There were four main ethical issues considered when designing this study, as follows: the PG in particular could be seen as being a ‘captive audience’, recruiting a group for the purposes of comparison, informing both the PG and CG about each other, and the use of incentives. Each of these will be discussed in turn.
There was a danger that the nursing students from the PG in particular, might feel compelled to take part, because of my role as a lecturer. This convenience sample could be viewed as a ‘captive audience’ in that sense, although it would have been
109 of little value to focus on any other group (Parahoo, 2006). The CG were not necessarily ‘captive’ in the same way as the PG might have been; they did not know me, although my job role was made known. The information sheets (cf. appendices 14 and 15; pp. 256 - 263) were designed to reassure students about the voluntary nature of their participation. They further outlined how neither volunteering to be included or excluded would interfere with their progression on their respective programmes. The information sheets also reminded both groups of their right to withdraw from the study at any time, without having to give a reason. The time- series for the PG in particular might be expected to show higher attitude scores than the CG, if they participated out of desire to ‘please’. High attitude scores for both groups might be expected, if both felt compelled to take part, rather than volunteer. Finally, the information sheets briefed potential respondents about what would happen in terms of storing, analysing and then reporting the data collected.
The recruitment of subjects for the purposes of comparison may also raise ethical concerns. In this case, denying them the programme could be considered unethical, because the perceived benefits of the programme, if realised, are not immediately available to them; they may feel that their ‘rights to equal access’ have been restricted (Trochim, 2006). Goodwin offers advice in relation to treatment or programme evaluations:
The comparison is seldom between the new treatment or no treatment; it is usually between the new treatment and the most favored [sic.] current
treatment. So, for control group members, available services are not really being withheld; they are receiving the normal, well established services. (Goodwin, 2009, p. 270)
Because those in the CG would be in exactly the same position as they would if they had not taken part, a nursing student on a validated pre-registration programme,
110 With regard to informing both the PG and CG about one another, the Research Ethics Committee at the University where the CG were studying were specifically asked for advice in relation to this point. Because of the threat of compensatory rivalry in particular to LMCV, this was an important feature of the study design (Trochim, 2006). They offered that the two groups did not need to be made aware of each other. As both groups were given the option to be sent a summary of the findings from this study, they did suggest giving consideration to questions from CG participants in the future, if and when they become aware that their scores were compared with those of another group who had had access to an educational programme that they had not.
With respect to the use of incentives, there is little consensus about their appropriateness within research studies. The main concern appears to be that this may encourage those who may be vulnerable to agree to participate, when it might not be in their best interests (Wright, et al., 2004). As suggested, this study was viewed to be low-risk for potential participants, and it was necessary to try to keep those who had consented ‘on board’. ӧith that in mind, three incentives (book tokens) were offered to both the PG and CG, in the form of prize draws at the start, middle and end of the study. Two participants were lost from the CG due to attrition, and one because their first mailing of the questionnaire at data point three was returned unopened. Eight were lost from the PG; one due to academic failure and seven due to an inability to attend the programme on both days. Other than that, the two groups remained intact. The use of incentives, then, may have justified the reason for their use.
Brief mention must be given to the type of incentive offered in this study. The offer of book tokens may not appeal to all, and hence, skew the samples. Only those who consider themselves to be academic and conscientious may have consented to take
111 part. This must be considered in the analyses, however, the percentages of those consenting to be included, 73% and 85% for the PG and CG respectively, suggest that it is unlikely that the groups are made up of only those who are the most academic.
By following a process of informed consent, and through reassurances about the voluntary nature of participation, the ethical concerns related to the points above were hopefully minimised; this study was viewed to be low in risk to potential participants. All nursing students in the samples were also informed that the repeated measures of attitude would allow a picture to be obtained of the attitudes of the PG, as a whole; individual confidentiality could then be maintained.
3:8:1 Access to the research environments and participants
The programme was delivered in the CLE, for pragmatic reasons. There was no time or free space within the curriculum being studied by the PG to include something new whilst the students were in University. The practical solution to this was to deliver it whilst the students were on placement. This was advantageous in that nursing students are known to value the teaching that occurs in clinical practice, as it is easier to contextualise what they are learning (Skaalvik, et al, 2012). Access to clinical teachers is also deemed to be of value to students; which gave further direction to my role as a ‘link lecturer’6 within placements where older people are cared for (Newton, et al., 2012). Katz (1960, p. 187) also discusses the ‘conditions for arousal’ of an attitude serving a particular function, which is similar to the critical realist conception of context, and its role in whether or not programme mechanisms are activated. From this point of view, the CLE may provide ideal conditions for the
6
The link lecturer role was established within higher education, to provide support for both staff and students during clinical placement provision and experience.
112 arousal of attitudes serving each of Katz’ (1960) functions, because over two-thirds of hospital beds are occupied by ill older people (DH, 2001).
Having decided that the CLE was possibly the only, and yet perhaps the ideal context for delivery of the educational programme, the next consideration was of access to this environment. The placement environment for the PG was a local NHS Trust, hence permission to deliver the educational programme in that environment was secured from the LREC (appendix 11; pp. 251 - 253), and the Research and Development Unit of the local Trust (appendix 12; p. 254). This approval also covered access to the students that would comprise the PG. Gaining ethics approval at this level is a requirement, if an NHS site will be accessed as part of research. It is a lengthy, but worthwhile process, in that it prompts the applicant to consider the appropriateness of their research approach. The Research Governance Committee at the University where the PG were studying advised that LREC approval would be sufficient, in terms of being able to access potential respondents, in order to avoid what it called ‘having to please too many masters’.
Approval to approach and recruit a group for the purposes of comparison was granted from the Research Ethics Committee of a similar University, which provided a pre-registration nurse education programme (appendix 13; p. 255). Initial meetings with both groups of students were arranged, to fit around their programmes. The study was explained in detail, alongside what it would mean for individuals, if they agreed to participate. Time was allotted at the end of these meetings, for potential participants to ask questions.
Two information sheets were developed, for potential participants to keep and refer to; one for the potential PG participants (appendix 14; pp. 256 - 259), and one for potential CG participants (appendix 15; 260 - 263). The content of each is different
113 in that the information sheet designed for the CG does not mention the PG, or the educational programme that the PG would attend. This was in order to avoid any bias upon the attitude scores of individuals in the CG, caused by intergroup, compensatory rivalry or demoralisation (Cook and Campbell, 1979; Trochim, 2006).
After the ‘question and answer’ session, the students in each respective group were asked whether or not they were willing to participate in the study. Those who agreed to participate were asked to sign a consent form (appendix 16; p. 264). The consent form also asked the respondent to indicate whether they would like to be informed of the results of the research upon its completion.