ORIGENES DE LA CRISIS EN EL GOLFO PERSICO

In qualitative research, both the researcher and the subjects being studied are interconnected in the social process of research (Kvale and Brinkmann, 2015). The researcher could be a veritable tool for generating new insights into the phenomenon being studied. However, even though the researcher is the instrument of data collection in qualitative research (Parahoo, 2014), it is pertinent that whatever influence the researcher has on the data generation and analysis process is made explicit to ensure the trustworthiness of the research findings (Baillie, 2015; Morse, 2015). Therefore, my role as the researcher and whatever influence I may have had on this research project is discussed here.

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Reflexivity involves self-awareness (Lambert, Jomee and McSherry, 2010) and that means the researcher being actively involved in the research process. It is the recognition as researchers that we are a part of the social world we seek to study (Ackerly and True, 2010; Morse, 2015). The process of reflexivity requires that a researcher should be critically aware of the ways his or her personal values, assumptions and prejudices may have affected the methodological design, conduct, analysis of the data and the conclusions drawn in the research project (Patton, 2014). Reflexivity was used in this research to enhance the quality of the findings in terms of its credibility, dependability and transferability (Lincoln and Guba, 1985).

Reflexivity involves a continuous process of my reflecting on my values as a researcher and recognising, examining and understanding how my assumptions, social background and locations affected the entire research processes (Hesser-Biber, 2012). Patton (2014) states that the process of reflexivity can be enhanced by using multiple researchers in discussing the beliefs, assumptions, values, and perspectives of the researchers during the research process. Although there have not been multiple researchers involved in the full conduct of this research project, I regularly engaged with my research supervision team, fellow doctoral researchers and other experienced researchers who have carried out and published extensive qualitative research studies to openly share my research work with them and to seek their views, comments and opinions regarding any aspect of the research work including my role, views and values as it relates to the research project. Koch and Harrington (1998, pg. 888) refer to this process as “critical gaze turned towards the self”, examining my personal position, self and identity within the research process. To ensure a transparent audit trail of all the decisions I made throughout the research project, I kept a reflexive journal throughout the three phases of the data collection and this was used as part of the data corpus during the data analysis phase. The reflexive journal contains information such as the field notes I took during the research, any participants` comments or observations of interest to the research project, private participant`s comments, thoughts, questions or concerns which they did not express during the interview processes; my thoughts about the patients` responses and observations were documented in the journal and rationales for taking any action were also recorded.

My roles in this research process included: researcher, nurse lecturer and a nurse as I had cared for two of the participants in my previous role as nurse in the similar clinical context must be acknowledged in this research. In this context I was aware of my “insider/outsider”

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role as a researcher on one hand and a former healthcare practitioner who had cared for some of the participants on the other. My influence on every aspect of the research process are discussed in the appropriate sections throughout the thesis.

I qualified as a Registered General Nurse (RGN) in 2010 having completed a five-year degree nursing programme in Ebonyi State University, Abakaliki, Nigeria. I worked initially in the adult surgical and medical wards, but I spent most of my clinical practice hours in the dialysis unit in two different hospitals in the Eastern and the Western part of Nigeria. Since 2012, I have maintained my skills in clinical nursing practice, but I have worked mainly as a nurse lecturer teaching and supporting undergraduate nursing students while I also practised part-time in a private hospital. The motivation to embark on this study arose from my professional experience as a nurse in the renal unit. I observed Nigerian HD patients suffering from CKD unable to access regular treatment, many patients dropping out and/or not attending treatment at all. In some cases, when these patients are given the information that they are suffering from CKD at the renal clinic, they are hardly seen to come back to the hospital for any follow up care and there is no mechanism for tracking any diagnosed patient to know what treatment options they are embarking on. Some of the patients when referred for RRT didn’t turn up for any session because they were aware that they could not afford the treatment costs long term, others attended once or twice a month depending upon their financial circumstances and other needs. Medical professionals, doctors and nurses felt helpless, I felt helpless but began to accept there was nothing I could do to rectify the situation. The whole health system was inequitable, this we knew in Nigeria, but I had not experienced it as starkly as inequitable treatment of CKD patients from lower socioeconomic backgrounds. There is no CKD register unlike the UK and no one follows people diagnosed with CKD, monitors their treatment choices and how their treatment progresses; those referred for HD treatment if they don’t attend appear to be forgotten. As I started my PhD I knew from the outset that I wanted to explore the plight of Nigerian people with CKD referred for HD, to find out what it means for them to live with their condition and receive dialysis services in a healthcare system with unequal access to healthcare. This is necessary to bring the plights of the renal patients to the attention of policy makers and to seek ways of improving access to dialysis care in the country.

Researcher motivation is crucial in carrying out a successful research project (Alvesson and Stoldberg, 2018). Although I was a relatively inexperienced researcher at the commencement of this study, I have been highly motivated to undertake this research and I

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brought certain knowledge and skills acquired during my professional life which has continued to strengthen me. I view myself this research as a “conveyor” of the voices or messages of the frail participants in this research who by their social and economic backgrounds ordinarily may not be heard. I do recognise that undertaking this research is an arduous project especially using a qualitative longitudinal research approach which would mean that I will spend a considerable period on the field collecting the relevant data. However, I am a very resilient person and my ability to manage large tasks without giving up will be a great asset during the research, to stay through and collect all the necessary data including the interviews, observations, and collecting useful information from the participants` hospital files to enhance the credibility and the transferability of the research findings.

Having conducted a primary research in the past, I had some knowledge and skills of conducting a research, but I was careful and deliberately conscious not to allow my previous knowledge or values interfere with or influence my decisions in the entire research process in a negative manner. Therefore, before the commencement of the data collection phase, I carefully considered my opinions regarding the plights of the patients and what my thoughts were regarding their experience of their condition and recorded this in my reflexive journal for reflection throughout the period of the data collection and analysis. I was also aware of the possibility of my tilting the direction of the interview towards my personal interests. To avoid this, I had to stick to the question items written in the interview guide while I am asking only probing questions following each of the questions to obtain rich and in-depth account of the phenomenon being studied.

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4.9.5

Summary

This research adopted a QLR approach, in capturing the experiences of a cohort of CKD (stage-5) patients over time (seven months) to better understand the obstacles and challenges they face when accessing HD treatment. The QLR approach was chosen in this study based on the belief that the experiences of the individual dialysis patient being studied is unique and these experiences constantly change over time. The choice of QLR approach was inspired by not only the desire to explore any possible changes but also to understand why and how the changes occurred within the social and cultural context. A total of 17 participants (5 females/12 males) were recruited for the study. To capture a wide range of lived experiences, the sample was drawn from across different age groups (over 18 years), cultures and economic status as appropriate, although it was just not possible to recruit an equal number of male and female participants.

The primary data collected was through semi-structured interviews while the secondary data included blood chemistry results of the participants within the period of the study. The data was collected in three phases over a period of seven months. The interview transcripts were analysed using framework analysis.

The findings chapters are split into with chapter five presenting the first two themes and chapter six presenting the next two themes of the study. Chapter five will present the analysis of the data generating relating to the two themes.

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