Gaining access

Obtaining access into the field can be seen as a process of negotiation (Hammersley and Atkinson, 2007: 41). This began several months before fieldwork ‘proper’ started and involved a series of meetings with key stakeholders. These included the hospice manager and medical director, ward manager, senior nurses, senior doctors and social workers. Access to meet these people was undoubtedly influenced by the role of my supervisor within the hospice and my own previous experience in working as a doctor in this setting. There was no concern about being able to meet with them, or even about carrying out the research. There were key areas to be negotiated however and these meetings were important in setting the groundwork of acceptance as a researcher into the unit. Issues pertaining to confidentiality and gaining consent from patients were the two areas which produced the most concern. Reassurance and tightening of the

processes of maintaining confidentiality (including combining groups with small numbers where professionals worked in isolation) eased many of these concerns. Having met these senior members of staff, I originally planned to hold a series of meetings to allow nurses and doctors working different shifts on different days to be introduced to the study. Following advice, however, from senior nurses, it was much less disruptive and proved easier to come in to the hospice regularly for several days to talk to nurses in a more informal manner. In this way I managed to speak to all nurses in an informal atmosphere. They were able to ask questions in a way, I realised with hindsight, they would not necessarily have done if part of a larger and more formalised meeting. I carried out the same process for registrars and junior doctors, often speaking to them individually in a more conversational manner. Specifically, I spoke to both doctors and nurses about approaching patients or their significant others on my behalf, before I could speak to them about participating. There were no objections to this and most seemed keen, having heard about the study for some time, for me to get on and begin the fieldwork. In addition I spoke to the other members of staff, such as social workers, physiotherapists and occupational therapists on a similarly informal basis. After each meeting I would give potential participants an information sheet and gain consent for observation from them at a later date. Over time I gained consent from all staff who regularly worked on the unit. An interim consent process was also in place for situations where new staff started, to enable me to observe meetings which they were part of, for a limited period prior to gaining full consent.

77 The above details the process of gaining access and negotiating consent from members of staff, but of course negotiating access is an ongoing process, not only involving consent to my being physically present, but also becoming involved in unit so as to be in a position to observe instances of sedation. This process took longer; while the information sheet detailed what would happen, what I would be observing and how, it became clear that acting this out was part of an ongoing negotiation. For instance, when I began my fieldwork I had consent for the observation from all current members of staff. I spent time in the nurses’ ‘team office’ and in the ‘MDT room’ where the doctors and allied healthcare professionals spent their time. Initially I was greeted a little

nervously, and with uncertainty it seemed. Conversations would be halted, or, if talking about sedation, staff would glance at me or smile nervously. Others asked if they could speak to me or not. I was definitely regarded as ‘different’, but not quite ‘an outsider’. This will be discussed in more depth later in this chapter. Negotiating access to patients through the first approach from staff, took some time. This was partly because of some issues of gate-keeping: patients were said to be ‘just settling in’, ‘too poorly’, or their significant others were ‘too upset’. I understood it would take time for staff to become used to my presence and to learn what my role was, before stepping out to ask patients something about which they were still uncertain themselves. Thus in the first few weeks of fieldwork I did not gain consent from many patients and focused on

establishing myself with the staff on the unit. I did feel some concern and tension about this and considered different strategies to improve this situation. The most successful of these was to enrol the assistance of the senior nurses, two of whom in particular, were extremely helpful in approaching patients and improving the rate of patient consents. They would speak to all of the patients or significant others on their ‘team’ who they considered would be ‘appropriate’ for the study. In general, they would approach all patients or significant others on the ward. From the start of the study it was important to involve members of staff in the consent process and rely on their judgement

regarding who it was appropriate or not to approach. Clearly this may have limited access to patients and highlights the issue of gate-keeping. Reasons given by these nurses for not speaking to patients or their significant others tended to be related to where a person was geographically (e.g. away for some form of treatment or scan) rather than subjective concerns about how a patient might react. Of course, there were patients who the nurses felt would be unable to take in information or whom it would be

78 inappropriate to speak to about the research. Reasons for this were often related to other issues going on for these patients such as recently receiving bad news or having difficult discussions about the future. Clearly the nature of the research topic may lead into discussion or trigger thoughts about future issues and what may happen: sensitivity to this was important. I believe, therefore, that this approach was justified in this group of patients not only because of their potential vulnerability but also because of the

sensitive nature of the topic under consideration. In addition, maintaining the trust and cooperation of staff in these early stages could have been undermined by challenging their opinions potentially restricting access further.