Ethical reflections: examining reflexivity through the narrative paradigm

Acceptability and barriers of a GP-physiotherapist partnership in the diagnosis and management of COPD in primary care: A qualitative study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is commonly diagnosed and managed in primary care but there is evidence that this has been suboptimal, with low confidence expressed in providing interventions requiring behaviour change. The aim of this study was to determine the acceptability of a general practitioner (GP)-physiotherapist partnership in the diagnosis and management of COPD in primary care and to explore the experiences of participants during the implementation of the model.

METHODS

Semi-structured interviews were conducted with physiotherapists (n = 3), GPs (n = 2), practice nurses (PNs) (n = 2) and patients (n = 12) who had participated in the InNovaTivE Gp-physiotheRapist pArTnErship for copD (INTEGRATED) trial. We sought to explore participants' views about their experiences and perceived benefits, barriers and facilitators to the implementation of this model of care. Interviews were transcribed, coded and thematically analysed. Synthesis of the data was guided by the Theoretical Domains Framework for clinician interviews and the health belief model for patient interviews.

RESULTS

All clinicians felt that this integrated model helped to optimise care for patients with COPD by facilitating evidence-based practice. GPs and PNs valued the physiotherapist's knowledge and skills relating to diagnosis and management, which was reported to complement their own management and improve patient outcomes. Patients reported a sense of empowerment following their appointments and acknowledged improved self-management skills. However, physiotherapists reported many patients were already engaging in positive health behaviours. Responses were mixed on the effectiveness of the model in facilitating teamwork between clinicians with different perspectives concerning management, communication pathways and logistical issues, such as time and room availability, being cited as barriers.

CONCLUSIONS

An experienced cardiorespiratory physiotherapist embedded into a small number of primary care practices to work in partnership with GPs for COPD diagnosis and management was acceptable and viewed as beneficial for patients. Barriers relating to logistics and resources remain, which must be addressed to optimise implementation.

PATIENT OR PUBLIC CONTRIBUTION

Patient input was obtained from qualitative feedback from a prior study conducted by two authors and was used to refine the model of care to determine the added value of a physiotherapist integrated into the primary care team. This feedback was also used to refine the interview guides utilised in this study determine the acceptability of this model of care. We had health service involvement from the rehabilitation service of the local health district who were directly involved in determining study aims and establishing the project around the priorities for their chronic disease integration service. For example, this project aimed to engage with a less severe patient population in primary care who would benefit from pulmonary rehabilitation. The findings from this study will be used to further tailor the model of care to the needs of the public and patients.

TRIAL REGISTRATION

ACTRN12619001127190.

Method in limbo? Theoretical and empirical considerations in using thematic analysis by veterinary and One Health researchers

This article spans a number of theoretical, empirical and practice junctures at the intersection of human and animal medicine and the social sciences. We discuss the way thematic analysis, a qualitative method borrowed from the social sciences, is being increasingly used by veterinary and One Health researchers to investigate a range of complex issues. By considering theoretical aspects of thematic analysis, we expand our discussion to question whether this tool, as well as other social science methods, is currently being used appropriately by veterinary and human health researchers. We suggest that additional engagement with social science theory would enrich research practices and improve findings. We argue that considerations of 'big theory' - ontological and epistemological positionings of the researcher - and 'small(er)' theory, the specific social theory in which research is situated, are both necessary. Our point of departure is that scientific discourse is not merely construction or ideology but a unique and continuing arena of debate, in part at least because of the elevation of self-criticism to a central tenet of its practice. We argue for further engagement with the core ideas and concepts outlined above and discuss them in what follows. In particular, and by way of focusing the point, we suggest that for veterinary, One Health, and human medical researchers to use thematic analysis to its maximum potential they should be encouraged to engage with both broader socio-economic theories and with questions of ontology and epistemology.

A multi-language qualitative study of limited English proficiency patient experiences in the United States

Objective

The purpose of this study was to understand the limited English proficiency patient experience with health care services in an urban setting in the United States.

Methods

Through a narrative analysis approach, 71 individuals who spoke either Spanish, Russian, Cantonese, Mandarin, or Korean shared their experiences through semi-structured interviews between 2016 and 2018. Analyses used monolingual and multilingual open coding approaches to generate themes.

Results

Six themes illustrated patient experiences and identified sources of structural inequities perpetuating language barriers at the point of care. An important thread throughout all interviews was the sense that the language barrier with clinicians posed a threat to their safety when receiving healthcare, citing an acute awareness of additional risk for harm they might experience. Participants also consistently identified factors they felt would improve their sense of security that were specific to clinician interactions. Differences in experiences were specific to culture and heritage.

Conclusions

The findings highlight the ongoing challenges spoken language barriers pose across multiple points of care in the United States' health care system.

Innovation

The multi-language nature of this study and its methodological insights are innovative as most studies have focused on clinicians or patient experiences in a single language.

The Role of Latina Peer Mentors in the Implementation of the Alma Program for Women With Perinatal Depression

This study examines the role that compañeras (peer mentors) play in the implementation of a program, Alma, which was designed to support Latina mothers who are experiencing depression during pregnancy or early parenting and implemented in the rural mountain West of the United States. Drawing from the fields of dissemination and implementation and Latina mujerista (feminist) scholarship, this ethnographic analysis demonstrates how the Alma compañeras facilitate the delivery of Alma by creating and inhabiting intimate mujerista spaces with other mothers and create relationships of mutual and collective healing in the context of relationships de confianza (of trust and confidence). We argue that these Latina women, in their capacity as compañeras, draw upon their cultural funds of knowledge to bring Alma to life in ways that prioritizes flexibility and responsiveness to the community. Shedding light on contextualized processes by which Latina women facilitate the implementation of Alma illustrates how the task-sharing model is well suited to the delivery of mental health services for Latina immigrant mothers and how lay mental health providers can be agents of healing.

Beliefs around help-Seeking and Support for Dementia in the Australian Arabic Speaking Community

BACKGROUND

The number of people with dementia in multicultural Australia is rapidly increasing. Despite its culturally diverse population, there is limited research about how people from ethnic minority groups understand and approach help-seeking and support for dementia. The aim of this study is to understand the perceptions of dementia symptoms, help-seeking and support in the Australian Arabic-speaking community.

METHODS

This study used a cross-sectional qualitative research design. Individual, semi-structured interviews using projective stimulus techniques were used. Participants were three Arabic-speaking people aged over 70 who were experiencing cognitive changes or dementia symptoms, six carers, and five health or social care practitioners experienced in working with Arab-Australians. Phone or video chat interviews were conducted in either Arabic or English. Interviews were audiotaped, translated when needed, transcribed verbatim and inductive thematic analysis was undertaken.

FINDINGS

Seven themes were identified. Participants described dementia as relating to symptoms of confusion and memory loss. Carers and older people believe that when older people are experiencing these cognitive symptoms, they must be cared for primarily by ensuring their happiness and comfort. Barriers to help-seeking and support included a lack of help-seeking due to cultural norms of family orientated care, families are unsure of where to seek help and fear of community judgement. Two ways to facilitate help-seeking and support were to build trust through culturally appropriate support and to educate the community.

CONCLUSION

Family, trust and community were identified as central pillars of the Australian-Arabic-speaking community. There is a need to increase dementia literacy in this community particularly around help-seeking and decreasing stigma. Education should be promoted by trusted community members and religious leaders. As the first point of professional contact, general practitioners need to be upskilled to support Arabic-speaking Australians around dementia.

"It's a Big Family Here." Becoming and Belonging in a Service Providing Employment-Related Support for People with Mental Health Problems: An Interpretative Phenomenological Analysis

The impact of employment for individuals with mental health problems is complex. However, research suggests that when support is provided for accessing employment and gaining roles and skills that are valued by others, a positive effect can be seen on recovery. Employment-related support can take many forms and there is a need for further research into the experience of accessing different kinds of services. The current paper examines the lived experience of 11 people participating in a UK social enterprise providing work experience, training, and skills development for those with mental health problems. Although 'sheltered', the organisational ethos strongly emphasised service-user empowerment, co-production, equality with staff, provision of valued social roles and person-centred support. Phenomenological analysis revealed that participants valued a sense of belonging and authentic relationships within the service, whilst being given the opportunity to rediscover an identity that may have been lost because of their mental health problem. However, participants also discussed how, although the service improved their self-value, some feared the 'real world' outside of the service and were unsure whether they would be met with the same support. Tensions between field dominant approaches in supported employment and the experiences and values of the participants are explored. We argue that the findings highlight the importance of a nurturing working environment and the value for recovery of a range of meaningful roles, beyond competitive employment.

Motherhood: Female Perspectives and Experiences of Being a Parent with ASC

Little is known about the emotional pressures and practical management of daily challenges and, intra and interpersonal demands of raising a child as a parent with a diagnosis of Autistic Spectrum Conditions. The present study utilised a qualitative approach to understand perceptions of females diagnosed on the autistic spectrum of ‘being a parent’. Eight semi-structured interviews were analysed using Interpretative Phenomenological Analysis. Benefits and challenges of being a parent were highlighted alongside population-specific skill and characteristics associated with strength and resilience, love, nurture, routine and sensory considerations. Findings identify the need for population-specific specialist parenting support, provide direction for professionals in clinical settings and expand the paucity of research in this area.

What do they get out of it? Considering a partnership model in health service research

A research study to evaluate the implementation of a long-term conditions model of care provoked questions regarding the potential impact of the researcher's role in health service research. Traditional methods of qualitative interviewing require researchers to be a disembodied presence, objective, and free from bias. When health service research is conducted by health professionals, role conflict may occur if the topic is one they have expertise in, and therefore the ability to provide guidance or information. An alternative perspective to the idea of an independent and objective researcher is the notion of a partnership. In this research collaboration, participants utilised the interview process to reflect and explore different perspectives, and the researcher bracketed their own participation in the phenomenon being studied. Reflexivity was utilised by both participants and the interviewer to ensure transparency and thus bridge the gap between subjectivity and objectivity in qualitative health service research interviewing.

Expectations and Concerns of Older Adults With Cognitive Impairment About Their Relationship With Medical Providers: A Call for Therapeutic Alliances

We sought to understand the expectations and concerns of older adults with cognitive impairment with regard to their relationship with medical providers. In particular, we observed whether study participants were involved in therapeutic alliances. Medical providers and patients create therapeutic alliances when they agree on the goals of the treatment and share a personal bond. Whereas such alliances have been studied in cancer research, little is known about therapeutic alliances in dementia research. Data were gathered in a qualitative study of 27 older adults with cognitive impairment and analyzed with narrative analysis. We introduce four case studies that illustrate the effects of having or missing a therapeutic alliance. Whereas the participant in the first case benefited from a therapeutic alliance, the other cases are marked by different experiences of abandonment. Findings suggest that interventions should concentrate on ways to enhance the relationship between medical providers and patients with cognitive impairment.

Ethical Challenges and Lessons Learned from Qualitative Research with Low-Income African American Women Living with HIV in the South

African American women living with HIV (WLWH) in the U.S. South encounter heightened marginalization due to the complex intersections of race, gender, poverty, and HIV status. Social vulnerabilities experienced by individuals and communities in daily life have the potential to sharpen ethical tensions in the context of research. Thus, conducting ethical research requires attention to the contextual challenges and concerns of diverse research populations to tailor participant protections to a particular sociocultural context. Using principles from the Belmont Report, the present report draws on data from a qualitative study with 42 African American WLWH in the South by highlighting the first author's accounts of ethical challenges that emerged during data collection. Findings suggest that engaging participants in their natural environments can inform the development of ethical research strategies germane to women's lived experiences. Study findings also contribute to empirical guidance for investigators engaging marginalized populations in scientific research.

Unraveling the Mobilization of Memory in Research With Refugees

In this article, we explore how narrative accounts of trauma are co-constructed through the interaction between researcher and participant. Using a narrative multiple-case study with Kurdish refugee families, we address how this process takes place, investigating how researcher and participants were engaged in relational, moral, collective, and sociopolitical dimensions of remembering, and how this led to the emergence of particular ethical questions. Case examples indicate that acknowledging the multilayered co-construction of remembering in the research relationship profoundly complicates existing deontological guidelines that predominantly emphasize the researcher's responsibility in sensitively dealing with participants' alleged autobiographical trauma narratives. Instead, our analysis invites qualitative researchers to engage in a continued, context-specific ethical reflection on the potential risks and benefits that are invoked in studies with survivors of collective violence.

Emotion work in qualitative research: interviewing parents about neonatal care

BACKGROUND

'Emotion work' is a term used to describe the emotional responses that may arise in qualitative research exploring difficult experiences. Parents' experiences of neonatal care can raise sensitive issues during interviews, which may lead to emotional responses.

AIM

To reflect on an interpretive study involving narrative interviews with parents of preterm neonates, to inform researchers about the potential emotive issues that may arise in such work.

DISCUSSION

Reflection on interviews with parents of preterm neonates revealed areas for discussion relating to emotion work, the role of the researcher, emotional connections and empathic interviewing. Consideration of these areas highlights the importance of reflexivity for researchers.

CONCLUSION

Qualitative researchers undertaking narrative interviews should be prepared for emotive issues that arise and recognise the need for emotional intelligence. Achieving a balance between being an empathic, emotionally aware interviewer and remaining objective can be challenging.

IMPLICATIONS FOR PRACTICE

Strategies that researchers can use to address this balance and to manage the emotion work involved in research of this nature are provided.

"Why Am I the Way I Am?" Narrative Work in the Context of Stigmatized Identities

There are particular complexities faced by people attempting to tell their stories in the context of social stigma, such as the hostility which often surrounds injecting drug use. In this article, we identify some of the distinct advantages of taking a narrative approach to understanding these complexities by exploring a single case study, across two life-history interviews, with "Jimmy," a young man with a history of social disadvantage, incarceration, and heroin dependence. Drawing on Miranda Fricker's notion of "hermeneutical injustice," we consider the effects of stigmatization on the sociocultural practice of storytelling. We note the way Jimmy appears both constrained and released by his story-how he conforms to but also resists the master narrative of the "drug user." Narrative analysis, we conclude, honors the complex challenges of the accounting work evident in interviews such as Jimmy's, providing a valuable counterpoint to other forms of qualitative inquiry in the addictions field.

Potential conflicts in midwifery practice regarding conscientious objection to abortions in Scotland

BACKGROUND:

This study was developed as a result of a court case involving conflicts between midwives' professional practice and their faith when caring for women undergoing abortions in Scotland.

RESEARCH QUESTIONS:

What are practising Roman Catholics' perspectives of potential conflicts between midwives' professional practice in Scotland with regard to involvement in abortions and their faith? How relevant is the 'conscience clause' to midwifery practice today? and What are participants' understandings of Canon 1398 in relation to midwifery practice?

RESEARCH DESIGN:

The theoretical underpinning of this study was Gadamer's hermeneutic out of which the method developed by Fleming et al. involving a five-stage approach was utilised.

PARTICIPANTS AND RESEARCH CONTEXT:

The research was conducted in the south of Scotland. A purposive sampling method was used. Eight participants who were practising Roman Catholics familiar with the subject of conscientious objection who were either midwives, lawyers (civil, canon or both) or priests contributed.

ETHICAL CONSIDERATIONS:

The major ethical issues related to respect for autonomy, maintaining confidentiality and obtaining voluntary informed consent. Parish priests agreed to act as gatekeepers to prospective participants. All legal requirements were addressed regarding data collection and storage. Approval was given by the ethics committee of the university with which one of the researchers were associated.

FINDINGS:

Three key themes provide an understanding of the situation in which midwives find themselves when considering the care for a woman admitted for an abortion: competing legal systems, competing views of conscience and limits of participation.

CONCLUSION:

Clear guidelines for practice should be developed by a multi-professional and consumer group based on an update of the abortion law to reflect the change from a surgical to medical procedure. Clarification of Canon 1398 in relation to what is and is not participation in the procurement of abortion would be of benefit to midwives with a conscientious objection.

Reconnecting with oneself while struggling between life and death: The phenomenon of recovery as experienced by persons at risk of suicide

The body of knowledge regarding health and recovery as experienced by patients at risk of suicide is limited. More research is needed into the meaning of recovery and what strengthens the desire to live. The aim of this study was to describe the phenomenon of recovery in a context of nursing care as experienced by persons at risk of suicide. In line with a reflective lifeworld research approach, 14 patients from a psychiatric clinic in Sweden participated in phenomenon-oriented interviews. Data were analyzed to describe the essence of the phenomenon. The results reveal that the phenomenon of recovery means 'reconnecting with oneself while struggling between life and death'. Three meaning constituents emerged: being in an expressive space and giving voice to oneself, regaining dignity through nurturing connectedness, and finding a balance in the tension between life and death. In conclusion, the meaning of recovery is to experience the ability to manage one's own life. Professional caregivers need to acknowledge patients' lifeworlds, in a way that enable patients to experience themselves as capable of managing their own lives. Professional caregivers should also facilitate the involvement of supportive relatives.

In our country tortilla doesn't make us fat: cultural factors influencing lifestyle goal-setting for overweight and obese Urban, Latina patients

Obesity disproportionately affects Latina adults, and goal-setting is a technique often used to promote lifestyle behavior change and weight loss. To explore the meanings and dimensions of goal-setting in immigrant Latinas, we conducted four focus groups arranged by language ability and country of origin in an urban, public, primary care clinic. We used a narrative analytic approach to identify the following themes: the immigrant experience, family dynamics, and health care. Support was a common sub-theme that threaded throughout, with participants relying on the immigrant community, family, and the health care system to support their goals. Participants derived satisfaction from setting and achieving goals and emphasized personal willpower as crucial for success. These findings should inform future research on how goal-setting can be used to foster lifestyle behavior change and illustrate the importance of exploring the needs of Latino sub-groups in order to improve lifestyle behaviors in diverse Latino populations.

"Three in the Room": Embodiment, Disclosure, and Vulnerability in Qualitative Research

The researcher's body in qualitative research is often absented, an absence that can render deceptively tidy research accounts. In this article, I reflect on the interplay of embodiment and disclosure in the interview dynamic and the way in which my body became an object of inquiry in the research process. Three qualitative studies inform the article: the first exploring the experiences of 40 people living with hepatitis C in New Zealand and Australia, the second comprising life-history interviews with 38 people who inject drugs in London, and the third following 27 people through hepatitis C treatment in London. Bodily and verbal disclosures of my history, as someone with/without hepatitis C and a former heroin user, affected the energy of the interview dynamic, also embodied understandings of illness and drug use. Disclosure can enhance researcher vulnerability and I close with reflection on the ethical implications of "enhanced rapport" in the research situation.

Multistakeholder Perspectives on the Transition to a Graduate-Level Athletic Training Educational Model

CONTEXT

The decision has been made to move away from the traditional bachelor's degree professional program to a master's degree professional program. Little is known about the perceptions about this transition from those involved with education.

OBJECTIVE

To examine multiple stakeholders' perspectives within athletic training education on the effect that a change to graduate-level education could have on the profession and the educational and professional development of the athletic trainer.

DESIGN

Qualitative study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 18 athletic training students (6 men, 12 women; age = 24 ± 5 years), 17 athletic training faculty (6 men, 9 women, 2 unspecified; 7 program directors, 5 faculty members, 3 clinical coordinators, 2 unidentified; age = 45 ± 8 years), and 15 preceptors (7 men, 7 women, 1 unspecified; age = 34 ± 7 years) completed the study.

DATA COLLECTION AND ANALYSIS

Participants completed a structured Web-based questionnaire. Each cohort responded to questions matching their roles within an athletic training program. Data were analyzed following a general inductive process. Member checks, multiple-analyst triangulation, and peer review established credibility.

RESULTS

Thirty-one (62%) participants supported the transition, 14 (28%) were opposed, and 5 (10%) were neutral or undecided. Advantages of and support for transitioning and disadvantages of and against transitioning emerged. The first higher-order theme, advantages, revealed 4 benefits: (1) alignment of athletic training with other health care professions, (2) advanced coursework and curriculum delivery, (3) improved student and professional retention, and (4) student maturity. The second higher-order theme, disadvantages, was defined by 3 factors: (1) limited time for autonomous practice, (2) financial concerns, and (3) lack of evidence for the transition.

CONCLUSIONS

Athletic training students, faculty, and preceptors demonstrated moderate support for a transition to the graduate-level model. Factors supporting the move were comparable with those detailed in a recent document on professional education in athletic training presented to the National Athletic Trainers' Association Board of Directors. The concerns about and reasons against a move have been discussed by those in the profession.

A forerunner of qualitative health research: Risueno's report against the use of statistics

In this article we discuss and examine the report presented to the Académie Royale de Médicine of Paris by the Spanish doctor Benigno Risueño de Amador in 1836, in which he argued against the calculation of probabilities in the health sciences. In his report, Risueño opposed the proposals put forward by Pierre Louis, precursor of the application of statistics in the health sciences. The report was a pioneering document that rejected the use of statistics in clinical practice and medical research. At the same time, however, it could well be considered a seminal document of a certain kind of qualitative research methodology in the health sciences.

Reflexivity and the capacity to think

Reflexivity is fundamental to qualitative health research, yet notoriously difficult to unpack. Drawing on Wilfred Bion's work on the development of the capacity to think and to learn, I show how the capacity to think is an impermanent and fallible capacity, with the potential to materialize or evaporate at any number of different points. I use this conceptualization together with examples from published interview data to illustrate the difficulties for researchers attempting to sustain a reflexive approach, and to direct attention toward the possibilities for recovering and supporting the capacity to think. I counter some of the criticisms suggesting that reflexivity can be self-indulgent, and suggest instead that self-indulgence constitutes a failure of reflexivity. In the concluding discussions I acknowledge tensions accompanying the use of psychoanalytic theories for research purposes, and point to emerging psychosocial approaches as one way of negotiating these.