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

Arksey and O'Malley's consultation exercise in scoping reviews: A critical review

AIMS

To explore how consultation exercises were described in a convenience sample of recent scoping reviews.

DESIGN

Critical literature review.

DATA SOURCES

We searched PsycINFO, Embase, CINAHL and PubMed in July 2020. Our inclusion criterion was a peer-reviewed journal article reporting a scoping review in Danish, English, Norwegian or Swedish.

REVIEW METHODS

We identified a convenience sample of articles (n = 66) reporting a consultation exercise as part of a scoping review. The descriptions of the consultation were charted, summarized and critically discussed.

RESULTS

The current analysis showed no widely accepted consensus on how to approach and report a consultation exercise in the sample of scoping reviews. The reports of stakeholder consultation processes were often brief and general, and often there were no reports of the effects of the stakeholder consultation processes. Further, there was no discussion of the principal theoretical problems mixing stakeholder voices and review findings.

CONCLUSION

The finding that conventional research ethics and research methods often were suspended could indicate that the stakeholder consultants were in a precarious position because of power imbalances between researchers and stakeholder consultants. We suggest that a consultation exercise should only be included when it genuinely invites participation and reports on the effect of alternative voices.

IMPACT

Scoping reviews are common across a range of disciplines, but they often lack definitional and methodological clarity. In their influential approach to scoping studies, Arksey and O'Malley introduced an optional 'consultation exercise', which has been heralded as a valuable tool that can be used to strengthen the process and outcome of a scoping study and to support the dissemination of the study's findings and its implications. However, there is no clear outline on about how to operationalize consultations of stakeholders in scoping studies/reviews. This article includes recommendations for consultation exercises, including encouraging an aspirational move from 'consultation' to 'participation'.

Exploring the Dynamics of a Research Partnership in a Co-Operative Inquiry: A Qualitative Study

Establishing a genuine partnership is a prerequisite when service-users become co-researchers. The practices of co-research challenges conventional scientific communities to rethink research processes and to learn to develop a genuine participatory research culture. This analysis investigated how a research partnership was created by exploring small group collaborative processes in a cooperative inquiry dealing with an interview study about psychosocial rehabilitation of elderly individuals bereaved by suicide late in life. The analysis highlighted how reciprocity can facilitate "epistemic user participation" and promote a research outcome that is co-created in a genuine partnership that reflects the perspective of service-users.

Embodying Experiences with Nature in Everyday Life Recovery for Persons with Eating Disorders

Eating disorders can be understood as attempts to manage a problematic relationship with one’s own body. The objective of this qualitative study was to explore and discuss perspectives of embodying “experiences with nature” related to recovery in everyday life for persons experiencing eating disorders. The study was carried out in the context of a hermeneutic phenomenological approach. Eight participants with an interest in nature and friluftsliv (outdoor pursuits), and with experiences with bulimia nervosa and/or binge-eating disorders, were interviewed twice. Interviews took place in nature, in combination with a “going together” method. The results reveal how the participants highlighted experiences with nature as accentuating feelings of calmness and an engagement of the senses. Participants described nature as a non-judgmental environment that also provided room for self-care. This article explores the implications of everyday life perspectives on nature in recovery, as well as of an integrated focus on body and mind in experiences with eating disorders. The article concludes with an emphasis on how participant’s embodying experiences with nature enabled a (re)connection with one’s own body.

Psychosocial Rehabilitation of Elderly Persons Bereaved by Suicide: A Co-operative Inquiry Study Protocol

Suicide is a major public health problem and there is a paucity of knowledge about the particular needs of people bereaved by suicide late in life. This study protocol describes a co-operative inquiry designed to collaboratively explore the needs for psychosocial support for this group and to use 'action circles' to develop and test psychosocial interventions. Further, it explores how the co-operative partnership influences the overall research processes. Data will be subjected to thematic analysis and discourse analysis. The protocol was approved in December 2016 and the study will take place between April 2017 and March 2020.

Ethical Challenges in Community-Based Participatory Research: A Scoping Review

Ethical challenges in community-based participatory research (CBPR) are of increasing interest to researchers; however, it is not known how widespread these challenges are or how extensively the topic has been explored. Using Arksey and O'Malley's scoping review method, studies on ethical challenges in CBPR were mapped. Findings indicate that researchers continue to raise questions about ethics associated with CBPR. Our purpose in this article is to present a thematic summary of international ethical challenges as a guide for researchers interested in community participatory approaches and to better prepare them for qualitative health research with communities.

Ethical complexities in child co-research

Child co-research has become popular in social research involving children. This is attributed to the emphasis on children’s rights and is seen as a way to promote children’s agency and voice. It is a way of putting into practice the philosophy, common amongst childhood researchers, that children are experts on childhood. In this article, we discuss ethical complexities of involving children as co-researchers, beginning with an analysis of the literature, then drawing on data from interviews with researchers who conduct child co-research. We identify six ethical complexities, some of which are new findings which have not been mentioned before in this context. In light of these possible ethical complexities, a key finding is for researchers to be reflexive – to reflect on how the research may affect child co-researchers and participants before the research starts. A separate overriding message that came out in responses from the researchers we interviewed was the need for support and training for child co-researchers. We conclude by providing a list of questions for reflexive researchers to ask of themselves when they use child co-research methodology. We also provide important questions for human research ethics committees to ask when they review projects using child co-research.

A Co-operative Inquiry Into Generating, Describing, and Transforming Knowledge About De-escalation Practices in Mental Health Settings

De-escalation is concerned with managing violent behaviour without resorting to coercive measures. Co-operative Inquiry provided the conceptual basis for generating knowledge regarding de-escalation practices in acute mental health care settings. The research included service users and staff members as co-researchers and knowledge was generated in dynamic research cycles around an extended epistemology of knowing: experiential, presentational, propositional, and practical. Through this process, co-researchers became de-escalation learners, implementing de-escalation practices while transforming violence management. Neighbouring mental health communities' involvement strengthened the transformation process and assisted in validating the research results.

Researcher-researched relationship in qualitative research: Shifts in positions and researcher vulnerability

Background

The researcher role is highly debated in qualitative research. This article concerns the researcher-researched relationship.

Methods

A group of health science researchers anchored in various qualitative research traditions gathered in reflective group discussions over a period of two years.

Results

Efforts to establish an anti-authoritarian relationship between researcher and researched, negotiation of who actually “rules” the research agenda, and experiences of shifts in “inferior” and “superior” knowledge positions emerged as central and intertwined themes throughout the discussions. The dual role as both insider and outsider, characteristic of qualitative approaches, seemed to lead to power relations and researcher vulnerability which manifested in tangible ways.

Conclusion

Shifting positions and vulnerability surfaced in various ways in the projects. They nonetheless indicated a number of similar experiences which can shed light on the researcher-researched relationship. These issues could benefit from further discussion in the qualitative health research literature.

Ethical Case Study of the Researcher-Participant Relationship in End-of-Life Research

Nurse-researchers studying interventions for patients at the end-of-life may become close with participants due to the nature of interactions within the research protocol. In such studies, participants may request further interactions that would constitute clinical care beyond the scope of the protocol. Nurse-researchers may feel a conflict of values between their obligation to the research goals and their inclinations and obligations as nurses to care for their patients. Nurse-researchers in this situation aspire to honor the bonds developed through close contact and ensure participants receive standard of care while maintaining standards of research ethics. Analysis of a case and review of applicable concepts in research ethics, including ethical relationships, therapeutic misconception, equipoise, and population vulnerability, are used to develop recommendations regarding the decision parameters for similar cases.

A stronger voice

PURPOSE

The purpose of this paper is to discuss learning about service-user and carer involvement from an action research (AR) study into self-directed support implementation in one English mental health trust. The paper promotes appointing and supporting carers and people with experience as co-researchers to obtain authentic local perspectives when undertaking service implementation or redesign.

DESIGN/METHODOLOGY/APPROACH

The researchers used an AR spiral method incorporating carers and people with mental health experience as co-researchers. The co-researchers worked alongside the lead researcher gathering data from focus groups, training sessions and other meetings over four years and attending collaborative steering group meetings alongside professional workers throughout the study.

FINDINGS

The authors suggest that participation gave co-researchers a powerful and effective voice in this service redesign. This approach revealed more authentic research data and required professionals to be more accountable for their perceptions and to make explicit their understandings throughout the study, which enabled more effective working. Steering group participation was central to securing this participation.

ORIGINALITY/VALUE

The paper illustrates how carer and service-user co-researchers can be supported to benefit both mental health organisations undergoing change and to co-researchers themselves. It also identifies AR's utility in uncovering learning as well as structuring change.

Older people as co-researchers: a collaborative journey

In recent years there has been a distinguishable trend towards user involvement in ageing research. Researchers and policy makers both are increasingly convinced that user involvement is necessary to adapt research questions and methods to meet the needs of older people. Little is known, however, about the quality of collaborations between older people and researchers. This study systematically evaluates a collaboration undertaken between two academic researchers and three older people acting as co-researchers in an effort to identify the conditions required for equal collaboration. To evaluate the collaboration the co-researchers and academic researchers took part in individual in-depth interviews (after six months) and two reflection meetings (after six and 12 months). Throughout the collaboration, field notes were taken by both academic researchers and co-researchers. A detailed description of the collaboration is provided here, using the metaphor of a journey to illustrate the dynamics and the learning process of the participants. Interim reflection meetings – at which mutual expectations were expressed along with a frank discussion of prejudices, tasks and role divisions, and the sharing of personal and project-related needs and information – were found to be fruitful in achieving a positive working relationship and fostering an effective collaboration. We conclude that a learning perspective on participation can be a resource for learning and adaptive change.

'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.

Utilizing participants' strengths to reduce risk of harm in a study of family estrangement

In this article I examine some issues involved in researching vulnerable populations and sensitive issues, and the challenges and risks of researching issues of a deeply personal nature. Participants might have complex needs and vulnerabilities, but they also have many resources to ensure their own well-being. I ask researchers to move beyond the minimum standards espoused by human ethics committees, and utilize participant strengths to further reduce the risk of harm. My reflections on a study of older people who were experiencing family estrangement highlight some of the actions that participants used to increase their personal safety. I discuss the usefulness of "strengths" questions in assessing risk and facilitating participant strengths to minimize harm. Finally, I propose a three-way model for reducing risk that involves the "lessons learned" from ethics committees, researchers, and the participants themselves.

Holding harm: narrative methods in mental health research on refugee trauma

In this article, we question narrative inquiry's predominant ethics of benefit when engaging in narrative research on trauma and social suffering. Through a particular focus on the use of a narrative methodology in a refugee health study, we explore the potential risk and protective function of narrative trauma research with vulnerable respondents. A review of ethical questions emerging during the course of a multiple-case study with refugee families documents how narrative methods' characteristics clearly revisit the impact of traumatization on autonomy, narrativity, and relationship building in participants and, thus, evoke the replay of traumatic experience within the research relationship itself. Blurring a straightforward ethics of benefit, this reactivation of trauma accounts for the research relationship's balancing movement between reiterating and transforming traumatic distress, and urges for the need to contain coexisting aspects of both harm and benefit in developing narrative research with traumatized participants.

The ethics of conducting research with mental health service users

There is a growing emphasis on conducting research that represents the voices of mental health service users in relation to their experiences of and desires for health care. However, this type of research may sometimes be complicated, as mental health users are frequently identified as a vulnerable research participant population. The aims of this article are to firstly highlight some of the main ethical issues that researchers encounter when carrying out research with people who use the mental health services and secondly to identify strategies that can be used to address these issues. The authors draw on their personal experiences of conducting this type of research. While of general relevance, this article is particularly designed to provide guidance to researchers conducting qualitative studies.

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.

User participation in mental health nurse decision-making: a co-operative enquiry

AIM

This paper is a report of a study to encourage participants to work together to identify strategies for increasing user participation in clinical decisions and to evaluate the value of co-operative inquiry as a vehicle for supporting learning in practice.

BACKGROUND

Service user participation in the clinical practice decisions of mental health nurses is considered essential for good practice. Methods need to be found which enable opportunities for shared learning, facilitate practice development and empower service users.

METHOD

A co-operative inquiry design engaged all participants (n = 17) as co-researchers and involved repeated cycles of action and reflection, using multiple data collection methods. The research was conducted over a two year period in 2004-2005, with mental health nursing students collaborating with service users.

FINDINGS

Factors inhibiting participation included stigmatizing and paternalistic approaches, where clinical judgments were made solely on the basis of diagnosis. Enhancing factors were a respectful culture which recognized users ''expertise' and communicated belief in individual potential. Inquiry benefits included insight into service users' perspectives, enhanced confidence in decision-making, appreciation of power issues in helping relationships and deconstruction of decision-making within a safe learning environment.

CONCLUSION

Learning from novel approaches which enable nursing students to develop their reflective and reflexive ability is essential to avoid practice which disempowers and potentially harms service users' recovery. Co-operative inquiry is a valuable vehicle for developing professional practice in higher education and practice environments.

A socially inclusive approach to user participation in higher education

AIM

This paper is a report of a study to evaluate the development of an innovative Service User Academic post in mental health nursing in relation to student learning and good employment practice in terms of social inclusion.

BACKGROUND

Institutions providing professional mental health education are usually expected to demonstrate user involvement in the design, delivery and evaluation of their educational programmes to ensure that user voices are central to the development of clinical practice. Involvement can take many forms but not everyone values user knowledge as equal to other sources of knowledge. This can lead to users feeling exploited, rather than fully integrated in healthcare professional education processes. Development of the post discussed in this paper was stimulated and informed by an innovative example from Australia.

METHOD

An observational case study of the development and practice of a Service User Academic post was undertaken in 2005. Participants were purposively sampled and included the User Academic, six members of a user and carer reference group, 10 educators and 35 students. Data were collected by group discussions and interviews. Data analysis was based on the framework approach.

FINDINGS

The evaluation revealed tangible benefits for the students and the wider academic community. Most important was the powerful role model the Service User Academic provided for students. The post proved an effective method to promote service user participation and began to integrate service user perspectives within the educational process. However, the attempts to achieve socially inclusive practices were inhibited by organizational factors. The expectations of the role and unintended discriminatory behaviours had an impact on achieving full integration of the role. Furthermore, shortcomings in the support arrangements were revealed.

CONCLUSIONS

The search for an optimum model of involvement may prove elusive, but the need to research and debate different strategies, to avoid tokenism and exploitation, remains.

Experiences of service user and carer participation in health care education

The agenda of involving service users and their carers more meaningfully in the development, delivery and evaluation of professional education in health is gaining in importance. The paper reports on a symposium which presented three diverse initiatives, established within a school of nursing and midwifery in the United Kingdom. These represent different approaches and attempts to engage service users and in some instances carers more fully in professional education aimed at developing mental health practitioners. Each is presented as achieving movement on a continuum of participation from service users as passive recipients to service users as collaborators and co-researchers. The paper concludes with a discussion of the lessons to be learnt which will hopefully stimulate service user involvement on a wider basis.