Of Newcomers and Supervisors: Ethical Issues in Supervising Newcomers in Qualitative Health Research

Abstract

This contribution focuses on our experiences as lecturers and supervisors in qualitative healthcare research in medicine, public health research and sociology, and the role of research ethics in guiding students in their qualitative studies. We argue that students themselves are vulnerable during the transition of becoming a qualitative researcher and that reflection on research is essential. Therefore, the selection of a topic, potential role conflicts and questions of field contingencies management become crucial elements in both teaching and researching. We use qualitative case vignettes, as suggested by Langer, to offer a reflective account of our experience. Protecting students from harm and preventing them from inadvertently causing harm to others are of utmost importance to us. Through these vignettes, we aim to provide a nuanced and reflective view of our experiences in supervising qualitative research.

Introduction

The significance of ethics and the notion of vulnerability are becoming increasingly critical in medical practice and healthcare research (e.g. Boldt, 2019; Mergen & Akpinar, 2021; Straehle, 2017). This can be observed through the development of ethical standards for medical procedures and new technologies (e.g. the introduction of standards for procedures such as deep brain stimulation), the institutionalization of ethics in medicine as a degree program (Schulz et al., 2020), and the growing importance of ethical case consultations and councils at university hospitals. The need for ethics proposals in research is becoming a standard requirement for publishing studies (European Commission, 2021). Due to the human rights violations perpetrated in the history of medical research (World Medical Association, 2013), the focus of ethical concerns in research is generally on the protection of research participants (Von Unger, 2016; von Unger et al., 2016). However, researchers are also vulnerable in their work and may experience emotional, physical and psychological consequences from their research (Langer, 2009). Researchers have been more frequently understood as vulnerable in the recent past (Moncur, 2013; Von Unger, 2016).

Learning and respecting one’s own boundaries is a crucial aspect of becoming a researcher. However, this important aspect is often overlooked in teaching and learning qualitative methods in medicine or healthcare research in Germany. Ethical issues and obligations for researchers do not only arise during the research process but also in the supervision of student researchers. We have a responsibility as supervisors to transfer our knowledge and guide students in navigating ethical considerations and situations that they may encounter as researchers (Pfadenhauer et al., 2018). As von Unger and colleagues (2010) highlight:

We see the need to establish new thinking and learning spaces in universities and research institutions that reflect the complex ethical realities of ethnographic work – among other things, with regard to the close collaboration with the target groups of a piece of research or one’s own positionality in the research process – at all levels of study and scientific work. (Translated by the authors)

In this article, we reflect on our experiences as lecturers and supervisors in the realm of ethical issues and critical situations in the course of student researchers’ qualitative healthcare research projects in medicine, public health research and sociology. Students who are newcomers to the field of research are an especially vulnerable group because of their positionality (e.g. influenced by their age, limited knowledge and structural hierarchies). Moreover, the transition into research may also leave them with limited competence and experience in setting personal boundaries. Despite the vulnerability and impact on study participants, researchers and especially students are not often recognized as vulnerable or, simultaneously, as a potential source of harm for participants in studies. This highlights the need for ethical considerations in guiding students how to become a responsible qualitative researcher, not only towards others but also themselves. It requires a focus on their own situatedness and positionality.

We reflect here on our experiences supervising student researchers and the ethical issues that arise during their qualitative research projects. We use qualitative reflexive case vignettes following Langer, which are not only an illustration of our reflections but “a distinct method of interpretative inquiry through writing” (2016, p. 735) (Section 2). In the next section, we describe significant ethical situations we have encountered in our teaching careers and explore the primary challenges we have faced when instructing students in qualitative methods. Our discussion covers a range of topics, including the choice of research subject, potential role conflicts and our responsibility to protect students from harm during their research projects (Section 3). Furthermore, we emphasize the importance of focusing on ethical issues in the supervision of students in medicine and other healthcare-related disciplines doing qualitative health research, and the need for attention, space and time to foster this. Reflecting on the researcher’s own situated positionality in research and responsible supervision is essential for mentoring research projects, as researchers themselves can potentially be vulnerable in their work (Section 4). This article serves as a starting point for future discussions and highlights the need for the recognition that researchers are also subjects who can be harmed by research.

Methodology

We are two sociologists connected to the medical field, who first met during the international spring school focusing on Research Ethics in Qualitative Health Research hosted by Ruhr University Bochum, Germany, in 2022. During the spring school, we encountered the question of how to handle ethically sensitive situations when teaching and supervising students conducting their first research projects. We noticed common ethical challenges in our respective roles as lecturers of qualitative methods in healthcare research, medicine, and sociology in Germany, and sought to reflect on these experiences. Accordingly, we utilized reflexivity as a tool, which we understand as “as an awareness of context and self in the process of knowledge construction”, as described by von Unger and coauthors (2022). We use qualitative case vignettes as a methodological access, regarding them as “reflexive accounts” (Langer, 2013, p. 114 f.; 2009) of our own experiences with ethically delicate moments while supervising student researchers in healthcare research, medicine, and sociology. The qualitative case vignettes exceed the level of illustration purposes by also being a method of interpretative inquiry through the process of writing, in order to tie the reflections to concrete personal experiences (Langer, 2016). This use of vignettes deviates from the typical understanding in medicine, where they are often used as data collection instruments (e.g. Baker & Wigram, 2004; Chan, 2014).

Our use of qualitative case vignettes as a form of experimental writing offers the readers the opportunity to form their own interpretations and reflections and engage in the discussion (Langer, 2013). When writing the vignettes, we captured a description of situations, our feelings and thoughts, and, moreover, a reflection on the ethical issues related to them. We invite people to form their own perspective by sharing these personal experiences and autobiographical reflections with them (Langer, 2013; Ploder, 2011; Ploder & Stadlbauer, 2013; 2016). The vignettes are written in the first-person form, but we have chosen not to personalize them because we see no benefit in doing so. Part of the writing process includes generative questions used in grounded theory methodology at the end of each vignette to explore our own challenges in guiding students to become qualitative researchers.

Reflections on the Role of Ethics in Teaching in the Medical and Qualitative Healthcare Field

Students are testing their own limits, experiencing possibilities and taking on new roles when they become researchers (Wolverton, 2017). Boundaries and possibilities are constantly evolving, and the balance between appropriate proximity and distance is permanently being renegotiated in each situation. It is important to learn to adapt and navigate students effectively as we navigate new roles and situations, especially when the latter are encountered for research purposes. As lecturers and supervisors, we face the challenge of fostering the development, creativity and curiosity of our students, while providing ethical support for their learning journey. In our experience, ethical questions about the vulnerability of prospective researchers often arise in our training and teaching. As educators, we play a crucial role in shaping our students’ future as researchers and bear a responsibility for their journey. Our position, lectures and personal experiences have a significant impact on our students, and we are, therefore, closely intertwined with their growth and development.

Selection of a Topic

The social science program in which I am teaching offers a broad freedom in the choice of students’ research topics. Students can explore their interests and specialize in areas of their liking. My role as a lecturer in qualitative healthcare research and in sociology means that I guide students to select topics that it are not overly broad, align with the seminar and possess a stronger social science focus. I learned that there is more to teaching than just imparting my own experiences and knowledge. Instead, the selection of a research topic is intertwined with ethical considerations that are not always recognized in this context. Hence, it is important to examine the topic selection and handling process more closely, as it has significant implications for all those involved.

The selection of a topic is already an important negotiation that not only defines the scope of the research and prepares students for conducting their work, but also establishes important boundaries of what is feasible and possible. We are researchers with our own positionality and play a role in defining these boundaries through negotiation. The latter involves determining the subject and the methods of access, both sources that may be potentially harmful. Selecting a research topic often brings me discomfort, as I strive to support students and their ideas while intervening as little as possible in their choice. However, this is not always an easy task, particularly when a topic appears to be potentially traumatizing, overwhelming, hazardous or infeasible. There have been instances that have lingered with me as a teacher, which I reflect upon in the following.

When a student expresses their desire to write a term paper based on the old letters and documents of their recently deceased father I am find myself in a dilemma. How do I approach this request? Is this appropriate in the context of a seminar paper? Should I allow the student to proceed with such a sensitive topic, and what are the potential risks and benefits for the student? The topic contains a form of coping work that may both facilitate and hinder the student’s grieving process and may block their study of the person. In discussion with the student, it becomes clear that the project is a way for them to process their loss and explore their research interest at the same time

As a lecturer, I find myself in a state of uncertainty about whether I can and should judge the suitability of the topic. I do not wish to dismiss the student’s openness and honesty, recognizing that the request is an act containing vulnerability. The question arises whether the topic may cause harm to the student, if it facilitates their grieving process and whether it is acceptable as a byproduct of a term. Working on such a sensitive topic may trigger retraumatization, blockades, mourning, shame and other negative emotions.

Nevertheless, it cannot be said per se that the research topics itself is not legitimate or unworthy of exploration. Take, for example, the poignant book “Mourning Diary” by Barthes ([1977]2009), in which he reflects on the loss of his mother through writing. It illustrates that it is possible for research to assist in coping with one’s own emotions and gain insights into otherwise unstudied cultural and subjective aspects of grieving and loss. Carrie Friese’s work (forthcoming) on grieving for the loss of her father is also an example of the productivity and relevance of using one’s own personal experience as a source of knowledge.

During another consultation hour, I am confronted with the challenge of addressing a student’s interest in exploring the issue of sexualized violence on Facebook. The student proposes research that involved sexualizing and exposing themselves to potential perpetrators. While I understand the student’s political interest, I also feel a strong responsibility to protect her from potential harm. I engage in a conversation with her about the topic to understand her motivations better and explore alternative approaches to conducting research on this sensitive topic. I am a female researcher, thus, my intervention is driven by both a desire to protect the student and my own positionality including fears and emotions. This supervision experience also made me reflect on my own biases and which topics I may find more challenging to address than others. This situation highlights the impact of my own experiences and positionality on setting boundaries in research. It is important for me as a supervisor and guide for students to recognize that my personal background (i.e. my experience as a relatively young woman and other elements) can influence the topics I find challenging and the boundaries I set.

I must reflect on the delicate nature of certain topics, whether it is because they are inherently problematic or due to my own biases and perceptions. This self-awareness allows me to be more sensitive when guiding students. It is not always easy to identity our own vulnerability or find a suitable and ethical topic to explore in the process of conducting research. It is crucial to create a space for reflexivity of self-awareness in research to help to identify any potential harm or ethical concerns. Rather than prohibiting or blocking certain topics outright, this space should provide an opportunity for open dialogue and discussion. This type of reflexive approach should be institutionalized in the supervision process to ensure that ethical considerations are taken into account at every stage of the research.

When it comes to certain topics, one’s personal experience can play a crucial role in utilizing an experience-based approach and giving voice to a marginalized group (e.g. Islam, 2000; Twine & Warren, 2000). Research can be used to process one’s own experiences, leading to empowerment for both the individual and the group represented. Participatory research and autobiographical methods, inter alia, have been used for this purpose in recent years (Brehm, 2021; Lovatt, 2021; Ploder & Stadlbauer, 2016; von Unger et al., 2022). Our situatedness provides an access to the world how we perceive and analyze it (Haraway, 1988). Emotions are particularly significant for research. This is highlighted by authors such as Devereux (1967), who argue that emotions, such as anxiety, can enrich research processes and provide valuable insights into social science, rather than standardized methods:

In short, behavioral science data arouse anxieties, which are warded off by a countertransference inspired pseudo-methodology; this maneuver is responsible for nearly all the defects of behavioral science. […] The behavioral scientist cannot ignore the interaction between subject and observer in the hope that, if he but pretends long enough that it does not exist, it will just quietly go away. (1967, p. XVII f.)

However, tackling certain subjects as researchers can also pose personal risks, such as retraumatization, blockades and other hazards. In other words, our own defense mechanisms and the repression of certain experiences serve to protect us. However, when we confront these emotions through research or put ourselves in situations that endanger us, we risk being pulled into a dangerous downward spiral. Turning the considerations towards me as a lecturer: finding a suitable topic that balances both a student’s creativity and workload is challenging for me as a teacher. It requires me to consider the consequences and weigh my own teaching philosophy: Do I want to be the ‘cool or flexible teacher’ or a stricter and protective teacher? The choice of topic is, therefore, not just about the content but also about the negotiation of relationships I want to build with my students. These relational aspects are important and have a lot to do with my own personal values and background.

I reflect on the feasibility of various research topics in the light of my experience. Are there topics that are too sensitive or inappropriate to explore? How does the student’s own situatedness and personal experience influence their topic selection? What is my role as a supervisor and what responsibilities do I have in guiding students through research processes? These questions are complex, and I do not have any definite answers. The situatedness of these questions, my own resources as a supervisor to advise students, my professional considerations and the level of trust I have established with my students are certainly crucial elements.

Role Conflicts

Research ethics issues in the field of medicine might be even more present than in other disciplines. This is historically driven, and the research participants are potentially burdened by investigative topics connected to onerous aspects, such as chronic disease or death (Visser, 2017). Medical students often do not have any training in qualitative research methods and particularly not in research ethics within the scope of their education. When sending them out to do research in order to develop their medical doctorate, they run the risk of ethical challenges. When teaching, I am concerned with making students aware of their role as researchers, which is different from that of a medical doctor. Working as a qualitative researcher at a medical faculty, training and supervising medical students working on their theses, are parts of my responsibility. This vignette describes my experience with a medical student who was supporting our research team in order to write his doctoral thesis.

Supervisors of doctoral students want to ensure that the data collection process is as ethical and respectful as possible for the chronically ill patients participating in the study. Most of these patients are already struggling with complex symptoms of their advanced, incurable diseases, and I do not want to add any further burden to their lives. Participants are involved in the overall study in which the interviews serve as complementary data. Consequently, it is crucial to me to avoid any additional burden for the few patients who were able to join our study and shape their participation to be as pleasant as possible. I planned a period of training of the doctoral student in doing field work to prepare him for conducting standardized interviews with chronically ill patients in their home environment. After having introductory discussions about research ethics, I invited him to observe me when conducting interviews and then accompanied his first interview. In doing so, I wanted to convey my own approach to conducting these interviews and emphasize the importance of avoiding hierarchical control and treating the interview partners with respect. This included following simple rules of etiquette, such as removing our shoes before entering the patients’ home. We researchers are invited as guests into their home to listen to what they have to say, which requires a certain degree of respect.

When we visited our first interview partner together, the student entered the flat without taking off his shoes. Despite my attempts to remind him, he did not seem to understand the importance of this simple gesture. During the interview, I also noticed that he was not fully engaged and displayed a rough attitude towards the patient being interviewed, which made me feel uncomfortable. I felt that I had not effectively communicated the importance of the student’s behavior and presence during the interview and was frustrated by the loss of control. When I brought up my concerns about the situation in the debriefing, the student reacted with incomprehension. I felt helpless because my strategy of preparing the student to do his fieldwork had not been fruitful and I asked myself whether I had failed as a supervisor.

It is important for me as a supervisor in medical qualitative research to ensure that my students understand the delicate nature of conducting research in potentially vulnerable situations. In this case, I felt a sense of responsibility for the behavior of the student during the interview with a chronically ill patient. Doing qualitative research requires me to reflect on the roles occupied and our own impact on the situation. Participants who are potentially vulnerable invite us to listen and share their stories. Hereby, we see the need to respect participants’ boundaries and rules. Therefore, it is important for me that students develop a sensitivity for research and critically reflect on their role as researchers and their own actions. While this type of reflection may differ from traditional medical training, it is essential for conducting ethical qualitative research. When students start on the work for their medical doctorate, most of them lack experience or training in the qualitative research involved in medical subjects. Von Unger and coauthors even see special hurdles for the students, based on the different philosophical foundations:

The institutional context of medical education in Germany tends to be characterized by a strong orientation towards the positivist research paradigm of the natural sciences. Against this backdrop, teaching qualitative research methods and introducing a social constructivist research paradigm from the social sciences constitutes a major challenge. (2010)

According to von Unger et al., self-reflection and awareness of one’s role are not usually taught in medical education, but they become crucial in qualitative research in health-related fields. The shift from being a practitioner-to-be to a qualitative researcher requires a navigation of different power dynamics and hierarchies, which can be challenging. A particular challenge may be the basic epistemological stance of the two roles of a practitioner-to-be (as the medical students are taught to be) and a qualitative researcher (Eakin & Mykhalovskiy, 2005). For these reasons, if qualitative research is used by medical students, proper training must be provided, with a focus on reflecting on the roles occupied and avoiding harm to participants. The time frame of supervision must be appropriate to address the specific challenges that arise.

Reflecting on my experiences as a supervisor of medical students engaged in qualitative health research, I question what is required to foster self-reflection and awareness of one’s role in conducting and teaching qualitative research. How can I cultivate an awareness of a critical situation that may put both my students and the participants at risk? Is there a discrepancy between the role of a researcher and that of a doctor, and is there a special need for medical students conducting research to reflect on this? What space is needed to discuss the challenges faced in research situations with students?

Contingencies of the Research Field

My experience in supervising qualifying work taught me that preventing harm is crucial to both students and research participants when conducting research. The last vignette highlights the contingencies of the research field as an important element in a research project.

One master student in health research completed an internship and was working on his thesis as part of a research project at a department of the medical faculty. As part of the study, the student was invited by a medical team ¹ to observe the clinical care routine in a home care setting. During one visit, two emergencies took place simultaneously, and the doctor, accompanied by the student, drove to the home of one of the patients. On the way there, the doctor informed the master student that a medical procedure ¹ would probably be necessary and he asked the student to assist because his colleague had to leave to deal with another patient. This sudden involvement in the field placed a great deal of pressure on the student, who was worried about losing consciousness while assisting in the procedure. What would happen if he made a mistake while assisting the doctor, as he did not have any medical education? During the debriefing after the experience, I spoke with the student about his experiences and emotions. The situation of assisting in a medical procedure without prior training weighed heavily on him and made me reflect on my responsibility as a supervisor. I could not help but question my actions in exposing him to a field work situation with these challenging experiences and asked myself how best to deal with this situation afterwards and in the future. It is important to me as a teacher and mentor to consider my obligations when guiding and supporting my students, and this situation has further emphasized the need to always be mindful of these responsibilities.

It is not always possible as supervisors to shield our students from harm. Research can often be unpredictable, with unexpected events, interactions and situations arising. Despite our best efforts, it is possible that our students may still find themselves in delicate situations. The risk of harm can present itself at any time, which creates ethical challenges for us as supervisors and prompts us to constantly question how we can best fulfill our role. It is important to us to understand the complex and crucial ethical principle of avoiding harm, not only regarding research participants but also the researchers themselves (Von Unger, 2016). While the focus here is on students, we should not disregard the pressures and challenges faced by more experienced researchers (Von Unger, 2016). The pressures on people in academia or guidance on how to deal with specific challenges have been publicly negotiated more often lately (Clark & Sousa, 2018; Guthrie et al., 2018). There is currently a lack of support and resources for dealing with these challenges, and it is often left up to the individual researcher to handle them. Our responsibility as supervisors to protect students from harm during their first research experiences is even more crucial and requires careful consideration of what experiences are appropriate for them in the research field.

Vulnerability can arise at any stage of the research process, whether it is due to contingencies or planned events, and it is a critical aspect that needs to be considered in research. Debriefing after burdensome experiences, as described by Von Unger (2018), can provide a space to reflect on and process these experiences. However, the extent to which a researcher can be exposed to these challenges depends on various factors, including the method, topic and setting of the research (“ethical environment”; Guillemin & Gillam, 2004). As such, these ethical considerations need to be addressed on an institutional level.

Exposure to the research field in qualitative research has the potential to present the researcher with challenging situations (e.g. Fichtner & Trần, 2018). While these experiences may be a part of conducting research and a potential access to the field, the question of how to expose students to these experiences and what level of responsibility the supervisor bears remains an important one. How (and) can I protect students from vulnerable situations? How can I support students after facing harmful contingencies?

Reflexivity as a Tool When Doing Research

The three vignettes presented showcase our personal experiences in teaching qualitative methodology. Our situated perspectives, shaped by factors such as age, gender, socioeconomic and academic background, and self-perception as supervisors, play a crucial role in these experiences. We are able to navigate situations that have tested, intrigued and presented us with challenges in teaching through situated and strong reflexivity. Strong self-reflexivity should be viewed as an epistemic tool in research that views “research as an inevitably situated social practice” and considers reality as situated:

Epistemically strong reflexivity, however, appreciates the perspective of the researcher and her relationship to the field as a decisive source of data and interpretation. Sympathies, prejudices, fears, emotional, mental, and physical reactions of the researcher are not conceived of as inescapable problems, but as a highly valuable epistemic resource. (Kuehner et al., 2016, p. 699, p. 699)

The “fleeting moments” (Inowlocki, 2016, p. 52) that deviate from our expectations and perceptions of ‘good teaching’ serve as valuable data in guiding both research and teaching. These experiences, which may initially appear disruptive, should not be seen as weaknesses but rather as intrinsic components of research, following i.e., the pragmatist John Dewey. Our own subjectivity serves as a resource in research and teaching and for the further development of ethical considerations. By embracing a strong reflexivity and acknowledging the situated nature of our experiences, we can engage in an ongoing process of interpretation and reflection that informs ethical considerations. Through this process, we open up space for discussion and invite readers to share their own experiences and perspectives. The process of interpretation is not solely limited to writing, but is an ongoing conversation carried forward by the readers (Langer, 2013).

Conclusion: Ethics and Reflexivity in the Supervision of Students Doing Qualitative Health Research

In this paper, we deal with delicate situations in research and supervising students which are not likely to be addressed in research ethics committees. Our approach can be captured under the term “ethics in practice” and describes ethical issues of doing research (Guillemin & Gillam, 2004). These ethical challenges show up in multifaceted ways in our teaching experiences: in the search for a topic, role conflicts and contingencies in being in unsettled research fields. Our own positionality and feelings which have arisen in the process of supervising served us as an access to these ethically demanding situations. Reflexivity was a tool to understand and clarify the cause of our discomfort. We have shown that teaching and researching create a certain amount of vulnerability – speaking in ethical terms, they cause delicate situations. Therefore, we see the need for accompanying newcomers more intensively and recognize them (as well as ourselves) as a vulnerable group as well as reflect our role and identity as supervisors.

Research is a field full of contingencies and unpredictability, which is why teaching itself can be challenging. We understand our task as supervisors to guide students on their way to becoming researchers, give them a space for reflecting on their experiences, make them aware of their own vulnerability as well as the vulnerability of others, and prevent harm to all involved. Reflexivity can be used as an epistemic tool for embracing research in social reality, forming and shaping practice, and recognizing our own situatedness as an entangled part of it. But how can this be realized? Seminar concepts have emerged on ethical considerations in the last two decades (Eakin & Mykhalovskiy, 2005; Lorenz et al., 2007; Pfadenhauer et al., 2018; von Unger et al., 2010). Despite this, these topics are not yet a regular part of student training or within the role of supervising students in their first field experiences. There is an urgent need to improve ethical education in Germany, not only in medicine but also in the social sciences, in order to help students, understand their own limitations and reflect on their identity and boundaries as new researchers. The mutual negotiation and reflection of roles in supervision are also an important part of this.

Practitioners-to-be with these well-developed skills can also benefit patients, research participants and even the researchers themselves (von Unger et al., 2010). Therefore, we argue that it is necessary to enhance the supervision and ethical guidance for students experiencing ethical concerns during their first field contacts in order to avoid burdens for both the participants and the students. To achieve this goal, we need to establish ethics-based and reflexivity-focused teaching programs or initiatives. These could take the form of regular reflection sessions for supervisors at the end of each semester, and other formats that offer process-oriented supervision for students and teachers. Additionally, promoting ethical supervision and guidance should also be a priority for informed and responsible research, in order to safeguard the reputation of the scientific community and the future of qualitative methods. Ultimately, it concerns the essential aspects of qualitative research in teaching, which involve assuming the roles of newcomers and a supervisor.