Reviewing the paradigms

Epistemology explores how knowledge is gained through research methods and explains how this knowledge can be validated. Modern social science research theories are informed by epistemological stances or paradigms such as constructionism with the defining characteristics of ontology, epistemology, and methodology all arising from the philosophy of knowledge. The ‘way of knowing’ in terms of social constructionism is related to notions of ontology from perspectives rooted in historical, cultural, political, and social viewpoints (Warr, Reference Warr1999).

From a traditional worldview or paradigm, and to ensure research validity, the qualitative researcher strives to be an objective presence and the interviewer’s role as a participant in the interview process may often not be fully considered in the data generated (Denzin & Lincoln, Reference Denzin and Lincoln2018). Although the interview process may be an opportunity for both researcher and participant to express thoughts and ideas, these aspects are often minimally incorporated into the research report (Sandelowski, Reference Sandelowski2002). Similarly, while qualitative interviewing is recognised as encompassing influences from the location, time, and the embodiment of the interviewer and how they are perceived by the participant, these constructs have not routinely been incorporated into the resulting research outputs (Denzin & Lincoln, Reference Denzin and Lincoln2018). Thus, the researcher often remains a ‘disembodied’ presence despite acknowledgment of the importance of the socially constructed manner inherent in the qualitative research process (Sharma et al., Reference Sharma, Reimer-Kirkham and Cochrane2009).

More recently, a growing body of research suggests a reflexive turn in the qualitative landscape, acknowledging the significance of the interviewer as a person and the influence of their presence and their interactions with interview subjects. Initially, feminist researchers began questioning the traditional qualitative stance and objectivity required by the purists in qualitative research (Yow, Reference Yow1997; Sharma et al., Reference Sharma, Reimer-Kirkham and Cochrane2009). Subsequently, there has been a shift to more fully acknowledge and incorporate the impact of the researcher’s gender, culture, age, and background, and acknowledge the influence they may have on the process of data collection, the data gathered, and the analysis and reporting of that data. Both Denzin and Lincoln (Reference Denzin and Lincoln2018) and Brinkmann and Kvale (Reference Brinkmann and Kvale2015) are advocates of flexible theoretical paradigms favoured by pragmatists such as Morgan (Reference Morgan2007). In a naturalistic constructionist paradigm, the interviewer and participants are interactive and inform each other, and the interview process is a mutually beneficial phenomenon from which both participants may gain knowledge and meaning (Brinkmann & Kvale, Reference Brinkmann and Kvale2015).

In health service research particularly, the issue of disclosing your professional self is an important consideration. Gaining insider status may favourably impact on recruitment of participants, as well as affecting the type and quality of data gathered, particularly when interviewing others from your own or other health professional groups. Gair (Reference Gair2012) reviewed the literature on insider/outsider status, which was a term introduced in 1981 by Evered and Louis. The literature suggests that while insider status may be desirable in terms of insight, access, and knowledge, this status may also inhibit critical awareness. Gair (Reference Gair2012) reveals that researchers with either insider or outsider status will both be prone to the complexities of social constructs within the interview process (Gair, Reference Gair2012).

In an NZ healthcare setting, the Mãori worldview suggests culturally safe practice requires you to share who you are, where you come from, and who your family is. This concept of whānaungātanga, or connectedness, informs a collective approach to health care and is equally relevant in health service research. Relationships in a research setting could be considered a key part of a successful and collaborative research journey, as they are in a successful relationship between a health professional and a patient or client (Barthow et al., Reference Barthow, Jones, Macdonald, Vernall, Gallagher and Mckinlay2015; Wepa, Reference Wepa2015).

A reciprocal epistemology

Historically, there has been debate about the validity of the role of an insider conducting qualitative research (Brinkmann & Kvale, Reference Brinkmann and Kvale2015). The use of ‘insider’ status is a pragmatic utility with a shared knowledge and relationships used to the researcher’s advantage. Health professionals conducting research are often working with their peers, utilising existing associations. In addition, insiders who have experienced the phenomenon being studied could potentially compromise the validity of the research. Normative assumptions and practices may go unnoticed, and therefore remain uninspected, by insiders who routinely work within the research setting. Ochieng (Reference Ochieng2010) deliberately explored her own insider status when interviewing African-American families. She argued that she maintained a dualism in her stance as both an insider and an outsider. Although she gained access to research participants through her own identity as an African American, she believed that she was not considered wholly ‘one of them’ as her identity as an African American was only one aspect of her identity (Ochieng, Reference Ochieng2010).

The concept of dualism in my own research was apparent from the beginning. Although I am an ‘insider’ as a health professional, my relationship with these study participants was as both a researcher and a health professional. My existing collegial relationships meant that access to this field site was easily granted, but it became evident during the first interview that these peer relationships and my ‘insider’ status could influence the dynamics of the interview. When the research aims were developed, it was with a clear aim of evaluating a model of care as a researcher. What I had not anticipated was that I might also be viewed by participants as a health professional, and therefore a potential source of information to guide the implementation of the new model of care. One of the nurse participants said to me as I walked in for the first interview: ‘We have more questions for you than you will have for us.’ As a result of these first interactions in the initial case study field site, I began to question the traditional role of the objective researcher utilising interviews to gather data and information from participants. The inequitable researcher role did not align with my primary moral values of caring and beneficence as a nurse (Hoglund et al., Reference Hoglund, Helgesson and Eriksson2010). Realising my input could enhance how this practice managed the new model of care, and as a consequence how patients experienced this programme, I felt a duty of care as a nurse and ethically obliged to provide answers to the questions asked. I made a deliberate choice to wear two hats, that of researcher and advisor. Hoglund et al. (Reference Hoglund, Helgesson and Eriksson2010) suggest that to cover both roles and maintain research integrity requires researchers to clearly state the research agenda and establish clear boundaries between the researcher’s potentially dual roles of health professional and researcher during the interview.

Warr (Reference Warr1999) suggests that valid research is about managing both subjectivity and objectivity, and despite the subjectivity inherent in understanding research participants’ worldviews, researchers should use a sound methodology to ensure objectivity, despite this being limited by the subjectivity of participants’ experience. Using bracketing in qualitative interviewing originates in phenomenology and is a method used to reduce bias in qualitative interviewing. Brinkmann and Kvale (Reference Brinkmann and Kvale2015) describe bracketing as the interviewers attempting to set apart their existing knowledge of a phenomenon to ensure they can be non-judgemental and open to all new information about that phenomenon. Kukkala and Astedt-Kurki (Reference Kukkala and Astedt-Kurki2015) suggest that bracketing in the interview process ensures that the interviewer becomes a repository for the information, rather than being a co-creator despite the social constructs inherent in the process of interviewing. In this study, bracketing was used to separate the different ‘hats’ I wore as the researcher and a health professional colleague. Gathering the participants’ perspective on the implementation journey was ‘on the record’, and during this process, my existing knowledge was bracketed. The subsequent ‘off the record’ part of our interaction was my role as a sounding board and potential resource as a health professional and the brackets were removed.

Harris (Reference Harris2015) in her research into hepatitis discusses the issue of being both a participant and a researcher. Her research draws on ethnographic, phenomenological, and feminist principles and she employs a reciprocal and reflexive attitude to her investigations. Harris shares her own experiences and answers questions pertaining to her journey with hepatitis C. She describes being both a researcher and a participant in the form of a peer educator and explores the uneasy positioning and the ‘messy reality’ of qualitative interviewing (Harris, Reference Harris2015). The concept of research as a partnership is also discussed by Eide and Kahn (Reference Eide and Kahn2008) in a health study completed by research nurses. Eide and Kahn (Reference Eide and Kahn2008) explore the dilemma between maintaining a research ‘stance’ with the ethics of caring (Eide & Kahn, Reference Eide and Kahn2008). Barthow et al. (Reference Barthow, Jones, Macdonald, Vernall, Gallagher and Mckinlay2015) discuss the issue of reciprocity with respect to following a Māori research framework. Reciprocity or ‘utu’ is considered an expectation under this NZ model, particularly when information is being provided freely by participants. My interviews with the nurses at the initial field site became a mutually beneficial arrangement. The process of semi-structured interviewing led to the discussion and reflection of issues, which inevitably led to questions from both the participants and myself during the on-record interview. Later, off-record discussions revealed that this process helped the nurses begin to make sense of their situation and clarify the issues they were having with the implementation of the model of care. Although the present research project was developed to evaluate a model of care, all participants gained from the experience through a mutual exchange of information and reciprocity was achieved. There are affinities here with action research where researchers and participants work together to accomplish a common goal for the benefit of the community – in the present case, the community is comprised of primary health professionals implementing a new model of long-term conditions care.

Is reflexivity the answer?

A key strategy in addressing the influence of professional roles on research outcomes is the art of reflexivity. Reflexivity is the process of ensuring research validity by reviewing and critiquing one’s own experiences and the process of research and considering how this may influence the research outcome (Jootun et al., Reference Jootun, McGhee and Marland2009). Personal reflexivity involves self-awareness and the cognizance of researchers to be both a research device and an individual with social, political, and cultural worldviews. Epistemological reflexivity requires researchers to explore assumptions about the world and about knowledge through the process of conducting research (Dowling, Reference Dowling2006). Researchers are considered a research tool and may have multiple roles over the course of the research, depending on the participants being interviewed. The interview settings can also sometimes allow research participants to explore and work through their own challenges through the discussion process. In this study, reflexivity occurred through my own reflective practice, honed through my nursing experiences. This was combined with research team meetings where I was able to honestly reflect and discuss these experiences and the conflict I felt in the researcher role.

Enosh and Ben-Ari (Reference Enosh and Ben-Ari2016) suggest that participants’ motivation to contribute to research is often fuelled by a desire to be reflective and to consider their own role in the phenomenon under study. Researchers might consider that their research is motivated by the desire to gather data and present academically sound research. This requires investment and curiosity in the topic. Both researcher and participant will therefore bring different agendas to the research process and both agendas must be considered (Enosh & Ben-Ari, Reference Enosh and Ben-Ari2016). Reflexivity requires a deliberate awareness of actions with researchers being mindful of the construct they create in the environment, and of the self that they present to participants in the research setting. Robust self-scrutiny and awareness of the impact and perspective of both their own role and that of the participant are also important. Reflexivity allows the examination of any agendas present (both personal and professional), which could impact on the data collected. The dialogue in the interview, not just the participants’ responses, must be scrutinised (Enosh & Ben-Ari, Reference Enosh and Ben-Ari2016; Yow, Reference Yow1997). Agreeing on a process to separate and delineate the data and any emergent issues that occur during the interview process also requires consideration.

Although ethics are a central tenet in healthcare research, these have often focused on confidentiality, informed consent, and ‘doing no harm’. Honesty through reflexivity is also an important consideration in ethical research (Bishop, Reference Bishop2011). The importance of acknowledging all factors that shape the research, including the impact and disclosure of professional roles, any relationship with the participants, and any input into the phenomenon is important in presenting sound and ethical research. Bishop (Reference Bishop2011) also suggests that despite reflexive research practice acknowledging all potential existing social constructs in the process, it is not possible to fully incorporate this in the data gathered because it is not possible to be fully objective within an interview process. Honesty through reflexivity demonstrates the desire and commitment to present sound and ethical research and acknowledges the inherent subjectivity inherent in interviewing.

Glasgow et al. (Reference Glasgow, Green, Taylor and Strange2012) discuss the importance of translational health research for health policy and practice. An evidence integration triangle suggests that an iterative and pragmatic research process should be rapid, practical, transparent, and relevant and that this is essential to ensure that health service research is relevant and easily applied across different settings (Glasgow et al., Reference Glasgow, Green, Taylor and Strange2012). Using a collaborative approach in research with health professionals means they can concurrently reflect on their practice, and therefore the research process can be mutually beneficial. While I, as the researcher gained valuable data on the implementation of a long-term conditions programme from a general practice at the start of their implementation journey, participants were provided with a means of exploring and reflecting on their experience of implementing the model of care. Consequently, they had the opportunity to immediately apply any learnings to the ongoing implementation of the model, which could ultimately have positive benefits for patients. In this sense, the research became a reciprocal process with mutual benefits for both researcher and participants.