Judging the ethics of qualitative research: considering the "ethics as process" model

Thinking Otherwise: Bringing Young People into Pediatric Concussion Clinical and Research Practice

Background:

As rates of pediatric concussion have steadily risen, and concerns regarding its consequences have emerged, pediatric concussion has received increased attention in research and clinical spheres. Accordingly, there has been a commitment to determine how best to prevent and manage this injury that so commonly affects young people. Despite this increased attention, and proliferation of research, pediatric concussion as a concept has rarely, if ever, been taken up and questioned. That is, little attention has been directed toward understanding what concussion ‘is’, or how young people are regarded in relation to it. As a result, pediatric concussion is understood in decidedly narrow terms, constructed as such by a biomedical way of knowing.

Aim:

We aim to demonstrate how conceptualizing concussion, and young people, ‘otherwise’, enabled the co-production of a more nuanced and complex understanding of the experience of pediatric concussion from the perspective of young people.

Approach:

Drawing on an illustrative case example from a critical qualitative arts-based study, we demonstrate how bringing young people into research as ‘knowers’ enabled us to generate much-needed knowledge about concussion in young people.

Implications:

The critical thinking put forward in this paper suggests a different approach to pediatric concussion, which is shared in the form of implications for clinical and research practice.

When people matter: The ethics of qualitative research in the health and social sciences

When research involves people, ethics are fundamental. In the health and social sciences, when qualitative methodologies are used, in addition to ensuring an ethical process approved by the ethics review board, it is also necessary to guarantee an ethical practice capable of responding adequately to the complex questions and dilemmas which arise as the study progresses. This theoretical article analyses some of the most sensitive issues involved in qualitative research and discusses the following questions: (a) How should ethics be approached when working with vulnerable groups? (b) Is informed consent enough? (c) Should we rethink anonymity? (d) What is the difference between confidentiality and anonymity? (e) What exactly do we mean by relational ethics? (f) How can we avoid hurting people, yet remain honest? In the conclusions, we discuss some basic aspects for ensuring ethical studies. This paper, therefore, may be of interest to all health and social researchers concerned about ensuring that their studies comply with ethical principles which recognise, protect and respect participants' rights.

How to deal with the consent of adults with cognitive impairment involved in European geriatric living labs?

BACKGROUND

Living labs are realistic environments designed to create links between technology developers and end-users (i.e. mostly older adults). Research in LLH (Living labs in health) covers a wide range of studies from non-interventional studies to CT (clinical trials) and should involve patients with neurocognitive disorders. However, the ethical issues raised by the design, development, and implementation of research and development projects in LLH have been the subject of only little interest thus far.

OBJECTIVE

Our aim was to determine a pragmatic, ethical and regulatory correct approach to seek the informed consent of patients with neurocognitive disorders according to the different types of studies carried out in European LLH, with a focus on the French context.

METHODS

A narrative review of regulatory texts and clinical articles was conducted, and a pragmatic procedure to determine the decision-making capacity of older adults in LLH was proposed.

RESULTS

Individuals must be adequately informed and freely agree to participate in CT. The capacity to consent should be assessed in CT including cognitively impaired older adults. We propose the following steps: first to assess for delirium using the 4 'A's Test (4AT) or the 3-min Diagnostic interview for Confusion Assessment Method (3D-CAM), second to search for medical history of major neurocognitive disorder, and third to assess the decision capacity using the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC).

CONCLUSIONS

Including individuals with neurocognitive disorders in research implies using an efficient and pragmatic strategy to inform participants and obtain their consent. The tool we offer here may be useful in the routine operation of LLH but can also be extended to all CT with this population.

Stakeholder Requirements for an Ethical Framework to Sustain Multiple Research Projects in an Emerging Living Lab Involving Older Adults

Living Lab (LL) research should follow clear ethical guidelines and principles. While these exist in specific disciplinary contexts, there is a lack of tailored and specific ethical guidelines for the design, development, and implementation of LL projects. As well as the complexity of these dynamic and multi-faceted contexts, the engagement of older adults, and adults with reducing cognitive and physical capacity in LL research, poses additional ethical challenges. Semi-structured interviews were undertaken with 26 participants to understand multistakeholder experiences related to user engagement and related ethical issues in emerging LL research. The participants' experiences and concerns are reported and translated into an ethical framework to guide future LL research initiatives.

Transition towards End of Life in Palliative Care: An Exploration of its Meaning for Advanced Cancer Patients in Europe

Transition as a concept in healthcare has been explored, but there is limited empirical work which considers transition in the context of palliative care, specifically from the patient perspective. This article reports findings from a qualitative study designed to explore transition experiences of 100 advanced cancer patients in six European countries. Data were analyzed using the ATLAS.ti program. Findings suggest that transition is a confusing time of mixed messages, poor communication, and uncertainty, but the physical environment of the hospice offers a place of ontological security from which to address this. Transition concepts fail to capture the palliative care experience fully. Transience, as an alternative concept, is reported, although further research is needed to explore this. In clinical practice, the value given to hospice by patients suggests that clinicians must carefully balance the benefit of mainstream integration with sensitive assimilation of hospice philosophy.

A University Wide Model for the Ethical Review of Human Subjects Research

In the United Kingdom (and elsewhere), there are moves to extend formal ethical review of research involving human subjects beyond the traditional oversight by NHS local or multi-centre research ethics committees of medical or clinical research, to also encompass all ‘non-clinical’ research involving human subjects. This paper describes and analyses the development and implementation of a model for ethical review within the university sector. At Cardiff University, a devolved or two-tiered system of ethics review has been created in which a top-level university research ethics committee provides policy advice to and oversight of school-based research ethics committees that engage in formal ethics review of research conducted in their respective schools. We describe the system and reflect on the challenges and benefits of implementing such a coordinated and comprehensive university-wide system of ethics review.

Co-production with "vulnerable" groups: Balancing protection and participation

BACKGROUND AND AIM

This paper explores the tension between participation and protection at a time when professionals are encouraged to engage patients and citizens in both the "R" (research) and the "D" (development) of services. Concerns to protect groups perceived as "vulnerable" can mean that not everyone is afforded the same opportunity to participate.

METHODS

Our data draw on the literature and secondary analysis of a study designed to explore the experiences of young peoples' transitions from health and social care to adult services. In seeking ethics approval, tensions between protection and participation were evident, and once the study was concluded, we reviewed group and individual interview transcripts, team email correspondence, and research notes. We considered aspects of participation, co-production, involvement, and research design in relation to the ethics concerns raised.

FINDINGS

In terms of privacy and confidentiality, young people were skilled at setting their own boundaries. Whilst young people leaving foster and residential care are frequently perceived as vulnerable, those in our study asserted their agency and desire to be "visible." Some experienced conditions aimed at protecting their confidentiality or safety as oppressive.

CONCLUSION

The risk reduction strategies that often underpin ethics approval processes can also carry risks. Limiting opportunities to play a part in research for people who may already be excluded on age, health, language, or other grounds reduces the range of lay knowledge on which we can draw, limits generalisability, and potentially adds to damaging social exclusion. Learning how to participate effectively is a life skill.

Being occupied: supporting ‘meaningful activity’ in care homes for older people in England

The benefits of meaningful activity in later life are well documented. Studies show that being occupied contributes to both physical and mental health as well as quality of life. Research also suggests that activity may be beneficial to people residing in care homes, including people living with dementia. This paper presents findings from a study which used the Adult Social Care Outcomes Toolkit (ASCOT) to measure quality of life in six care homes located in the south-east of England. The study found, like previous ones, that care home residents’ days were characterised by a lack of activity. Drawing on observations, interviews and focus groups with residents and staff from these homes, this paper attempts to understand why care home residents do not engage in meaningful activities. We reject the idea that these low levels of activity are a natural part of the ageing process or that they can be explained by notions of resident choice. Instead, the findings point to both insufficient funding and working practices within care homes as more substantive explanations. These explanations inform a discussion of how the low levels of engagement in meaningful activity could be addressed and residents’ quality of life improved.

A Narrative on The Witch-Hunt Narrative: The Moral Dimensions

Ross Cheit's The Witch-Hunt Narrative raises a number of complex moral issues. Cheit's principal purpose is to challenge the belief that our society has overreacted to claims about the sexual abuse of children. Both directly and indirectly, Cheit's in-depth analysis broaches moral concerns pertaining to the integrity of child abuse allegations, investigations, civil litigation, and criminal prosecution, with an emphasis on the mixed motives of the parties involved in key cases. This article provides an overview of ethical questions pertaining to gathering information from very vulnerable individuals, informed consent, institutional review, protection of research participants, the use of deception and coercion, confidentiality and privacy, reporting research results, and conflicts of interest. In addition, the author discusses the phenomenon of whistle-blowing as it pertains to professionals' ethical judgments about disclosure of wrongdoing and misconduct. The author outlines key ethics-related concepts, applies relevant moral theory, and explores the implications of the moral issues raised by The Witch-Hunt Narrative for child sexual abuse victims, perpetrators, child welfare and law enforcement professionals, scholars and researchers, and the public at large.

Complexity in programme evaluations and integration studies: what can it tell us?

Purpose

Complexity received increasing attention from researchers in integration and evaluation studies. Complex adaptive systems are the most prominent formulation of complexity used in programme evaluations. However, there remain significant theoretical and conceptual barriers to using complexity as an explanatory model in social sciences, and thus in applying it successfully in integration and evaluation studies. The paper aims to discuss these issues.

Design/methodology/approach

Discussion paper outlining the potential uses and risks of complexity theory for studying integration programmes in health and social care and programme evaluations in general. The paper proceeds by synthesising the work of various critics and proponents of complexity theory in the social sciences and evaluation theory.

Findings

Complexity offers opportunities and risks to social scientists working in programme evaluations and integration studies. The opportunities are defined by additional modelling and verification/falsification of possible cause and effect links in programme settings. The risks, on the other hand, are twofold. Social scientists may use complexity as a shorthand for as yet insufficient understanding of the contexts under examination, or they mistake it for an explanatory device without testing its potential to explain. The second risk emerges as a result of the nature of complexity and its role in natural sciences. Assigning complexity an explanatory role may prevent further investigation of a given setting that may reveal that complexity is insufficient to understand what is going on.

Originality/value

Researchers should make clear how they have operationalised and measured the various features of the complexity model to allow robust verification of the evidence. Scholars should also assume that complexity as defined by the natural sciences is philosophically and epistemologically problematic when transferred into the realm of social sciences that largely operate with concepts informed by the paradigm of understanding social behaviour.

The acceptability and feasibility of using the Adult Social Care Outcomes Toolkit (ASCOT) to inform practice in care homes

BACKGROUND

The Adult Social Care Outcomes Toolkit (ASCOT) measures social care related quality of life (SCRQoL) and can be used to measure outcomes and demonstrate impact across different social care settings. This exploratory study built on previous work by collecting new inter-rater reliability data on the mixed-methods version of the toolkit and exploring how it might be used to inform practice in four case study homes.

METHOD

We worked with two care home providers to agree an in-depth study collecting SCRQoL data in four case-study homes. Data was collected about residents' age, ethnicity, cognitive impairment, ability to perform activities of daily living and SCRQoL in the four homes. Feedback sessions with staff and managers were held in the homes two weeks after baseline and follow-up data collected three months later. Interviews with managers explored their views of the feedback and recorded any changes that had been made because of it.

RESULTS

Participant recruitment was challenging, despite working in partnership with the homes. Resident response rates ranged from 23 to 54 % with 58 residents from four care homes taking part in the research. 53 % lacked capacity to consent. Inter-rater reliability for the ASCOT ratings of SCRQoL were good at time one (IRR = 0.72) and excellent at time two (IRR = 0.76). During the study, residents' ability to perform activities of daily living declined significantly (z = -2.67, p < .01), as did their expected needs in the absence of services (z = -2.41, p < .05). Despite these rapid declines in functionings, residents' current SCRQoL declined slightly but not significantly (Z = -1.49, p = .14). Staff responded positively to the feedback given and managers reported implementing changes in practice because of it.

CONCLUSION

This exploratory study faced many challenges in the recruitment of residents, many of whom were cognitively impaired. Nevertheless, without a mixed-methods approach many of the residents living in the care homes would have been excluded from the research altogether or had their views represented only by a representative or proxy. The value of the mixed-methods toolkit and its potential for use by providers is discussed.

Colliding discourses

The aim of this paper is to bring to the surface issues of power and authority in the process of seeking ethical approval for health service research in the UK in relation to the dominant discourse about methods to generate data and results that constitute legitimate ‘evidence’. In order to demonstrate how alternative and competing discourses may be silenced, I offer a deconstructive readings of the term ‘evidence’ as applied to healthcare, and excerpts of policy documents, which provide the framework for the ethical review of research proposals. I debate how the discourse shaped my own experience of seeking ethical approval for a participatory evaluation project involving Consultant Nurses. Furthermore, I engage in a dialogue with other texts in the literature in order to open up possible patterns and to generate alternative explanations and discourses which seek to promote constructive dialogue rather than regulation.

Reflections on conducting focus groups with people with learning disabilities

This paper examines the use of focus groups as a methodological approach when undertaking research with people with learning disabilities. This is presented within the context of an ongoing research project that has principally adopted a participatory research approach and that is seeking to understand how people with learning disabilities conceptualise and understand their mental health. As such, this paper may be seen as a critical case study of the ongoing methodological challenges of using focus groups, as well as exploring some of the thornier practical issues such as recruitment, attendance, data collection, ethical issues and matters of consent, facilitation, venue and payment in adopting this approach when undertaking research with people with learning disabilities. The paper concludes that the focus group approach is a legitimate methodological approach within the research process in the field of learning disabilities.

Are we ethical? Approaches to ethics in management and organisation research

We are currently witnessing two concurrent trajectories in the field of research ethics, namely the increasingly explicit and formalised requirements of research governance and the ongoing debate around the implicit nature of ethics, which cannot be assured by these methods, and related—for some—the role that reflexivity can play in research ethics. This article seeks to address two questions. First, given the focus of these discussions is often theoretical rather than on practice, how do our colleagues engage with research ethics and what is their ethical position? Second, given reflexivity is typically focused on knowledge construction, to what extent does it influence (if at all) their ethics throughout the research process? Interviews were undertaken with senior colleagues who have established modes of research practice and ethical approaches. Drawing on understandings of reflexivity and ethics, this article explores an ethical subjectivity that was typically reflective and sometimes reflexive and was usually related to personal rather than procedural ethics. It demonstrates contrasting ethical concerns of society, participant and researcher community, and how some researchers saw their ethical obligation as focused on producing meaningful research at the expense of more traditional concerns for the research participant.

Feelings and Intersubjectivity in Qualitative Suicide Research

In this article, we explore how feelings permeated our qualitative research on suicide. Drawing on phenomenological theory, we argue for the epistemic and ethical importance of the feelings that emerge through research encounters, considering them to be embodied, intersubjective, and multilayered, and requiring careful interpretation through a "reflexivity of feelings." We sketch a tentative framework of the ways that we experienced feelings in our research and give three in-depth examples to illustrate some of the different layers and types of feelings we identified. We reflexively interpret these feelings and their role in our analysis and then discuss some of the ethical and methodological issues related to examining feelings in suicide research, and research more generally.

Transforming a conservative clinical setting: ICU nurses' strategies to improve care for patients' relatives through a participatory action research

This study focuses on change strategies generated through a dialogical-reflexive-participatory process designed to improve the care of families of critically ill patients in an intensive care unit (ICU) using a participatory action research in a tertiary hospital in the Balearic Islands (Spain). Eleven professionals (representatives) participated in 11 discussion groups and five in-depth interviews. They represented the opinions of 49 colleagues (participants). Four main change strategies were created: (i) Institutionally supported practices were confronted to make a shift from professional-centered work to a more inclusive, patient-centered approach; (ii) traditional power relations were challenged to decrease the hierarchical power differences between physicians and nurses; (iii) consensus was built about the need to move from an individual to a collective position in relation to change; and (iv) consensus was built about the need to develop a critical attitude toward the conservative nature of the unit. The strategies proposed were both transgressive and conservative; however, when compared with the initial situation, they enhanced the care offered to patients' relatives and patient safety. Transforming conservative settings requires capacity to negotiate positions and potential outcomes. However, when individual critical capacities are articulated with a new approach to micropolitics, transformative proposals can be implemented and sustained.

Reconsidering 'ethics' and 'quality' in healthcare research: the case for an iterative ethical paradigm

Background

UK-based research conducted within a healthcare setting generally requires approval from the National Research Ethics Service. Research ethics committees are required to assess a vast range of proposals, differing in both their topic and methodology. We argue the methodological benchmarks with which research ethics committees are generally familiar and which form the basis of assessments of quality do not fit with the aims and objectives of many forms of qualitative inquiry and their more iterative goals of describing social processes/mechanisms and making visible the complexities of social practices. We review current debates in the literature related to ethical review and social research, and illustrate the importance of re-visiting the notion of ethics in healthcare research.

Discussion

We present an analysis of two contrasting paradigms of ethics. We argue that the first of these is characteristic of the ways that NHS ethics boards currently tend to operate, and the second is an alternative paradigm, that we have labelled the ‘iterative’ paradigm, which draws explicitly on methodological issues in qualitative research to produce an alternative vision of ethics. We suggest that there is an urgent need to re-think the ways that ethical issues are conceptualised in NHS ethical procedures. In particular, we argue that embedded in the current paradigm is a restricted notion of ‘quality’, which frames how ethics are developed and worked through. Specific, pre-defined outcome measures are generally seen as the traditional marker of quality, which means that research questions that focus on processes rather than on ‘outcomes’ may be regarded as problematic. We show that the alternative ‘iterative’ paradigm offers a useful starting point for moving beyond these limited views.

Summary

We conclude that a ‘one size fits all’ standardisation of ethical procedures and approach to ethical review acts against the production of knowledge about healthcare and dramatically restricts what can be known about the social practices and conditions of healthcare. Our central argument is that assessment of ethical implications is important, but that the current paradigm does not facilitate an adequate understanding of the very issues it aims to invigilate.

Online support for children of parents suffering from mental illness: a case study

From epidemiologic research, we know that children of parents with a mental illness (COPMI) have an elevated risk of developing a serious mental disorder. Aside from studies based on risk and resilience, there has been little research on the children's own perceptions. The aim of this study was to expand our understanding of key variables influencing COPMI's seeking support and to explore whether a website targeted at COPMI could help them improve their ability to cope with their circumstances and to find professional help. This case study illustrates one visitor's use of a website that was specifically designed to help COPMI. The visitor was a young adult female whose two parents both suffered from mental illness. She participated for 3 years in an intervention delivered through the website. Several things helped to inform us about her perspective on living with parents suffering from mental illness, her use of the website and the benefits she derived from using the website. These included (a) her story as she told it in the exit interview, (b) her messages to her peers and counsellors, (c) her user data and (d) the content of her chat conversations with her peers.

Therapeutic engagement between consumers in suicidal crisis and mental health nurses

Registered nurses within public mental health services play crucial roles in helping people recover from suicidal crisis. However, there is a lack of understanding of how care is experienced in this context, and available evidence suggests that nurses and consumers are often dissatisfied with the quality of care. There is thus an imperative to generate understanding of needs and experiences of both groups with a view to informing practice development. This article summarizes qualitative findings from a multimethod study undertaken in Australia, which surveyed and interviewed mental health nurses who had recent experience of caring for consumers in suicidal crisis in a hospital setting, and interviewed consumers who had recovered from a recent suicidal crisis. A framework was developed to guide the study and support ethical imperatives; in particular, the promotion of consumer well-being. The findings highlight that therapeutic interpersonal engagement between nurses and consumers was central to quality care. This was particularly noted, as engagement could help reduce consumer isolation, loss of control, distress, and objectification of the delivery of potentially-objectifying common interventions. Of concern, the results indicate a lack of therapeutic engagement from the perspective of both consumers and nurses. Recommendations to promote fuller therapeutic engagement are presented.

The work of living with a rare cancer: multiple myeloma

AIM

To report findings from a qualitative study of the experiences of long-term survivors of multiple myeloma.

BACKGROUND

Multiple Myeloma is a malignant disease of the bone marrow. Until recently, it was rapidly fatal. Although it remains incurable, people diagnosed with it are living longer on average, largely due to new treatments, some of which have onerous side effects.

DESIGN

Prospective descriptive study.

METHOD

A series of 47 in-depth interviews were conducted at 6-12 month intervals over 18 months in 2008-2010 with 10 long-term survivors of myeloma and their primary support person. Interviews were analysed using the constant comparative method (Grounded Theory).

FINDINGS

To adapt to the effects of both the disease and ongoing medical treatments, participants undertook extensive 'illness work'. Most of this work fell into two broad categories. Risk work aimed to mitigate risks to the well-being of both the person with myeloma and his/her carer. Emotion work aimed to manage the feelings of self and others in a protracted cycle of remission and relapse.

CONCLUSION

The experience of myeloma is increasingly characterized by issues associated with chronic disease and 'survivorship'. It is important for nurses working with people with myeloma to understand the overwhelming nature of illness work in this context. Nurses can put in place supportive measures to address the two main 'drivers' of this work: constant risk to well-being of survivors (including carers) and the recurrent need to manage emotions in social interactions.

Informed consent, vulnerability and the risks of group-specific attribution

People in extraordinary situations are vulnerable. As research participants, they are additionally threatened by abuse or exploitation and the possibility of harm through research. To protect people against these threats, informed consent as an instrument of self-determination has been introduced. Self-determination requires autonomous persons, who voluntarily make decisions based on their values and morals. However, in nursing research, this requirement cannot always be met. Advanced age, chronic illness, co-morbidity and frailty are reasons for dependencies. These in turn lead to limited abilities or opportunities for decision-making and self-determination. Exclusion of vulnerable people from research projects would disadvantage them by not covering their needs, which would violate the ethical principles of justice and beneficence. Commonly, vulnerability is attributed to social groups. The consequence for individuals, attributed as belonging to such a vulnerable group, is that the principles of respect for autonomy, justice and beneficence are subordinated to the principle of non-maleficence, understood as avoiding the risk to cause more harm than good. In addition, group-specific attribution could lead to stigmatizing because labelling a person as deviation from a norm violates integrity. For clinical nursing research, the question arises how the protection of vulnerable people could be granted without compromising ethical principles. The concept of relational ethics provides a possible approach. It defines vulnerability as the relation between a person’s health status and the extent to which this person is dependent on the researcher and the research context. Vulnerability is not attributed solely to a person but to a situation, meaning the person is viewed in context. By combining vulnerability as a context-related and situational concept with existing approaches of informed consent, the different ethical principles can be balanced and preserved at every step of the research process.

'That was helpful … no one has talked to me about that before': Research participation as a therapeutic activity

There is considerable interest in the various ethical problems associated with undertaking health and social science research. Participants in such research are often considered vulnerable because of their health status, social position, or dependence on others for health and welfare services. Researchers and ethics committees pay scrupulous attention to the identification and amelioration of risks to participants. Rarely are the benefits to participants of engaging in research highlighted or drawn to the attention of potential participants. Such potential benefits need to be considered by researchers and reviewers when considering the balance of benefits and harms associated with research projects. In this paper, we particularly consider the psychotherapeutic benefits of participation in research.

Mind the gaps in ethical regulations of nursing research

The introduction of and the commitment to evidence-based nursing in all care settings have led to a rapid increase of intervention and outcome-based research programs. Yet, the topics of nursing research are not only affected by interventions and outcomes but also affected by the concept of caring derived from humanistic philosophy. Considering this twofold orientation of nursing science, nuanced ethical regulations for nursing research programs are called for. In addition to the different research approaches, further arguments for ethical regulations are as follows: first, the different degrees of contextualization and the variety of participation models regarding the target groups; second, the capacities and opportunities of participants; and third, the caring relationship between nurses and research subjects. To capture these special features of nursing science, four approaches to fill the gaps in existing ethical regulations for nursing research are proposed: (a) process orientation, (b) community orientation, (c) context orientation, and (d) relation orientation.

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.

Trust in health research relationships: accounts of human subjects

TRUST IS FUNDAMENTAL in health research, yet there is little empirical evidence that explores the meaning of trust from the perspective of human subjects. The analysis presented here focuses on how human subjects talked about trust in the in-depth interviews. It emerged from the accounts that trust could not be assumed in the research setting, rather it was portrayed as a dynamic concept, built and easily broken, characterized by reciprocity and negotiation. Human subjects were ambivalent about who, when, what, and how much to trust in the research endeavor. This paper adds a fresh perspective to the literature on trust, and so offers a currently neglected, and little understood dimension to the discourse around health research ethics.

Talking about suicide

While it is acknowledged that there is a need for more qualitative research on suicide, it is also clear that the ethics of undertaking such research need to be addressed. This article uses the case study of the authors’ experience of gaining ethics approval for a research project that asks people what it is like to feel suicidal to (a) analyse the limits of confidentiality and anonymity and (b) consider the ways in which the process of ethics review can shape and constrain suicide research. This leads to a discussion of the ways in which ethics committees assess and monitor qualitative research more generally and some preliminary suggestions for how this might be improved.

Understanding the Risks of Recent Discharge: The Phenomenological Experiences

Background: Evidence indicates that people whose mental health problems lead them to require psychiatric hospitalization are at a significantly increased risk of suicide, and the period of time immediately following discharge after such hospitalizations appears to be a particularly high-risk time. Aims: This paper reports on phenomenological findings from a federally funded, mixed-methods study that sought to better understand the observed increased risk for suicide following discharge from an inpatient psychiatric service. Methods: A purposive sample of 20 recently discharged former suicidal inpatients was obtained. Data were collected from the participants in hermeneutic interviews lasting between 1 h and 2 h and analyzed according to van Manen’s (1997) interpretation of hermeneutic phenomenology. Results: Two key themes were induced: “Existential Angst at the Prospect of Discharge” and “Trying to Survive While Living Under the Proverbial ‘Sword of Damocles’.” Each of these was comprised of five themes with the second key theme – the focus of this paper – encompassing the following: “Needing Postdischarge Support,” “Feeling Lost, Uncertain and Disorientated,” “Feeling Alone and Isolated,” “Suicide Remains an Option,” and “Engaging in Soothing, Comforting Behaviors.” Conclusions: The authors conclude that early exploration of and reconciling patients’ expectations regarding inpatient care for their suicidality would appear to be an empirically based intervention that could diminish the postdischarge risk for further suicide attempts.

Understanding the risks of recent discharge: the phenomenological lived experiences--“existential angst at the prospect of discharge”

BACKGROUND

Evidence indicates that people whose mental health problems lead them to require psychiatric hospitalization are at a significantly increased risk of suicide, and that the time immediately following discharge after such hospitalizations is a particularly high-risk time.

AIMS

This paper reports on phenomenological findings from a federally funded, mixed-methods study that sought to better understand the observed increased risk for suicide following discharge from an inpatient psychiatric service.

METHODS

A purposive sample of 20 recently discharged former suicidal inpatients was obtained. Data were collected in hermeneutic interviews lasting between 1 h and 2 h and analyzed according to van (1997) interpretation of hermeneutic phenomenology.

RESULTS

Two key themes, "existential angst at the prospect of discharge" and "trying to survive while living under the proverbial 'sword of Damocles'" were induced. Each of these was comprised of five themes with the first key theme (which is the focus of this paper) encompassing the following: "Feeling scared, anxious, fearful and/or stressed," "Preparedness," "Leaving the place of safety," "Duality and ambivalence," and "Feel like a burden."

CONCLUSIONS

Early exploration of and reconciling of patients' expectations regarding inpatient care for their suicidality would be empirically based interventions that could diminish the postdischarge risk for further suicide attempts.

Untold stories: biases and selection effects in research with victims of trafficking for sexual exploitation

Recent discussions of trafficking research have included calls for more innovative studies and new methodologies in order to move beyond the current trafficking narrative, which is often based on unrepresentative samples and overly simplified images. While new methods can potentially play a role in expanding the knowledge base on trafficking, this article argues that the solution is not entirely about applying new methods, but as much about using current methods to greater effect and with careful attention to their limitations and ethical constraints. Drawing on the authors' experience in researching trafficking issues in a number of projects over the past decade, the article outlines and exemplifies some of the methodological and ethical issues to be considered and accommodated when conducting research with trafficked persons -- including unrepresentative samples; access to respondents; selection biases by "gatekeepers" and self selection by potential respondents. Such considerations should inform not only how research is undertaken but also how this information is read and understood. Moreover, many of these considerations equally apply when considering the application of new methods within this field. The article maintains that a better understanding of how these issues come into play and inform trafficking research will translate into tools for conducting improved research in this field and, by implication, new perspectives on human trafficking.

Researching the intoxicated: informed consent implications for alcohol and drug research

This article considers the informed consent process in relation to carrying out research with intoxicated participants in 'field' research settings. There is little discussion in the literature of the potential problems that the intoxication of research participants may pose to research. Intoxication is a potential problem for all researchers but is heightened in field research that takes place in settings where participants are likely to be intoxicated, such as licensed venues, in drug consumption rooms, or police custody suites. The risks to research participants that intoxication poses should not be resolved by electing not to do research with intoxicated participants; it is argued that these risks can be managed to some extent, and are offset by the benefits of such research. Moreover, intoxication (and the impairment of cognitive functions relevant to valid informed consent) may not always be identifiable through behavioural or biochemical methods of detection. The search for accurate and field-practical methods for identifying intoxication amongst participants is useful, but not the only strategy for researchers who want to ensure the validity of the consent process. Suggestions are provided for devising research protocols that acknowledge and accept intoxication of research participants and attempt to protect them. One solution is to side-step identification of intoxication per se as a strategic objective in the consent process, and turn instead to established methods for ensuring that information has been understood by potential research participants.

A Relational Ethical Dialogue With Research Ethics Committees

The aim of this article is to take relational ethics concepts and apply them to the context of application to research ethics committees for approval to carry out research. The process of a multinational qualitative research application is described. The article suggests that a relational ethics approach can address two issues: how qualitative proposals are interpreted by research ethics committees and how this safeguards potentially vulnerable respondents. In relational terms, the governance of a research project may be enhanced by shared ownership and willingness to engage in mutual dialogue. This challenges both researchers and research ethics committees to reframe their understanding of roles and functions in the assessment of research protocols, particularly those of a qualitative nature and those that address end-of-life issues.

Ethical components of researcher researched relationships in qualitative interviewing

Qualitative interviews are widely and often uncritically adopted for health care research, with little justification of therapeutic value. Although they might provide valuable insights into the perspectives of participants, they represent only a version of reality, rather than "truth" per se. Qualitative research is vulnerable to bias through the attitudes and qualities of the researcher, social desirability factors, and conditions of worth. Exploitation, through role confusion, therapeutic misconception, and misrepresentation are particular risks for health care-related research. Ethical codes, biomedical principles and care philosophies provide little contextual guidance on the moral dilemmas encountered in the practice of research. If nurse researchers are to navigate the moral complexities of research relationships, then sensitivity to risk to participants must be of continual concern, from conception of the study to the reporting of outcomes. Examination of the self through critical reflection and supervision are therefore necessary components of ethical research.

Confidentiality and autonomy: the challenge(s) of offering research participants a choice of disclosing their identity

In this article, the authors present one of the key ethical features of research: confidentiality as maintained by nondis-closure of participants' identities. In light of (a) the contingency that certain participants might vest interest in research studies through their identity and (b) the concept of respect for participants' autonomy, the authors consider the possibilities of offering research participants the choice of nonconfidentiality, afforded as an autonomous (negative) right of refusal of nondisclosure of identity. They address the issue that this possibility generates within the context(s) of current codes of ethics related to health research and the manifest responsibilities of the institutional review process. In this way, they attempt to elucidate potential benefits and consequences that arise from confidentiality and nonconfidentiality.

A modified grounded theory study of how psychiatric nurses work with suicidal people

BACKGROUND

People with mental health problems continue to present a disproportionately high risk of suicide. Despite the relevance of suicide to psychiatric/mental health (P/MH) nurses, there is a documented paucity of research in this substantive area undertaken by or referring specifically to P/MH nurses; there is currently no extant theory to guide P/MH nursing care of the suicidal person.

OBJECTIVES

Accordingly, this paper reports on a study undertaken to determine if P/MH nurses provide meaningful caring response to suicidal people, and if so how.

DESIGN

The study used a modified grounded theory method and was conducted in keeping with the Glaserian tenets of Grounded Theory.

SETTINGS

The study was conducted in two geographical locations within the United Kingdom, one in the North and the other in the Midlands; both locations contained large urban centres.

PARTICIPANTS

A total of 20 participants were selected across the locations by means of theoretical sampling. All the participants were over 18 years old, had made a serious attempt on their lives or felt they were on the cusp of so doing and had received 'crisis' care from the 'emergency' psychiatric services.

METHODS

The study adhered to the principle features of Glaserian grounded theory namely-(a) theory generation, not theory verification; (b) theoretical sampling, (c) the constant comparative method of data analysis; and (d) theoretical sensitivity (searching for/discovering the core variable, one which identified the key pychosocial process and contains temporal dimensions stages). Further, the authors ensured that the study was concerned with generating conceptual theory, not conceptual description.

FINDINGS/CONCLUSION

The findings indicate that this key psychosocial problem is addressed through the core variable, 're-connecting the person with humanity'. This parsimonious theory describes and explains a three-stage healing process consisting of the sub-core variables: 'reflecting an image of humanity', 'guiding the individual back to humanity' and 'learning to live'.

Listening to young people with special needs: the influence of group activities

The article reports on the experiences of group activities within an area of Yorkshire that helped young people with special needs to express their views and opinions. Significant issues were raised by the ethics of undertaking work with young people and these are reviewed. The young people involved in the research reported that their participation in the groups developed their self-confidence and advocacy skills. This led them to be more confident in expressing their needs at school and in the community. To establish wider generalizability for the study findings, the Yorkshire group activities were compared with another similar group in London where further data were collected from the young people involved. In facilitating group activities, willing staff were an important addition to the group because their presence provided and encouraged positive reactions to the distinctive achievements of the young people themselves. In both groups, members were committed to participation in project-based activities that raised their self-esteem and helped establish a sense of their own identity and purpose.

Essentials of research ethics for healthcare professionals

Whether conducted in a university or the healthcare field, research with human subjects gives rise to a multitude of ethical questions for healthcare professionals. While engaging in ongoing professional development on how to conduct research ethically, both clinicians and scientists need to expand their knowledge to provide answers to the following questions: Which ethical theories serve as a foundation for ethical principles in research ethics? What ethical principles should a researcher respect when conducting research with human subjects? What does it mean to conduct research ethically? What ethical dilemmas are encountered by a researcher in conducting research? This paper provides a review of ethical theories, and the ethical basis of guidelines developed and used to guide human subject research. Ethical behaviors and the personal responsibility of the researcher conducting research with human subjects are discussed along with the ethical considerations in research designs and methods.

Cooperation or co-optation?: Assessing the methodological benefits and barriers involved in conducting qualitative research through medical institutional settings

In this article, the authors highlight some benefits of and barriers to doing qualitative research in association with hospital-based services. They first describe an ongoing qualitative research project that involves interviewing women about their post-sexual assault medicolegal experiences in hospital-situated sexual assault centers across a large Canadian province. Their methodological journey led them to engage program coordinators at these centers to assist with locating participants and qualified interviewers, and with negotiating the demands of their respective research ethics boards. They outline the ways in which their project was shaped, positively and negatively, by working with them in medical institutions. They conclude by recommending that hospitals and hospital ethics boards counteract tendencies toward paternalism by recognizing the value of feminist qualitative research contributions to the activities of their own sexual assault centers and to the recovery of sexually assaulted women. Such recognition might be productively engaged by adopting an ethics-in-process approach.

Nurses' views of longitudinal genetic screening of and research on children

There is a lack of empirical data exploring ethical issues of genetic screening and longitudinal research involving children. Therefore, this pilot interview study explored the perceptions of nurses and midwives in relation to their involvement in an ongoing genetic preventive screening process involving children - the All Babies in South-east Sweden (ABIS) study (n=17,005). Data were collected through semistructured interviews with 10 nurses involved in all information and sampling procedures. While providing the preliminary nature of this study, it supports the idea of the importance of further research, both from a nursing professional perspective and from other parties involved in clinical research. The findings made in this study suggest that for such studies it is vital that nurses and midwives are fully informed about aims, methods, and potential intervention/prevention since in many cases they have a central role in several areas of screening and clinical longitudinal research involving children, e.g. information to potential research participants, obtaining informed consent, and data collection. With a thorough understanding of the research, including both basic aims and methods as well as potential future prevention aims, the nursing staff involved will be better placed to help participants make an informed choice and to provide additional information to the participants. Further research may be needed that aims to develop effective methods in preparing data collectors. It is also suggested that the design of the information process, and especially in longitudinal research involving young children, is of utmost importance before such studies are commenced.

The ethics of conducting a co-operative inquiry with vulnerable people

BACKGROUND

Mental health services users have been calling for greater participation in clinical research. Participation in this context means research 'with' rather than 'on' groups of people. Conducting a co-operative inquiry involving the participation of vulnerable individuals as co-researchers, in particular those with a history of mental health problems, places an obligation on researchers to articulate and justify sound ethical procedures.

AIMS

The aim of this paper is to consider how the ethical issues encountered when conducting participative research with vulnerable people can be addressed in the implementation of a co-operative inquiry with users of mental health services.

METHOD

The study was based on personal reflection and a critical review of associated literature obtained from a database search using Boolean logic.

FINDINGS

The findings, presented under the headings of the four prima facie moral principles, suggest the need for researchers using participative approaches to demonstrate the humanistic attributes required for engaging and working with people over a period of time. These include building and maintaining trusting relationships, assessing competence to participate, managing interpersonal and group dynamics and making complex collaborative decisions about participants' continued participation in a study.

CONCLUSIONS

When using a co-operative inquiry approach involving vulnerable individuals, researchers need to demonstrate clearly how a balance between autonomy and paternalism will be achieved, how risks will be anticipated and managed and how fairness will be maintained throughout all procedures. Researchers using participative approaches need to have developed a level of personal insight and self-awareness through access to supervision which focuses on sources of unintended manipulation and interpersonal dynamics that may arise at the inception of a study and throughout its course. Researchers and ethics committees have a shared responsibility to ensure that vulnerable people are appropriately engaged to maintain the advancement of user knowledge which informs nursing practice.

Leveling the playing field? Exploring the merits of the ethics-as-process approach for judging qualitative research proposals

There has been a recent growth in claims that qualitative research proposals are not treated equitably by ethics committees. In response, recent arguments centered on establishing the ethics of qualitative research, in the eyes of ethics committees, have indicated the need for an "ethics-as-process" approach. Accordingly, in this article, the authors illustrate the merits of this approach and provide three examples from the field: the outcomes of participating in qualitative interviews, sensitive handling of ending in qualitative research relationships, and the ongoing establishment of informed consent. The authors hope to increase awareness of the potential benefits of this approach and contribute to the ensuing debate.