Unanswered questions on access from the margins Elise Paradis In their article published in this issue, Høyland et al.1 discuss an important and underappreciated issue faced by qualitative researchers in the field: access to clinical settings and participants. Qualitative researchers face serious legitimacy issues that do not plague others in the health care field because their practices are mostly misunderstood and underappreciated by clinicians and clinical researchers.2,3 Researchers in health professions education thus have much to learn about the ethics and pragmatics of access from this article. Given the breadth of the scholarship conducted by qualitative health researchers, however, it is important to consider where the authors’ perspective comes from and to highlight some of the issues they cannot address. Qualitative researchers face legitimacy issues that do not plague others in the field; their practices are misunderstood and underappreciated
Høyland et al.1 write within a tradition, the aim of which Cho and Trent4 call ‘truth seeking’, which has often been called post-positivist.5 The authors’1 orientation is visible in many ways, including in the article’s aim to ‘synthesise’ accounts of access, rather than to show their variety or expose their
Toronto, Ontario, Canada
Correspondence: Elise Paradis, Department of Anaesthesia, The Wilson Centre, University of Toronto, 200 Elizabeth St 1ES560, Toronto, ON, M5G 2C4, Toronto, Ontario, Canada. Tel: 00 1 416 340 3841; E-mail: [email protected]
contradictions, in the goal of the broader study to ‘explore how safety is achieved in surgical operations’1 [my emphasis] rather than perceived, constructed or enabled by the rise of the patient safety discourse, and in the authors’ view that the ‘contextual nature’ of their findings is a limitation of their study, rather than something to be richly documented and interpreted. In short, although they are conducting qualitative research, the authors seem to share many of the assumptions of the broader medical paradigm.6 Moreover, the authorial team counts members with formal nursing and medical training, and is affiliated with clinical departments and hospitals, elements that contribute to their being perceived as legitimate researchers (something Bourdieu would call ‘symbolic capital’7). In sum, theirs is a relatively privileged academic position within qualitative research (epistemologically and symbolically), and their experiences may not reflect those of less favourably positioned others. ‘Truth seekers’ may have an easier time with access as their language and research goals more closely align with those of clinical settings. Although they are conducting qualitative research, the authors seem to share many of the assumptions of the broader medical paradigm
Others within the traditions associated with what Cho and Trent4 call ‘thick description’, ‘developmental’, ‘personal essay’ and ‘praxis/social’ may not be able to similarly anchor their research within clinical conversations and priorities, and may
‘translate’ their interests strategically, an option that Høyland et al.1 would seem to decry as ‘deceptive’ and less transparent, and thus an indicator of a lowerquality research endeavour. The following fictitious cases highlight conundrums and challenges that were not observed by the authors, but raise important questions about the politics of knowledge production: who gets to study what? Whose voices matter? What is legitimate research? Who is a worthwhile consumer of research? ‘Truth seekers’ may have an easier time with access as their language and research goals more closely align with those of clinical settings
Imagine a researcher who is interested in transforming power dynamics in surgery, a ‘praxis/ social’ aim often associated with the critical traditions. Høyland et al.1 present their own choice of transparency as a reference standard, an indication of quality, and a means of avoiding deceptiveness. In her access negotiations, will our researcher explicitly share this aim, for the sake of transparency, when key gatekeepers may perceive it as a threat? Will she couch her ambitions in ‘tamer’ language about ‘interprofessional collaboration’ in surgery? Will she do so with the research ethics board she must report to? What kind of language (power? collaboration?) will consent forms mobilise? Is the choice to be transparent the ‘right’ thing to do in this case? Will it thwart the project? Will it taint participants’ responses, trans-
ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 138–146
commentaries form their behaviour? And finally: where will she publish this research? Who will want to hear her message? In her access negotiations, will our researcher explicitly share this aim, for the sake of transparency, when key gatekeepers may perceive it as a threat?
Now imagine another researcher who is affiliated to a sociology department and who sees his audience as his disciplinary peers. He has been socialised into asking conceptual questions and is interested in documenting the impact of the patient safety discourse on surgeons’ presentation of self8 during interactions with patients, a project that would fall within the ‘developmental’ tradition described by Cho and Trent.4 How does he operationalise these concepts to make them meet the rigid format of the ethics board forms? How does he translate his research interest into something that is understandable and meaningful to the clinicians and administrators he will encounter on his way to the research site? If the surgeons learn about some of the key concepts underpinning this researcher’s project (discourse, presentation of self, interactionism), will they refuse to participate? Will they alter their behaviour? Will surgeons ever read his research?
How does he translate his research interest into something that is meaningful to the administrators he will encounter on his way to the research site?
The move forward on access, according to Høyland et al.,1 involves the identification, teaching and implementation of best practices, but also greater transparency on access. The cases above open up the issue of access: beyond its technical aspects, access is also about legitimacy and power relationships in health research. What is a legitimate research question? What is the legitimate terminology to use to frame the research problem? Who has the power to decide what is legitimate? By broadening the conversation to consider types of qualitative research that are less well aligned with the dominant medical research paradigm and thus more likely to be marginalised, I sought to invite health professions education researchers to consider the politics of knowledge production, and how gatekeepers – ethics boards, clinicians, administrators, but also, downstream, editors and reviewers – may actually prevent the conduct and dissemination of novel, creative, critical, transformative research. Access has important implications for what it is possible for us as a community to know and act upon.
REFERENCES 1 Høyland S, Hollund JG, Olsen OE. Gaining access to a research site and participants in medical and nursing research: a synthesis of accounts. Med Educ 2015;49: 224–32. 2 Albert M, Laberge S, Hodges BD. Boundary-work in the health research field: biomedical and clinician scientists’ perceptions of social science research. Minerva 2009;47:171–94. 3 Goguen J, Knight M, Tiberius R. Is it science? A study of the attitudes of medical trainees and physicians toward qualitative and quantitative research. Adv Health Sci Educ Theory Pract 2008;13 (5):659–74. 4 Cho J, Trent A. Validity in qualitative research revisited. Qual Res 2006;6:319–40. 5 Denzin NK, Lincoln YS. The Sage Handbook of Qualitative Research, 3rd edn. Thousand Oaks, CA: Sage Publications 2005. 6 Tilburt J, Geller G. Viewpoint: the importance of worldviews for medical education. Acad Med 2007;82 (8):819–22. 7 Bourdieu P. The forms of capital. In: Szeman I, Kaposy T, eds. Cultural Theory: An Anthology. Oxford: Wiley-Blackwell 1986 ; 81–93. 8 Goffman E. The Presentation of Self in Everyday Life. Garden City, NY: Doubleday Anchor Books 1959.
ª 2015 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 138–146
Unanswered questions on access from the margins.
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