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Fieldwork and the practical implications for completing qualitative research in the British Armed Forces Alan Finnegan Correspondence to Col Alan Finnegan, L/QARANC, Academic Department of Military Nursing, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham B15 2SQ, UK; Alan.fi[email protected] Received 29 November 2013 Accepted 1 December 2013 Published Online First 9 January 2014

ABSTRACT This article provides direction regarding the practical implications of undertaking qualitative research within the British Army, and in particular the Defence Medical Services (DMS). Qualitative researchers must gather sufficient data to answer their research question, and guidance on using DMS healthcare professionals as the research sample is offered, including dealing with the ‘gatekeepers’ who control access, and the principles for creating a conducive environment to gather reliable data. Data collection is often through intensive interviewing where communication skills and personal awareness are vital to a successful study. Aids to a productive study include memo writing and listing factors that may later provide an insight into how the interviewees characterise and describe particular activities, events and groups. Guidance is offered to develop an interview schedule with questions related to each other in a seamless, meaningful way. Both the researcher’s and participant’s conscious and unconscious biases must be acknowledged. In this narrow and specialist field, DMS researchers need extensive knowledge of clinical practice and the military’s distinctive language, characterised with nuances and abbreviations. These words portray meanings and perspectives that signpost the participants’ view of their empirical world. Early identification, without having to seek clarification, means that the researcher can examine hidden assumptions in the sample’s own language.

Key messages ▸ Experienced Defence Medical Services (DMS) clinicians provide an exceptional source of knowledge to offer insight into healthcare issues of soldiers, particularly in differing peacetime and operational settings. ▸ A well defined interview schedule is a key component for a successful research project. It will improve validity and reliability as the quality of the questions and how the interviews are conducted shape the power of the results. ▸ There are significant difficulties for a researcher who does not have an in-depth knowledge of the study group. DMS researchers have an advantage in being acknowledged as a member of the defence research population. ▸ DMS studies are conducted within a relatively narrow and specialist field, and the DMS researcher requires knowledge of both clinical practice and the military. In both these areas, there is a particular language, characterised with nuances and abbreviations. ▸ In DMS qualitative research, there is clear potential for bias that should be balanced through a strategy based on self-awareness, an open mind and the requirement for supervision.

INTRODUCTION There are many excellent books detailing how to undertake qualitative research,1 describing specific theories2 or undertaking certain tasks such as developing a research proposal.3 This paper aims to provide explicit direction regarding some of the implications of undertaking qualitative research within the British Armed Forces, and in particular the Defence Medical Services (DMS). This includes practical issues such as: selecting a research group; interview skills and the interview schedule; memo writing; and undertaking fieldwork. It identifies potential pitfalls and guidelines on how to navigate the numerous hazards. Details regarding qualitative theories, choosing a theoretical framework, analysing the data and ethical approval are described in a companion article within this edition.4

SAMPLE SIZE, GATEKEEPERS AND LOCATION

To cite: Finnegan A. J R Army Med Corps 2014;160:141–145.

Having decided what to research, how to do it and what the importance of the study is, the researcher should be aware that there are a number of practical implications that are common within qualitative research that need to be addressed. An important factor is to consider what constitutes sufficient

Finnegan A. J R Army Med Corps 2014;160:141–145. doi:10.1136/jramc-2013-000222

sample size to ensure that the research question has been answered, how to gain access to this sample and to consider the implications of where these data will be gathered (Table 1).

SELECTING THE RESEARCH POPULATION AND USING DMS HEALTHCARE PROFESSIONALS Having accepted that qualitative research sample sizes may be small, it is imperative to gather data from a research cohort that can provide sufficient data to answer the research question; for example, to determine the reasons why young women wanted to leave the army, the target audience would be women serving with the Army, with a stated inclusion age. An alternative option is to use a research population that has experience dealing with this sample, in particular healthcare professionals. This approach is well established and advocated, for this group has been recognised as being particularly well placed to address complex factorial disorders such as Deliberate Self-Harm.11 This assumption extends to indicate that DMS clinicians can provide a reliable method of identifying how a soldier’s world functions, particularly in differing 141

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Review Table 1 Guidance on sample size, gatekeepers and location issues when performing qualitative research Issue

Guidance

Sample size

A small sample population means that a convenience sample, that is, using subjects who are available, may be required due to issues such as geographical distribution and other restrictions. In firmbase locations (a peacetime setting for training for deployment), this can be due to personnel being posted overseas or being unavailable due to operational commitments. In operational areas, this can be due to personnel being inaccessible due to their environment and the battle tempo. In the few qualitative studies conducted within the British DMS, sample groups range between 11 and 21 personnel.5–9 The Armed Forces provide a stark example of a closed organisational setting where a ‘gatekeeper’ controls access to a research sample that is often subject to intense scrutiny. This can be particularly pertinent in groups such as recruits, operational casualties or Service personnel dealing with mental health problems such as Post-Traumatic Stress Disorder or mild Traumatic Brain Injury. The issue being discussed may contain sensitive information and access will require that the researchers or their supervisor has the necessary military and clinical profile. For studies where the researcher aims to deploy specifically for data collection, then the appropriate Defence Professor and Royal Centre for Defence Medicine Medical Director must be engaged to obtain Permanent Joint Headquarters sanction. With this assistance, the researcher can precisely target when to arrive in theatre to undertake data collection while ensuring that participants have been deployed for a sufficient period of time to provide the appropriate data. This is more challenging due to varying lengths of operational tour. There are practicalities to be considered such as having to travel significant distances. This can have important implications, and reduce the opportunity to go back to subjects with the initial results in order to refine them in light of the emerging themes. In a military cohort, if using interviews, it is vitally important that these interviews are carefully co-ordinated and structured. Attention should be provided to ensure an appropriate location is used for data collection, even on deployment, where the following general principles should be aspired too. Interviews should be conducted in a quiet, well-ventilated, comfortable room with good lighting; dedicated time must be identified for the session; and interruptions minimised.10

Gatekeepers

Location

DMS, Defence Medical Services.

peacetime and operational settings, while existing within the military ‘family.’ It is often useful in this situation to maximise ‘organisational memory’ and to use only experienced DMS clinicians who often have many years’ experience supporting Armed Forces personnel. DMS clinicians can provide insight into the complexities associated with clinical disorders while providing sufficient information within the explored categories to provide data to answer the research question. The researchers can then define a theoretical position and explanation through accurately reflecting their interpretation of a wide range of emotions and behaviour of the soldiers (Box 1). Having navigated the practical implications of targeting and gaining access to an appropriate study sample, the researcher then needs to address how the data will be collected. There are several methods within the qualitative researcher’s toolbox such as direct observation, but this article focuses on the common method of gaining information through interviews.

INTERVIEW SCHEDULE To gain the sample’s views; intensive interviewing is widely practiced. An advocated method is to conduct interviews soon after an event to get the subject’s reaction before the participant starts to edit the incident. Information is obtained through the

Box 1 The use of Defence Medical Services healthcare personnel in qualitative research and the use of inclusion/ exclusion criteria A Grounded Theory qualitative research study with Defence mental health (MH) clinicians was conducted to determine their views regarding the factors leading to depression in the Army.12 The research sample was drawn from a population of 86 serving military and civilian Army MH clinicians. In order to obtain details from an experienced group, a number of junior, inexperienced personnel were excluded. This left a sample group of 61 personnel with five or more years employment within the Army. Nineteen clinicians completed interviews with 380 years of clinical experience between them and an average of three operational tours each, providing significant knowledge to address the research questions. 142

use of open questions and unobtrusive methods. In this context, the phrase of ‘rubbish in—rubbish out’ is particularly pertinent, and a well defined interview schedule is a key component for a successful research project. Planning should be extensive and the schedule should be constructed following significant input from clinical, military, lay personnel and research supervisors. This will improve validity and reliability as the quality of the questions and how the interviews are conducted shape the power of the results. This will also improve the potential for the proposal gaining Ministry of Defence Research Ethical Committee approval and lead to minimal alterations once the interviews have commenced. The interview schedule should be comprehensive and invite a non-judgemental, open ended detailed discussion focused on significant matters. The questions should be designed to encourage respondents’ participation by providing them with the scope to express their views and cater for the exploration of unanticipated replies as they emerge.1 Questions should be related to each other in a seamless, meaningful way. The questions must be balanced and not just concentrate on the issues that the researcher perceives as problematic. For example, if the researcher wishes to question the challenges of working alongside multi-national colleagues on deployment, then the questions should be designed to also explore the benefits, and afford the interviewee the opportunity to describe how working practices could be improved. An example of a semistructured interview schedule from a study exploring the factors affecting the delivery of nursing care on deployment is given in Box 2.9

INTERVIEW SKILLS Interview skills are vitally important, and it is beneficial to have experience in undertaking consultations. DMS clinicians need good communication skills within their scope of practice which may be underpinned by specific training, such as taught counselling skills. The objective is to actively listen and remain impartial throughout the interview. The researcher should make constructive use of silence, keeping an open and attentive posture, only interject as necessary while focusing on the relevant topic and consistently encouraging respondents to produce their own accounts.10 Finnegan A. J R Army Med Corps 2014;160:141–145. doi:10.1136/jramc-2013-000222

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Review

Box 2 An exploration and critical analysis of the predisposing factors that affect the delivery of nursing care during an operational deployment Interview schedule ▸ Outline the rationale for the study: ‘The study aim is to advance knowledge within Defence Nursing through an understanding of the predisposing factors that affect the delivery of nursing care on an operational deployment.’ General opening question ▸ How has the tour been so far? Specific questions Educational preparation Regarding the educational preparatory training required for your deployed role: ▸ Has this training adequately prepared you for the patients (ie, including complex multi-polytrauma) that you are caring for? ▸ If yes, can you expand on the particular benefits? ▸ If no, where are the omissions? ▸ What extra training would be useful? Multi-professional and multi-national boundaries In your opinion: ▸ What are the benefits of working within a multi-professional team in Camp Bastion? ▸ What are the challenges of working within a multi-professional team in Camp Bastion? ▸ What changes to pre-tour preparation could enhance multi-professional working practice? ▸ What are the benefits of working within a multi-national team in Camp Bastion? ▸ What are the challenges of working within a multi-national team in Camp Bastion? ▸ What changes to pre-tour preparation could enhance multi-national working practice? Local population In your opinion: ▸ What are the challenges of providing nursing care for the local population? ▸ What are the benefits of providing nursing care for the local population? ▸ What changes to pre-tour preparation could enhance caring for the local population? Standard of nursing care In your opinion: ▸ How would you describe the standard of nursing care? ▸ Is there anything that would improve the standard of nursing care? Other stressors ▸ Have there been any other factors that have affected the delivery of nursing care? (Note: discuss relationship issues, family issue, significant others and occupational stressors) Well-being of nursing staff ▸ Overall, what impact does the delivery of operational nursing care have upon the mental well-being of nursing staff? Conclusion ▸ Are there any other aspects that you would like to discuss? During the interviews, every effort should be taken to highlight that while the researcher shares some experiences, these are not necessarily the respondent’s viewpoints, and to guarantee Finnegan A. J R Army Med Corps 2014;160:141–145. doi:10.1136/jramc-2013-000222

anonymity. When dealing with colleagues, personal referencing and inclusion should be expected, and during the interviews the researcher should acknowledge the link and regularly reinforce the need to exclude assumptions regarding the researcher’s views or experience. For example, ‘Try and remove the rank structure out of this interview, I’m an external researcher, interested only in your views regarding this research project’. Reinforce that there are no right or wrong answers within a strategy aimed at obtaining an honest, open and detailed account. However, the researcher should still expect personal references; these might include ‘we are colleagues, we know each other’, or a subject’s assumptions that the researcher was already aware of the respondent’s beliefs: ‘Well you know my view on this anyway’. In the author’s experience that has included anticipating knowledge of military research, even when the findings would not be published for another 2 years: ‘but as you know from the recent work that we have been doing, the Army has got an alcohol issue’. When interviewing clinicians, it is important to also acknowledge that they are an intelligent, professional group who presumably understand the objectives of the research and are used to engaging in consultations as part of their normal working life. From commencing the research and during the data collection phase, the researcher should make field notes and list factors that may later provide an insight into how the interviewees characterise and describe particular activities, events and groups (Table 2). This provides the first basis for conveying explanations and eliciting participants’ opinions on when, why or how particular things happen.

Transcribing interviews and data storage For accuracy, interviews are normally recorded using a digital recorder and transcribing verbatim texts is a key aspect of the qualitative research experience, in particular for the novice. Transcribing is self-developmental, improves personal interview skills and the researcher is empowered to pursue leads as they emerge. The aim is to transcribe soon after the interview, while acknowledging that this is a time-consuming activity. However, the benefits are significant. Careful consideration should be undertaken before using other personnel such as medical secretaries to transcribe, especially when the discussions include sensitive and distressing issues, such as involving children, futility in healthcare and medical practices. Data can then be transferred to a password protected computer that allows flexible access to the information and be used to facilitate personal mentorship and support from research supervisors.

FIELDWORK Rank and military culture is such that soldiers have a disciplined persona which they adopt at work, which may not be Table 2

Memo writing in Grounded Theory (from Charmaz 2006)2

Early memos

Advanced memos

▸ What is going on within the field setting or interviews? ▸ What are people doing and saying? ▸ What do participants take for granted? ▸ How do structure and context serve to support, maintain, impede or change their actions and statements? ▸ What connections can you make? ▸ Which ones to check?

▸ Trace and categorise data subsumed by the topic ▸ Describe how the category emerges and changes ▸ Identify beliefs and assumptions ▸ View the topic from various viewpoints ▸ Place the topic within a debate ▸ Make comparisons

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Review particularly insightful into the causes of any external distress.13 There are also significant difficulties for a researcher who does not have an in-depth knowledge of the study group and share some experiences (if not necessarily all the viewpoints). DMS personnel have an advantage in being acknowledged as a member of the military population, which can ease the dilemma of gaining access to Ministry of Defence (MOD) employees; they can then use their knowledge to provide a familiarity with the studied phenomena that is seen as a prerequisite in qualitative research.14 This inner familiarity develops a bond between researcher and subject, and without this rapport the investigator may be denied trustworthy interviews or observations.15 Studies are conducted within a relatively narrow and specialist field, which may be exacerbated if dealing with a specialist clinical cadre and the DMS researcher will need an extensive knowledge of both clinical and military duties. In both these areas, there is a particular language characterised with nuances and abbreviations and referencing an environment that many investigators could not relate too.16 The codes that emerge from languages, meanings and perspectives signpost the participants’ view of their empirical world. Early identification, without having to seek clarification, means that the researcher can examine hidden assumptions in the samples’ own language.1

POTENTIAL PROBLEMS While the researcher may form part of the research cohort, this can have significant implications that could negatively affect the reliability of the results. The role of the ‘self ’ has to be acknowledged. This recognition almost certainly means that certain difficulties will be presented, including the acknowledgement that there is a gap between beliefs and action and between what people say and what people do.17 Therefore, interviewees may provide the answer they feel is expected of them, rather than what they truly feel. There is a clear potential for bias that needs to be carefully addressed to obtain the study group’s subjective opinion rather than simple objective reporting.18 It is also important to note that within interviews, powerful or disempowered individuals may distrust the interviewer, the sponsoring institution and the stated purpose of the interview as well as how the findings will be published.1 Interviews may be influenced by the researcher’s occupational identity such as being a nurse or doctor. These implications can be less constrained when the research is not undertaken for funding, the researcher is not in the direct chain of command, and not engaged in the power displacement associated between clinician and patient. Researchers have to remain attuned to how they are perceived by participants, and how past and immediate identities could affect the balance. For DMS personnel, this can be compounded by military rank and dealing with juniors, seniors and MOD civilian employees. Considerations include: will the group tell the researchers what they think they want to hear? Will they leave out information thinking the researcher already knew their views? Will they avoid controversial opinions?10 Will the researchers be viewed differently by military or civilian practitioners, nurses or specialist clinicians? Unless these issues are tackled, the study results will be significantly diluted. Therefore, the researchers’ position, their ‘self ’, has to be recognised to minimise the impact this position would have on the validity of the study findings. The researcher must acknowledge personal preconceptions emanating from the social influences of class, gender, age, political, clinical and historical viewpoints. These may have been nurtured through many years in the Armed Forces and could permeate the analysis and negatively affect the research conclusions. 144

IMPROVING VALIDITY AND RELIABILITY To successfully navigate these problems, the researcher should develop a strategy based on published findings and consultation with their research advisors that is based on self-awareness, an open mind and the requirement for supervision.1 Researchers should document personal views and pre-research opinions into a research diary to provide a footprint for later retrieval. There are practical implications, such as conducting an interview wearing civilian clothes rather than military uniform, visiting the research group in their workplace rather than in the researcher’s workplace and considering conducting interviews

Box 3 Practical advantages and disadvantages of undertaking operational qualitative research Advantages ▸ The research sample are a captive audience, and if an appointment is cancelled due to a higher priority such as clinical tempo, then it is easy to rearrange. ▸ Significant data collection can be achieved in a short period of time and complete multiple interviews in a day. ▸ The time in theatre allows the researcher to become fully immersed in the subject area, as there are no routine distractions. ▸ A prime research activity is transcribing the interviews. Being in theatre provides an opportunity to transcribe immediately. It should be noted that 8–10 min of an interview can take an hour to transcribe. ▸ Operational deployments can be routine, and personnel may welcome the opportunity to engage is something different. Many Defence nurses volunteered to be interviewed, and then reported that they found the research experience beneficial. ▸ The researcher’s rank did not appear to restrict participants from engaging fully and honestly. Disadvantages ▸ Appointments may be cancelled due to higher priorities such as clinical tempo. ▸ The interview location may be challenging. In this study, the interview room was small and the temperature was up to 50°C. There was also considerable ambient noise due to the close proximity to a helicopter landing site, the hospital intercom system and hospital cleaners. The effect being that the quality of the digital recording may be compromised. ▸ The nature of qualitative research is unfolding, presenting new themes to be explored as they emerge. The constraints of wavering from a Ministry of Defence Research Ethical Committee approved study reduce these opportunities. ▸ No immediate research supervisory support. ▸ The concentration required to complete multiple interviews in a single day is extremely draining. ▸ Each tour brings specific challenges. The researcher gets a snap shot of the operational environment. Issues such as leadership, management, clinical tempo and experience can all affect the clinician’s views. ▸ Participants may stray from the research question and use the interview as a means of addressing other issues. The researcher needs to be prepared to deal with distressed personnel and have the competencies to adapt to presenting challenges.

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Review on first name terms. Background information of where the interviews will be held should be obtained and the researcher should be well versed with the facilities and use this knowledge to establish an appropriate conducive environment (see ‘Location’ issue in Table 1). It is important not to conduct an interview at the end of the working day as the interviewee may want to go home. Be prepared for cancellations, and do not attempt to organise too many interviews in a day as the sessions are likely to be personally exhausting.10 Even for experienced interviews, three interviews per day should be the maximum. Following these guidelines should prove beneficial, but the researcher should still expect challenges, and despite what happens, the situation has to be handled. These principles are best practice, but obviously have to be modified in the operational environment. There are both advantages and disadvantages of operational qualitative data collection as highlighted by a recent study in Camp Bastion, Afghanistan (Box 3).

Competing interests None.

CONCLUSIONS

10

Qualitative research provides an opportunity to gain empirical insight into the views of an informed research sample and address military problems. This paper provides researchers with a reference to positively address some of the challenges they will face; they can then add to the few qualitative studies undertaken in the DMS, while noting that similar research has presented novel insights into Defence healthcare. This includes information to inform and change educational programmes and clinical practice, thereby presenting an opportunity to improve operational capability and the quality of operational tours for DMS personnel. It is anticipated that these guidelines will provide guidance to personnel from other Armed Forces and those undertaking research with military veterans.

Provenance and peer review Not commissioned; internally peer reviewed.

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5 6 7 8 9

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Correction notice Author’s affiliation has been updated since published Online First.

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Fieldwork and the practical implications for completing qualitative research in the British Armed Forces Alan Finnegan J R Army Med Corps 2014 160: 141-145 originally published online January 9, 2014

doi: 10.1136/jramc-2013-000222 Updated information and services can be found at: http://jramc.bmj.com/content/160/2/141

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Fieldwork and the practical implications for completing qualitative research in the British Armed Forces.

This article provides direction regarding the practical implications of undertaking qualitative research within the British Army, and in particular th...
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