BACKGROUND AND RATIONALE 1 Research in a clinical setting

This research was conducted within a clinical setting. Specifically, interviews were conducted and data were collected by me, both as a clinician and researcher, in a hospital environment with research participants who had potential co-existing roles as patients and participants. While I am aware that the tradition of separating research from clinical work has been a common practice within both qualitative and quantitative research processes, there is also a movement towards the accommodation of clinical needs within a research activity (Borckhardt et al., 2008; Silverstein & Auerbach, 2009; Silverstein, Auerbach, & Levant, 2006).

This process, of concurrent clinical work and research activity, may be both particularly relevant and necessary in the context of resource-scarce environments. This was a predominant consideration in the two State hospitals at which I both worked as a clinician and operated as a researcher interviewing participants. As described in Chapter One, in both these settings I was faced with the knowledge that there was no alternative mental healthcare professional to whom I could refer the potential participants. If I did not see and treat the referred individuals clinically, either as an alternative to the research process should they decline to participate, or

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subsequently, even concurrently, during the research process, they would have had no alternative access to mental health assistance.

In such situations, the challenge is to operate within appropriate ethical constraints as well as to offer a real and viable mental healthcare service. Smyth and Schorr (2009), in exploring effective ways in which to provide relevant amenities to “vulnerable and marginalized” populations, raise the challenge of mechanisms of operation in certain organisations and under certain conditions. While they acknowledge the necessity of evaluating efficacy both in terms of research process and subsequent clinical application, they suggest that strictly experimental designs are not necessarily best suited to either assessing the results or ensuring accountability (Smyth & Schorr, 2009). They suggest that responsible but innovative ways (which they term “what it takes”) may ensure that these populations have greater access to clinical services. They offer suggestions regarding the kind of programmes and interventions that will maximize and support enduring and pertinent change (Smyth & Schorr, 2009) rather than merely supply academic and scientifically grounded data. The need to be innovative in resource poor settings is an on-going challenge to both clinician and researcher in South Africa and has been the focus of research and exploration by local and international clinicians, researchers and academics (C. Smith, Lobban, & O‟Loughlin, 2013; Smyth & Schorr, 2009).

3.2.2. Dual role

In the specific context in which I conducted my research, the ethical dilemma of “dual role” was central (S. Swartz, 2015). It also required that the conundrum associated with the process and the quandary in which I felt myself to be should be clearly acknowledged and made visible. I have written at some length in Chapter One about the difficulty in moving between the two roles. It might have been more methodologically efficient to have been able to concentrate on the research question exclusively, without consideration of clinical responsibilities. However, in the spirit of “best interests of the patient”, I felt justified in conducting my research under these particular circumstances and in this specific manner. I received supervision, both clinical and academic, in negotiating my way through the process. Research highlights the value of supervisory structure and support particularly where the roles of clinical work and research may overlap (Girot, 2010; McMaster, Jammali-Blasi,

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Andersson-Noorgard, Cooper, & McInnes, 2013; Woodward, Webb, & Prowse, 2007). I will consider this more fully in the subsequent section on ethics (3.5.).

I am not alone in attempting to negotiate this process (Coy, 2006; S. Swartz, 2015; Woodward, Webb, & Prowse, 2007). The challenges in sustaining the dual role, the personal and professional conflicts and the need to manoeuvre the on-going and iterative transition between research and clinical service provision, have been well described by Coy (2006). Although the specific contexts differ, Coy (2006) clearly articulates the ethical dilemmas inherent in maintaining a balance between providing a mental healthcare service at one end of the spectrum, while eliciting sound and valid information for research at the other. Not least of this is, as Coy (2006) describes, the need to negotiate between the nuances of clinical constraints regarding patient confidentiality while structuring the inclusion of pertinent and valuable research data which has been elicited from the same individual.

Privileged insider knowledge obtained through the clinical relationship may add to the depth and understanding of data. However, there is also a continual and on-going necessity to evaluate issues of confidentiality and possible conflicts of interest. This needs to be foregrounded as a meticulous methodological requirement of the researcher. In addition, there may also be the need for particular sensitivity in managing potential feelings of confusion, even suspicion, experienced by the patient- participant. Within the hospital situation this confusion may relate to the participants‟ particular perception and understanding of the dynamic between patient and medical profession enacted in this unique and complex dyadic relationship. As Coy (2006) describes, the process of finding resolution to these issues became an integral part of my research journey, both personally and professionally, and will be examined in the final chapter. There is some acknowledgement that researchers and clinicians have the potential to deliver valuable insights to each other in the service of strengthening both understanding and client or patient service (Silverstein & Auerbach, 2009; Silverstein et al., 2006). Silverstein et al. (2006) advocate the use of qualitative research as a potential and valuable mechanism in strengthening clinical practice. When the two coexist within a single process, that is, research and clinical work being rendered by one individual, this mutual contribution becomes exponentially more visible and more complex. Certainly in the process of my own research, the heightened awareness

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encouraged by the rigour of recorded and transcribed research interviews, provided me with valuable insights into my clinical functioning and expertise. Barrett (1988) describes with great clarity and insight the often unacknowledged interpretative transition which occurs during the transcribing of verbal clinical exchange into clinical notes. My own research process highlighted the way in which note taking and construction colours and transmutes the content of the clinical exchange. My experience was that in an almost symbiotic and iterative process my research refined and honed my clinical skills, and my clinical training possibly provided me with the expertise to conduct interviews more sensitively and effectively.