INTRODUCTION
Since the 1990s qualitative research methods have become an intrinsic aspect of primary care research. They have provided insight into the complexity of healthcare professionals’ and patients’ perspectives on health and health care, utilising a range of methods including interviews, observations, and focus groups.1 These methods require flexibility on the part of the researcher and participant in relation to time, location, and what they share of themselves.
It is our view that although primary care research employs rigour when considering which method and analytical approach best fits the research context, there remains a relative neglect of the stance of the researcher and research participant relationships in the design and conduct of primary care studies.
Research encounters may provide an encouraging space for individuals to discuss feelings and views. The sharing of such information can likewise be a profound and moving experience for researchers who may encounter emotions inside themselves and others – feelings which may be challenging. Yet little has been said about emotions in primary care research. How should one deal with these? Similarly, while physical safety for participants is explicitly considered during study design and ethical review, qualitative research takes place outside a lab-based environment and requires researchers to consider their own safety too.
This article discusses the emotional safety of participants and researchers and physical safety considerations for researchers by describing approaches we have used. We hope this will encourage debate within the primary care research community and by doing this will enhance research quality and enable clinicians and researchers to make more informed decisions about involving patients in qualitative research.
APPROACHES TO QUALITATIVE RESEARCH
Following Pope and Mays1 we would argue that the manner in which physical and emotional safety is approached is dependent on the epistemological and methodological perspectives of the research team, broadly between positivist and interpretive approaches.
From a positivist perspective, emotions are acknowledged as being the preserve of the subjective rather than the objective being and therefore as something that should be put aside during research, as it risks introducing bias and undermining validity.
In contrast the interpretive approach, influenced by feminist scholarship, acknowledges researchers’ and research participants’ emotions as a ‘valid’ part of the field.2 Power relations within the research encounter are acknowledged and a reciprocal approach to the research encounter offers a richer engagement with research participants.3 This approach is also a key feature of disability studies research.4
In primary care, engagement with such issues can be seen most clearly in the use of participatory research methods.5
What are the implications of such differing approaches for the emotional safety of researcher and participant?
From a positivist position, the emotional aspects of research are overlooked and neglected in favour of other technical competencies expected of the researcher, which may leave field researchers discounting emotions too readily and questioning their own practice as not being objective.6 Researchers may be unable to voice concerns or talk through distressing and sad encounters. In contrast, an interpretive approach may enable researchers to reflect on encounters and view this as an integral part of research. Further, this reflection fosters the ethical practice of considering the impact of research on participants.
PROMOTING RESEARCHER SAFETY
Framing risk from the researcher’s perspective
If team members are from mixed disciplinary backgrounds then it helps to have early discussions regarding disciplinary perspectives about risk. Roles and responsibilities for flagging concerns and taking action need to be identified, especially when safeguarding children and vulnerable adults. For example, clinician researchers may approach issues of cognitive impairment, substance misuse, or mental illness in terms of perceived safety and the capacity of participants to engage in research, differently from social science researchers. It has been our experience that incorporating discussions about knowledge, understanding, and responsibilities is required throughout the development and implementation of studies to enhance physical and emotional safety for all involved. The framework7 in Box 1 articulates the potential risks when planning and conducting research.
Box 1. Triggers for action
Consider these as threats to physical safety zones and psychological (we use ‘emotional’) safety zones:
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The participant or others in the house are intoxicated with alcohol or street drugs to a degree that the interview cannot be conducted meaningfully or with the risk that the threats listed below are more likely to occur.
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Actual or perceived threats of physical violence directed against researcher, accompanier, or other persons present in the house by participant or person in house.
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Sexually inappropriate verbalisation that persists such that the researcher or accompanier feels threatened.
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Sexually inappropriate behaviour directed against researcher, accompanier, or other persons present in the house by participant or person in house.
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Other concerns, such as the production or presence of an object that is perceived by the researcher or accompanier to be a weapon that may be used against them.
Researcher emotional safety
Research team members will have a range of skills for coping effectively with emotionally distressing experiences that arise during research. These will be determined by their disciplinary background, professional and personal experience, and each individual’s own psychological characteristics. We think it should be a core function of the research team to acknowledge the range of perspectives and skills apparent in the team and to utilise them to promote a supportive and effective learning environment appropriate for the study context. This will enable team members to develop their skills and enhance resilience, such as understanding a safe level of emotional involvement with a participant’s distress. Research teams should make their duty of care to team members explicit, share and agree models of understanding for the project, articulate and agree the rules of emotional work, and set aside time for field work briefs and debriefs. Occasionally team members may require additional emotional support outside the immediate team, such as access to counselling.
Physical safety
Although in our experience it is rare for the physical safety of researchers to be compromised, there is also likely to be an impact on researchers’ emotional safety if their physical safety is breached. Reasonable steps can be taken to avoid these risks by planning actions to promote safety for researchers (dependent on the perceived level of risk within the study and the resources available). We describe one approach used when conducting interviews with participants in their own home in Box 2.8
Box 2. Physical safety strategies
Advance preparation
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Gather background information. This can be clinical risk assessment information or prior telephone contact with the proposed participant. If using telephone contact it is useful to ask about current health issues, who else may be present during the interview (including pets), and directions to the participant’s home. This establishes a level of rapport and allows some insights into participants’ conversational style and emotional regulation.
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Schedule the interview for as early in the day as possible and always within office hours and in daylight.
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Check out the location of the home to be visited either through local knowledge (researcher or informant) and familiarise with location, entry, and exit from the area.
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Ensure that the vehicle to be used is in good working order, has sufficient fuel, and has no visible items on display prior to the visit.
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Carry the minimum equipment necessary to the interview and the minimum amount of cash (for example, for participant payment).
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Dress appropriately for the research setting; flat shoes, trousers, smart casual.
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Ensure your mobile phone is charged fully and has emergency contact numbers programmed in. Keep the phone switched on at all times.
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Take a personal screech alarm and check it is fully functional and worn within easy access but unobtrusively located.
Research team
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Use a research accompanier to accompany the researcher. An accompanier is a colleague experienced in working in risky research or clinical settings. Brief each other ahead of the contacts regarding triggers (Box 1) that will necessitate abandoning the interview.
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Leave full details of the location and time of the participant contact with a member of the research team who is able to respond to emergencies.
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Phone the research team member just before the participant contact and phone again when it is over and the researcher and accompanier have reached a safe area.
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Give the estimated time of the interview and ask the research team member to phone the researcher’s mobile when the allocated time has passed.
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Agree on a code sentence that if said to the research team member by phone will trigger an immediate call for the police to attend the participant contact site. An example, ‘Mary you will have to cancel my meeting with Martha Carney today’.
Participant contact
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Park the vehicle as close to the participant’s home as possible ensuring it is parked so that the exit can be prompt.
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Identify the safe exits from the participant’s home as you go in.
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Conduct the interview in a public room where possible.
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Provide no personal details to the participant beyond the researcher name and contact number provided on the participant information sheet.
PROMOTING PARTICIPANT SAFETY
Framing risk from the participant’s perspective
Like researchers, participants bring their own life experience, knowledge and expectations to the research encounter. While participants may have long-established patterns of interaction and disclosure with professionals they have encountered, the difference between a clinical and research interaction should be made explicit, particularly where researchers are also clinicians. Box 3 describes an example when this was apparent. Researchers should also be mindful of the power imbalances between themselves and participants. Sensitively setting out the participant and researcher role, including clear boundaries and the necessary safeguarding principles described above at intervals throughout the research relationship will help to mitigate this. This may help participants avoid under- or over-estimating the effect of disclosing distressing information, and the influence or skills the researcher has in effecting change or an intervention on their behalf.
Box 3. Clinicians as researchers: navigating roles
In a study interviewing patients who had been repeatedly removed from GP lists, AEW as a clinician researcher attempted to conceal her clinician identity because she thought it might bias the interaction with participants who had previous negative experiences of general practice. However when recruiting patients through their current GPs she was only able to interview one patient when his GP felt he needed to gain his trust by reassuring him of her safe credentials: that she was a GP known to him who was an expert in working with patients with problem drug use and would therefore treat him well.
‘This did influence the research interview because the participant talked to me about his health problems which I had to be careful to listen to in a way that enabled him to feel understood. At the same time I had to do this in a way that it was clear I was not assuming a medical role and giving a medical opinion about his problems. However, my fears about him tempering his account of his previous negative GP experiences were not realised and the interview data was rich in content.’
Participant emotional safety
The research experience can be a profound one especially for individuals who may be socially and physically isolated. It is important that participants know their views will be respected, that participation is voluntary to ensure informed consent and that expectations about the outcome and impact of research for individual participants are discussed fully. We think research teams need to agree and articulate which circumstances and triggers will suggest that participants may benefit from follow-up work with other professionals. Box 4 describes what might be said.
Box 4. Prompting follow up: researchers responses
‘If you tell me something that is difficult for you I will treat it in confidence. However, if someone is in a vulnerable situation I may need to inform relevant people, OR I can give you information about sources of help, OR would you like me to contact someone for you on your behalf?’
CONCLUSION
Qualitative methods have contributed to primary care greatly over the past two decades, providing greater insights into health care professionals’ and patients’ experiences. In providing these it is important to care for the health and wellbeing of researchers in the field and the participants in research. We finish with an example of a participant–researcher encounter in Box 5, the risks considered, and the actions taken. Taking into account your own research or clinical practice context what action would you have taken?
Box 5. An example of a safety assessment and its outcome
NB was involved in detailed ethnographic work involving observation and interviews for a project exploring the experiences of users of mental health services in remote and rural locations. During interview at a local drop-in centre, a research participant offered to take NB to the places he would go when feeling distressed. A keen hill walker, the participant informed NB they would be going to a nearby mountain range and suggested they would be out all day and to wear appropriate clothing and footwear. In deciding whether to accept the offer NB considered not only her own physical and emotional safety but that of the participant too.
“The research team were keen to make the research a safe experience for all who participated. We would be out all day, first in my car and then walking. I sought the views of the professionals running the centre on the area (the participant did not wish to reveal the exact location) and on my safety both in the area and with the participant. I felt safe with the participant, I had been in his company on several occasions and had not witnessed any of the issues identified in Box 1. The emotions of those who use mental health services are often scrutinised by the medical profession, informing diagnoses and indicators of becoming ‘well’ or ‘unwell’.
I explored with the participant and staff at the drop-in whether it was safe for the participant to engage in this trip. Aware that the location was of great significance to the participant, we discussed whether he would feel emotionally safe taking me to the area. We discussed the ability to stop the walk at any time. I discussed this with the wider research team and it was agreed that both the participant and I should have frequent opportunities to stop the trip.
We embarked on our day, and I asked questions, but at other times remained silent. We had a great day.”
As planned, the research team discussed the trip with NB. NB’s feelings about the day informed the writing up of her field notes.
Notes
Provenance
Freely submitted; externally peer reviewed.
- © British Journal of General Practice 2014
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