Making researchers moral: Why trustworthiness requires more than ethics guidelines and review

Research ethics, once a platform for declaring intent, discussing moral issues and providing advice and guidance to researchers, has developed over time into an extra-legal regulatory system, complete with steering documents (ethics guidelines), overseeing bodies (research ethics committees) and formal procedures (informed consent). The process of institutionalizing distrust is usually motivated by reference to past atrocities committed in the name of research and the need to secure the trustworthiness of the research system. This article examines some limitations of this approach. First, past atrocities cannot provide the necessary justification unless institutionalized distrust is a necessary or efficient means to prevent future ones – and there are several reasons to doubt this. Second, the efficacy of ethics review in safeguarding morally acceptable research depends on the moral competence and integrity of individual researchers – the very qualities that institutionalized distrust calls into question. Third, ethics guidelines cannot, as is sometimes assumed, educate or guide researchers in moral behaviour unless they already possess considerable capacity for moral judgment. Fourth, institutionalized distrust is a potential threat to the moral competence and integrity of researchers by encouraging a blinkered view of ethical issues, inducing moral heteronomy through incentives, and alienating them to research ethics. We conclude that the moral problem posed by inappropriate short-term behaviour on behalf of researchers is dwarfed by the potential long-term consequences if their moral competence is allowed to deteriorate. Measures must therefore be taken to ensure that researchers are equipped to take their individual responsibility and are not obstructed from so doing.

Extending the olive branch

Using data from a study of qualitative researchers' experiences with ethics review and our own lens as both researchers and REB/IRB members, we explore the ethics review process and provide recommendations for improvements. Our findings suggest that the review process would benefit from a strengthened trust relationship between REB/IRBs and qualitative researchers that would require a commitment from both sides. Regarding REBs/IRBs, increased transparency of the review process, consistent application of federal guidelines, and a more collaborative review approach may improve the trust of qualitative researchers. Regarding researchers, approaching ethics review as a form of academic peer review, similar to other types of assessments of scholarly products such as grants and publications, may promote the integration of ethics review as an intrinsic part of the research process. Recognizing that responsibility for ethical research is a shared goal of both researchers and REB/IRBs, improved collaboration and constructive interaction can assist in understanding each other's perspective and work toward the development of mutual trust and respect.

Research ethics in accessing hospital staff and securing informed consent

Qualitative researchers cannot rely on research ethics to be a static practice. In this article we discuss how observation of guidelines for inquiry and international agreements on the dignity of health care research are not sufficient on their own to ensure that the challenges inherent in the everyday management of a project are regulated. We focus in particular on ethics in accessing participants and the construction of informed consent. During our study, important contrasts emerged between the ideal presented for the standard ethics review process and practical ethics. As a result, we focused on building open communication with the participants through rigorous project management. We analyzed the data and wrote this article collaboratively to represent the empirical reality of a team of researchers aiming to take ethical challenges seriously while collecting data in three National Health Service Trusts in the United Kingdom.