Keywords: Critical reflection, qualitative research, diary entries, professional distress

Introduction and context

Critical reflection is widely used in qualitative research (1). It helps us understand participants’ internal dialogues and analyse their thought processes. The use of oral or written reflections is a well-documented data collection method, particularly in educational research (2).

This case study presents the ethical distress of a public health researcher engaged in a study that sought to explore the preparedness of health professionals who had recently graduated from a particular branch of health services, to practise independently.

The case

The drastic commercialisation in this branch of medical education over the past three decades has resulted in a tremendous increase in the number of graduates and of private practices, and intensified competition in the private job market. This called for an enquiry into how prepared graduates were for these changes, and to provide quality care.

Recent graduates with independent practices were asked to record their daily clinical practice experiences for eight weeks in diary entries. They were asked to introspect on how their strengths and weaknesses as practitioners could have contributed to these experiences. They were also asked to identify those professional areas in which they considered themselves inadequately prepared for independent practice. Diary entries were to be reviewed at two weeks, with a second review along with face-to-face interviews at six weeks, and a third review at eight weeks. Apart from the time and effort that the participants had to invest, no other potential harm was anticipated from the study.

On preliminary review at two weeks, the researcher found that the diary entries were superficial, with hardly any reflection. She then impressed upon the participants the need for honest introspection and detailed recording.

After another four weeks, the researcher collected the diaries for analysis and found that the entries had become more detailed. In addition to reflections about daily clinical happenings, they included confessions of participants’ insecurities as professionals responsible for the lives of other human beings, particularly because of the quality of their training. Most practitioners who had graduated from private institutions confessed that they had little experience in handling routine clinical situations. The patient inflow in many private colleges did not allow for adequate training in clinical procedures. Poor training had contributed to low confidence and subsequently to fear of practice.

Some diary entries described how they felt “inadequate and incompetent” as healthcare practitioners. The tone and language reflected disillusionment and dejection. In addition to emotional accounts of “not belonging” to the profession, there were conclusions such as “Maybe I am not suited for this profession” and “Joining this course was a huge mistake in life.” The same emotional breakdowns, uncertainties and fears were expressed in face-to-face interviews.

  

My technical skills are poor. I didn’t seen many cases in my college, since there was poor patient inflow there. Now I   am paying money to the government to work here after graduation so I get to see more cases and improve my skills. I   am trying, but I am not confident. I don’t know if I am good enough. I mean, we are dealing with real human beings. I   don’t think I will survive in this field for long.

(Senior resident currently working in a public health facility.)

The researcher’s distress

In this study, reflection was used as a research method to explore participants’ thought processes regarding their current performance as clinicians. The researcher’s intention was to generate recommendations to improve the training and curriculum of this branch of medical education so that graduates would be better prepared to suit the demands of their profession. However, while making the diary entries, the participants developed certain views about their choices and training which they connected to their current performance. The reflections also indicated that the participants considered their training to be compromised in many areas. None of this had been anticipated by the researcher.

The researcher was distressed by some participants’ self-descriptions as “a failure”, “incompetent”, with “no future in the field”. She was concerned that this would result in lasting damage to their lives and careers.

Some participants expressed their intention to leave the field in which they had trained, and pursue other interests. However, many had taken loans for this expensive training; they also had to face the expectations of their families and society. Hence at this stage in their lives, leaving their current profession and pursuing other options could have terrible personal consequences.

The researcher was also concerned about the possibility that if the graduates had not engaged in this exercise, they would have come to terms with their inadequacies over time, worked on them and emerged successful.

With two weeks left of the exercise, the researcher wondered if she should dissuade at least those participants who had responded strongly in their entries from continuing the reflection process. It was possible that the more time spent reflecting, the more convinced they would become of their own inadequacies.

Questions raised by the case

1. Can this be considered a case of research-induced harm?
2. Could the researcher have taken steps before and during the research to prevent the harm or reduce it?
3. What can the researcher do at this point to address the participants’ feelings?