Otros edificios judíos: Orfelinatos, escuelas y locales comerciales

In preparing to observe participants in their natural setting, Zaman outlines two things that the researcher must do: gain access to the setting and take on a role within that setting (Zaman, 2008). Here I will address the former and in the section titled

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described in the literature for a researcher seeking to access healthcare settings: physician resistance due to dislike of regulation and fear of criticism, and the

bureaucracy of healthcare organisations which can make access difficult (Zaman, 2008). Hammersley and Atkinson describe gaining access as a practical matter but also as an ongoing process which requires the use of intra- and inter-personal skills and strategies in order to navigate potential obstacles (Hammersley and Atkinson, 2007). In

preparation for data collection, I made formal contact with the ward staff in January 2014 and first emailed all of the consultants on wards A and B. I then met individually with all but one of the consultants to explain the research. The consultants provided the names and contact details of the senior nurses on the wards, whom I emailed and met with individually. All of the senior staff members were positive about the research and gave permission for the project to go ahead on wards A and B.

Following approval by the NHS Research Ethics Committee (Reference 14/NE/0104) and from the Research and Development department at the NHS Trust, I contacted the senior medical and nursing staff on wards A and B to inform them of these permissions and arrange to meet the wider staff team. Correspondence with senior ward staff prior to commencing data collection was entirely positive and encouraging. During my

observation on the wards I found the same attitude amongst ward staff as I had from the senior staff. They were interested to hear about the research, and happy for me to observe their practice. However, though gaining access was relatively straightforward, I found the description given by Hammersley and Atkinson of gaining access as a process to be correct (Hammersley and Atkinson, 2007). While the ‘gatekeepers’ of the ward (consultants and senior nurses) gave permission, I felt it was important to work continually to build rapport and respect with each staff member in order to ensure ongoing permission for observation.

I had never worked as a doctor in this hospital, however, the staff asked me about my background and knew that I was a palliative medicine registrar. I wondered if my status as a doctor, rather than simply a researcher, caused them to see me as an ‘insider’

(Brewer, 2000). I initially felt very out of place as a researcher, but I found that the staff members quickly began to treat me as one of the team. Though some acknowledged that it was a bit ‘weird’ to have me observe them initially, none of them objected and some told me that they were always happy for me to observe and I need not ask their

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permission. I was made welcome in all aspects of ward life, both formal and informal, and was even invited to nights out with the staff team. Brewer describes the importance of maintaining the balance between the dual roles of ‘insider’ and ‘outsider’ when

working as an ethnographer in order to avoid either ‘going native’ or appearing cold and aloof (Brewer, 2000, p. 60). While it was nice to feel so welcomed, I remained aware that I was not a ‘regular’ member of the team. This was sometimes an uncomfortable position especially when work as a researcher felt lonely and I missed the

companionship of a clinical team. However, it made me conscious of the need to reflect on my impact on the environment around me and how I ought to behave as a researcher. I hoped that if staff viewed me as part of the team they would conduct their work in their usual manner, almost forgetting that I was observing them. And I think this was often the case, as on many occasions I observed staff members making comments about the patients, their own practice, and general ward life, which were neither politically correct nor polite and that I would not have expected them to say in front of a

researcher.

Gaining permission to conduct research with deteriorating and dying patients involved careful thought and negotiation. Research in end-of-life care has been discussed in the literature with concerns raised about the risk of overburdening patients and their family members at a very vulnerable time (Agarwal, 2003; Casarett, 2005; Duke and Bennett, 2010; Blair, 2012). However, it has also been argued that to exclude the views of dying patients and their relatives stops important views from being heard (Henry. B. and Scales, 2012). Furthermore, in a critical interpretive synthesis of the literature Gysels et al. found that the majority of patients were willing to take part in research. In fact some found the process empowering and described it as therapeutic and something that gave them comfort (Gysels et al., 2012). They conclude that the concern that all patients at end-of-life are too vulnerable to participate in research is unjustified and paternalistic. Instead, they call for carefully planned research conducted with due care and attention to the needs of this specific group of participants (Gysels et al., 2012).

The NHS research ethics committee and the research and development department at the Trust, granted me permission to conduct the research study as planned in the study protocol and in line with foreseen events. However, in spite of thorough planning there will always be unforeseen events with which the researcher will have to grapple during

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time in ‘the field’. Seymour et al. outline some of the many unexpected ethical dilemmas that researchers may face while conducting research in palliative care (Seymour et al., 2005b). For example, ethnography and participant observation present the researcher with particular ethical difficulties such as: defining the boundaries of data collection, managing different roles, knowing their varying responsibilities while in ‘the field’ (Seymour et al., 2005b). A researcher’s underlying theoretical assumptions will

naturally influence what they perceive to be an ethical issue and therefore ethical issues in qualitative research are closely tied to methodology (Seymour et al., 2005b).

Seymour et al. encourage all researchers to develop an ethical mind-set and to reflect on the ethical challenges faced throughout the research process (Seymour et al., 2005b). In the next section, I will outline how I conducted this research project and sought to apply an ethical mind-set in response to unanticipated challenges.