Nurse Researcher
Methodological and ethical issues related to qualitative telephone interviews on sensitive topics Cite this article as: Mealer M, Jones J (2014) Methodological and ethical issues related to qualitative telephone interviews on sensitive topics. Nurse Researcher. 21, 4, 32-37. Date of submission: February 26 2013. Date of acceptance: June 4 2013. Correspondence to Meredith Mealer [email protected]
Abstract
Meredith Mealer MSc, PhD is a research instructor at the University of Colorado Denver, United States
Aim To explore the methodological and ethical issues of conducting qualitative telephone interviews about personal or professional trauma with critical care nurses.
Jacqueline Jones RN, PhD is an associate professor at the University of Colorado Denver, United States Peer review This article has been subject to double-blind review and checked using antiplagiarism software. Author guidelines nr.rcnpublishing.co.uk
Background The most common method for conducting interviews is face-to-face. However, there is evidence to support telephone interviewing on a variety of sensitive topics including post-traumatic stress disorder (PTSD). Qualitative telephone interviews can limit emotional distress because of the comfort experienced through virtual communication. Critical care nurses are at increased risk of developing PTSD due to the cumulative exposure to work-related stress in the intensive care unit. We explored the methodological and ethical issues of conducting qualitative telephone interviews, drawing on our experiences communicating with a group of critical care nurses. Data sources Qualitative research interviews with 27 critical care nurses. Fourteen of the nurses met the diagnostic criteria for PTSD; 13 did not and had scores consistent with high levels of resilience.
Introduction ‘SENSITIVE’ RESEARCH topics include a variety of issues, such as those that may damage an individual’s financial standing, employability or reputation in a community, or that contain information about personal use of drugs and alcohol, information about illegal activity or sexual attitudes, and/or information that may lead to social stigmatisation or discrimination, such as research related to psychological wellbeing and mental health (Bankert and Amdur 2006). When sensitive topics are the focus of research, there should 32 March 2014 | Volume 21 | Number 4
Review methods This is a methodology paper on the authors’ experiences of interviewing critical care nurses on sensitive topics via the telephone. Discussion The authors found that establishing rapport and connections with the participants and the therapeutic use of non-verbal communication were essential, and fostered trust and compassion. The ethical issues of this mode of communication include protecting the privacy and confidentiality associated with the disclosure of sensitive information, and minimising the risk of psychological harm to the researcher and participants. Conclusion Qualitative telephone interviews are a valuable method of collecting information on sensitive topics. Implications for research/practice This paper explores a method of interviewing in the workplace. It will help inform interventions to promote healthy adaptation following trauma exposure in the intensive care unit. Keywords Critical care nursing, interpretive analysis, theory, resilience, telephone interviews be reasonable and appropriate safeguards to minimise the risk associated with invasion of privacy and breach of confidentiality. There is evidence in the literature about qualitative interviews being used to explore sensitive topics (Elmir et al 2011, Taylor et al 2011). Qualitative interviews of individuals diagnosed with posttraumatic stress disorder (PTSD) have been conducted with rape survivors (Campbell et al 2001, Koss et al 2003, Jenkins et al 2000), war veterans (Toomey et al 2007, Sayer et al 2009) and survivors of natural © RCN PUBLISHING / NURSE RESEARCHER
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Virtual communication disasters (Green et al 2006, Lowe et al 2011). The most common form of interviewing is the face-toface interview and there is little discussion about telephone interviewing and the methodological and ethical issues involved (Novick 2008). Qualitative telephone interviews can limit the emotional distress experienced by participants because of the comfort afforded by a virtual communication forum (Trier-Bieniek 2012) and we contend that they are an effective way to explore sensitive topics. Critical care nurses are at an increased risk of psychological distress due to the stressful work environment. Cumulative exposure to work-related stress in the intensive care unit (ICU), such as end of life issues, post-mortem care, performing cardiopulmonary resuscitation and prolonging life in terminally ill patients, has been associated with an increased prevalence of PTSD, anxiety, depression and burnout syndrome (Mealer et al 2007, Mealer et al 2009). PTSD is a psychiatric disorder that results from direct or indirect exposure to a traumatic event that is responded to with extreme fear, helplessness and horror (Yehuda 2002). To meet the diagnostic criteria for PTSD, an individual must have (Sheeran and Zimmerman 2002): ■■ Had exposure to a traumatic event, felt helpless or terrified during the event and have had at least one episode of a ‘re-experiencing’ symptom – for example, nightmares or reliving the traumatic event, ■■ Three ‘avoidance’ symptoms – trying to avoid activities or places that remind him or her of the traumatic event and not being able to remember important parts of the event, ■■ Two ‘arousal’ symptoms – being overly alert, jumpy or easily startled. The lifetime prevalence of PTSD in the general population is approximately 8-10% (Breslau et al 1997, Yehuda 2002, Baxter 2004), but it has been reported as being as high as 33% in critical care nurses (Mealer et al 2009). It is therefore important to understand the contextual perspectives of nurses traumatised by the work environment as well as of those who are able to adapt using positive coping skills, with the hope of developing strategies to improve nurses’ capacity to function in the ICU and improve their work environment through organisational changes. The purpose of this paper is to explore the methodological and ethical issues of conducting qualitative interviews over the telephone, drawing on our experience communicating with these critical care nurses (Mealer et al 2012b). Half the nurses in the study (n=14) met all the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for a diagnosis of PTSD and the other half (n=13) were © RCN PUBLISHING / NURSE RESEARCHER
highly resilient and did not have symptoms of PTSD. Telephone interviews were chosen for this cohort of critical care nurses because of convenience related to geographical considerations and the highly technical environment that these nurses had been accustomed to communicating in.
Methods Surveys were sent to a randomly selected mailing list of 3,500 registered critical care nurses in the United States who were members of the American Association of Critical-Care Nurses (AACN). The first section of the survey included the following demographic questions: marital status, age, race, ethnicity and highest nursing degree earned. The second part of the survey included questions related to the work environment, such as primary shift, nurse-patient ratio, type of ICU and years practising as a nurse. The survey also included well-validated PTSD and resilience measures. The Post-traumatic Diagnostic Scale (PDS) is a validated, self-report tool that yields a PTSD diagnosis according to DSM-IV criteria and a measure of the severity of PTSD symptoms. While the gold standard for diagnosing PTSD is the Clinician-administered PTSD Scale (CAPS), the PDS is highly correlated with the clinician-rated measures diagnosing PTSD (Foa et al 1997, Mueser 2001, Sheeran and Zimmerman 2002). It consists of a screener for criterion A – a checklist of 12 traumatic events (including an ‘other’ category) – and criteria B, C and D, which assess the 17 DSM-IV symptoms by using a four-point scale, with zero equivalent to ‘not at all’ or ‘only one time’ and three equivalent to ‘five or more times a week/almost always’. A positive diagnosis for PTSD is determined if the following criteria are present: having experienced a traumatic event and felt helpless or terrified during that event (criterion A), and at least one episode of a ‘re-experiencing’ symptom (criterion B), three ‘avoidance’ symptoms (criterion C) and two ‘arousal’ symptoms (criterion D). Symptom severity can be calculated by adding up the scores of the 17 items addressed in criteria B, C, and D (Mealer et al 2009). The PDS also has a section that asks how the problems rated in criteria B, C, and D have interfered with any of the following areas of life in the previous month: work, household chores and duties, relationships with friends, fun and leisure activities, schoolwork, relationships with family, sex life, general satisfaction with life, and overall level of functioning in all areas of life. The PDS is a well accepted and validated survey instrument for diagnosing individuals with PTSD (Foa et al 1997, March 2014 | Volume 21 | Number 4 33
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Nurse Researcher Mealer et al 2009), with high internal consistency reliability (Cronbach’s alpha range 0.78-0.92). In this study, nurses were asked to complete criterion A by focusing only on traumatic events that were experienced in the ICU environment, and to fill out criteria B, C, and D for only those. Test-retest reliability coefficients of the total PDS score in our study demonstrate satisfactory reliability: 0.83 for total symptom severity, 0.77 for re-experiencing, 0.81 for avoidance and 0.85 for arousal (Foa et al 1997, Mealer et al 2009). The Connor-Davidson Resilience Scale (CD-RISC) was used to assess resilience (Connor and Davidson 2003). The CD-RISC was developed as a short, self-report assessment to quantify resilience and as a clinical measure to assess treatment response. The CD-RISC is copyright-protected and permission was obtained before mailing out the surveys. It is a 25-item, self-report scale with total score ranges from zero to 100. Higher scores reflect greater resilience. Resilience is defined as a CD-RISC score of more than 80, with a median score of 82. Highly resilient is defined as one standard deviation greater than the mean, and therefore a score of 92 or greater is defined as a positive score for being highly resilient (Connor and Davidson 2003, Campbell-Sills et al 2009). The CD-RISC has been extensively used in community samples, primary care outpatients, general psychiatric outpatients, a clinical trial of generalised anxiety disorder and two clinical trials of PTSD. The CD-RISC maintains excellent reliability (Cronbach’s alpha of 0.89) and a test-retest reliability correlation of 0.87 (Connor and Davison 2003). For our analysis, the Cronbach’s alpha for CD-RISC was 0.92 (Mealer et al 2012a).
Qualitative research interviews Qualitative research interviews are differentiated from everyday conversations as social and emotional encounters by the relationship between the researcher and participant. We adopted a ‘social constructivist’ approach to understanding reality (Charmaz 2004, Mayan 2009). ‘Symbolic interactionism’ (Blumer 1969) helps us to understand how people act towards situations based on the meanings they give them. Such meanings are derived from social interactions with others and their context, modified by interpretation. The telephone provides a virtual space for communication in which we used inductive, interpretive techniques to generate research data with the participant through language and reflection (Prasad 2005). Rubin and Rubin (2012) called this ‘responsive interviewing’: healthcare workers and researchers accept the ‘complexity and ambiguity of real life’ 34 March 2014 | Volume 21 | Number 4
and engage the participants as partners rather than the subjects of our research.
Methodological issues The most important methodological issues associated with telephone interviewing are: establishing rapport and connections between the researcher and participant, and the therapeutic use of non-verbal communication. Establishing rapport It is paramount to establish a trusting relationship with research participants to overcome the barriers and fears that would prevent honest disclosure yet enhance the participants’ willingness and desire to share feelings related to sensitive issues (Elmir et al 2011, Tahan and Sminkey 2012). Through effective rapport, an individual may be more willing to exchange personal and sensitive information (Trier-Bieniek 2012). In our study, one author (MM) called each of the nurses who had expressed an interest in using in-depth interviews about traumatic exposures. This initial call was to introduce the researchers and to obtain verbal consent for the interview. Verbal consent was essentially a waiver of documented consent and had all the elements of informed consent, including: the purpose of the study, the time needed for the interview, the types of questions that would be asked, the voluntary nature of participation, potential risks and benefits, and contact information for questions and/or concerns about the study. The interviews were scheduled for a time that was convenient for the participants and they were asked to choose environments that would allow them to speak freely about their traumatic experiences. The interviews were semi-structured with a script of questions intended to explore the traumatic ICU experiences of each of the nurses, personal traumatic experiences that may have influenced further traumatisation at work and coping mechanisms used to ameliorate psychological distress caused by these experiences. Both authors conducted the first five interviews to enhance the credibility of the questioning framework (Thomas 2006). The script then underwent iterative changes based on common themes that developed over the course of the interviews that were relevant to a deeper understanding of the lived experiences of these nurses (Thorne 2008). All subsequent interviews were conducted by MM. During the second call, and before the semistructured interview, rapport was further established by asking innocuous questions related to where the participants lived, the types of hospital they worked in, the types of ICU that they worked in and the years © RCN PUBLISHING / NURSE RESEARCHER
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Virtual communication of experience they had in nursing. This was also a time for us to disclose as necessary, by sharing experiences of being ICU nurses and our research interests. This allowed us to connect by sharing our similar work backgrounds and to further support collegial rapport. The geographic distance also served to promote rapport and allow honest communication because the subjects did not work in the same institution as we did, thus eliminating the fear of breaches in confidentiality and privacy. Rapport was further supported by the use of nonverbal communication. Non-verbal communication The four types of non-verbal communication are: ■■ Proxemics. ■■ Kinesics. ■■ Chronemics. ■■ Paralinguistic. Proxemics is the way in which an individual communicates attitudes and trust by controlling his or her personal space (Adler and Towne 2003, Fontana and Frey 1994). Kinesics is the use of posture, gestures and facial expressions to communicate rapport and relationships among individuals. Chronemics relates to the use of time, such as the length of silence in conversations and the pacing of speech. Paralinguistic communication is the way our voice communicates through its tone, speed, pitch and volume, which also lends support to rapport during interviews as it can reinforce the message that the words convey (Adler and Towne 2003, Onwuegbuzie et al 2012). It is the first two types of conversation that are lost in telephone interviewing and it has been argued that this is a disadvantage (Novick 2008). However, our experience suggests that this loss may be an advantage when interviewing individuals exposed to trauma. The lack of visual cues allows emotional distance, which is perceived as removing judgment and provides the subjects with an environment to engage with their reality. There is a difference in power between researcher and participant that can be ameliorated through virtual space. While protecting emotional distance, the use of chronemics and paralinguistics can be a powerful tool for eliciting rich contextual information. At times, the intensity of an experience was echoed in the fast pace or sombre tone used by the participant in recounting it. Silence during a phone conversation is often awkward but in this study it allowed the participant the necessary time to complete a thought or to regain composure when describing a very emotional and traumatic memory. Since there were no visual cues to validate active listening, it was important to convey compassion and empathy by occasionally interjecting phrases such as © RCN PUBLISHING / NURSE RESEARCHER
‘Please continue’ and ‘Take all the time that you need’. We also found that it was well received, after listening to a nurse’s traumatic story, to acknowledge how difficult it must have been to share the information and how appreciative we were that the nurse was able to share this information with us. However, the researcher must take a more active and engaged stance towards the participant and not allow extraneous events to cause distractions. Some of the traumatic events that were shared in the interviews were uncomfortable to listen to and the lack of visual cues helped promote discussion, since the response to what was being said could not be seen. The participants benefited from the disclosure of their traumatic experiences and the intimacy achieved through rapport, which were further supported by the virtual space of the phone conversation and the opacity of interpreted meaning by the researchers. Vicarious traumatisation – being indirectly traumatised by listening to someone describe their own personal trauma – did occur at times, so both researchers needed debriefing with one another and others. It prompted deeper reflection on trauma and personal or professional experiences that we had encountered ourselves.
Ethical issues The main ethical considerations encountered in our experience with this group of traumatised nurses were protecting the privacy and confidentiality associated with the disclosure of sensitive information, and the efforts needed to prevent psychological harm to the researchers and participants. Research that involves sensitive topics, such as exposure to trauma, can provoke emotional responses and place participants at risk of discrimination, recrimination or other harm (Bankert and Amdur 2006). The process of obtaining informed consent does tell participants about these risks and the individual should therefore have control over what information is disclosed (Corbin and Morse 2003). However, once participants begin to express feelings and emotions, they may find this therapeutic and choose not to withdraw from the interview because they want to co-operate, be heard and be understood. Clinicians and researchers working with individuals who are traumatised or experience physical or psychological distress can develop the same psychological responses as the victims themselves (Argentero and Setti 2011). There are many reports of healthcare professionals with compassion fatigue (Meadors and Lamson 2008, Dominguez-Gomez and Rutledge 2009), secondary traumatic stress (Quinal et al 2009, Robins et al 2009, Von Rueden et al March 2014 | Volume 21 | Number 4 35
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Nurse Researcher 2010) and PTSD (Mealer et al 2007, Mealer et al 2009, Mealer et al 2012a). Developing a plan to protect researchers from this type of distress is therefore necessary before conducting in-depth interviews with a traumatised group. Self-reflection through writing journals and debriefing was one method used in our study. This involves making oneself aware of uncomfortable feelings and thoughts, critically analysing those thoughts, and developing a new perspective that allows cognitive, affective and behavioural changes (Freshwater et al 2008). Self-reflection helps to mitigate adverse psychological outcomes (Scott et al 2009) and participants were encouraged to use this strategy when discussing their traumatic events. Another ethical consideration is the protection of privacy and maintaining confidentiality related to the information shared during interviews. Privacy refers to ‘having control over the extent, timing, and circumstances of sharing oneself (physically, behaviourally, or intellectually) with others’ (Bankert and Amdur 2006). To ensure privacy, nurses were asked during the introductory telephone calls to
schedule their interviews for a time when they would not be disturbed, preferably when they were not working or caring for children at home, for instance. They were also asked to choose an environment in which they were comfortable talking about the traumatic experiences they have had in the ICU. For some, this was their home but others chose to sit in their cars before going to work or coming home from work. Since the interviews were conducted over the phone from a work office, MM ensured that participants’ privacy would be respected by keeping the door closed and hanging up a sign that she was not to be disturbed. Confidentiality of research interview information is concerned with the secure storage of research data on paper or electronically, so anonymising data and destroying them after the analysis is complete eliminates the potential for inadvertent disclosure (Bankert and Amdur 2006). For this study, the telephone interviews were recorded so that they could be transcribed at a later time. Notes regarding the conversations were taken at the time to serve as
References Adler R, Towne N (2005) Looking Out, Looking In. Thomson Wadsworth, Boston MA.
Journal of Interpersonal Violence. 16, 12, 1239-1259.
Argentero P, Setti I (2011) Engagement and vicarious traumatization in rescue workers. International Archives of Occupational and Environmental Health. 84, 1, 67-75.
Campbell-Sills L, Forde DR, Stein MB (2009) Demographic and childhood environmental predictors of resilience in a community sample. Journal of Psychiatric Research. 43, 12, 1007-1012.
Bankert EA, Amdur RJ (2006) Institutional Review Board: Management and Function. Jones and Bartlett, Boston MA. Baxter A (2004) Posttraumatic stress disorder and the intensive care unit patient: Implications for staff and advanced practice critical care nurses. Dimensions of Critical Care Nursing. 23, 4, 145-150. Blumer H (1969) Symbolic Interactionism: Perspective and Method. University of California Press, Berkeley CA. Breslau N, Davis GC, Peterson EL et al (1997) Psychiatric sequelae of posttraumatic stress disorder in women. Archives of General Psychiatry. 54, 1, 81-87. Campbell R, Wasco S, Ahrens C et al (2001) Preventing the ‘second rape’: rape survivors’ experiences with community service providers.
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Charmaz K (2004) Premises, principles and practices in qualitative research: revisiting the foundations. Qualitative Health Research. 14, 7, 976-993. Connor KM, Davidson JR (2003) Development of a new resilience scale: the Connor-Davidson resilience scale (CD-RISC). Depression and Anxiety. 18, 2, 76-82.
Elmir R, Schmied V, Jackson D et al (2011) Interviewing people about potentially sensitive topics. Nurse Researcher. 19, 1, 12-16. Foa E, Cashman L, Jaycox L et al (1997) The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale. Psychological Assessment. 9, 4, 445-451. Fontana A, Frey JH (1994) The art of science. In Denzin NK, Lincoln YS (Eds) The Handbook of Qualitative Research. Sage Publications, Thousand Oaks CA. Freshwater D, Taylor BJ, Sherwood G (2008) International Textbook of Reflective Practice in Nursing. John Wiley & Sons, New York NY.
Corbin J, Morse JM (2003) The unstructured interactive interview: issues of reciprocity and risks when dealing with sensitive topics. Qualitative Inquiry. 9, 3, 335-354.
Green J, Gill D, Kleiner A (2006) From vulnerability to resiliency: assessing impacts and responses to disaster. Southern Rural Sociology. 21, 2, 89-99.
Dominguez-Gomez E, Rutledge DN (2009) Prevalence of secondary traumatic stress among emergency nurses. Journal of Emergency Nursing. 35, 3, 199-204.
Jenkins MA, Langlais PJ, Delis DA et al (2000) Attentional dysfunction associated with posttraumatic stress disorder among rape survivors. The Clinical Neuropsychologist. 14, 1, 7-12.
Koss MP, Bailey J, Yuan N et al (2003) Depression and PTSD in survivors of male violence: research and training initiatives to facilitate recovery. Psychology of Women Quarterly. 27, 2, 130-142. Lowe SR, Chan CS, Rhodes JE (2011) The impact of child-related stressors on the psychological functioning of lower-income mothers after Hurricane Katrina. Journal of Family Issues. 32, 10, 1303-1324. Mayan J (2009) Essentials of Qualitative Inquiry. Left Coast Press, Walnut Creek CA. Meadors P, Lamson A (2008) Compassion fatigue and secondary traumatization: provider self care on intensive care units for children. Journal of Pediatric Health Care. 22, 1, 24-34. Mealer ML, Shelton A, Berg B et al (2007) Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. American Journal of Respiratory and Critical Care Medicine. 175, 7, 693-697. Mealer M, Burnham EL, Goode CJ et al (2009) The prevalence and impact of post traumatic
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Virtual communication a reminder of the nonverbal communication that was taking place. The participants were informed that the interviews were being recorded and, after the interviews were complete, they were given the opportunity to ask for all or a portion of the interview to be deleted. The interviews were later uploaded to a secure and encrypted repository for digital audio files so they could be transcribed by a medical transcriptionist hired for the study. The transcription was then uploaded to a secure, password-protected server for review and the audio file deleted. Any paper documents collected were stored in a locked file cabinet and only referred to the participant by study number.
Conclusion Based on the literature, and from our perspective of interviewing traumatised nurses, qualitative telephone interviews are a valuable way of collecting information on sensitive topics. Telephone interviews offer an avenue for rich, in-depth exploration of meaning in the context of vulnerability that should be considered a primary rather than additional approach for qualitative
study. Thoughtful consideration should be given to the ethical and methodological issues of exploring sensitive topics through this mode of communication. This would include the ability of the researcher to establish rapport in the hopes of enhancing authentic communication, as well as the therapeutic use of non-verbal communication to convey compassion and empathy during interviews. The ethical issues include the protection from psychological harm of participants and researchers, and protecting privacy and confidentiality. The use of critical reflection and rigour in generating qualitative data was emphasised. In addition to the value of telephone interviewing on sensitive topics, this research holds important implications for nursing practice by elucidating the specific mechanisms by which resilient ICU nurses are able to positively adapt to the stressful work environment and the triggering events that cause the most distress to those with a diagnosis of PTSD. These insights may allow for the development of interventions to improve the psychological health and satisfaction of ICU nurses, as well as organisational improvements to the work environment.
stress disorder and burnout syndrome in nurses. Journal of Depression and Anxiety. 26, 12, 1118-1126.
Prasad P (2005) Crafting Qualitative Research: Working in the Postpositivist Traditions. ME Sharpe, New York NY.
Mealer M, Jones J, Newman J et al (2012a) The presence of resilience is associated with a healthier psychological profile in intensive care unit (ICU) nurses: results of a national survey. International Journal of Nursing Studies. 49, 3, 292-299.
Quinal L, Harford S, Rutledge DN (2009) Secondary traumatic stress in oncology staff. Cancer Nursing. 32, 4, E1-E7.
Mealer M, Jones J, Moss M (2012b) A qualitative study of resilience and posttraumatic stress disorder in United States ICU nurses. Intensive Care Medicine. 38, 9, 1445-1451. Mueser KT, Salyers MP, Rosenberg SD et al (2001) Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness. Psychological Assessment. 13, 1, 110-117. Novick G (2008) Is there a bias against telephone interviews in qualitative research? Research in Nursing and Health. 31, 4, 391-398. Onwuegbuzie AJ, Leech NL, Slate JR et al (2012) An exemplar for teaching and learning qualitative research. The Qualitative Report. 17, 1, 16-77.
Robins PM, Meltzer L, Zelikovsky N (2009) The experience of secondary traumatic stress upon care providers working within a children’s hospital. Journal of Pediatric Nursing. 24, 4, 270-279. Rubin HJ, Rubin IS (2012) Qualitative Interviewing: The Art Of Hearing Data. Third edition. Sage Publications, Thousand Oaks CA. Salmons J (2009) Designing and Conducting Research with Online Interviews. Sage Publications, Thousand Oaks CA. Sayer NA, Friedemann-Sanchez G, Spoont M et al (2009) A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry. 72, 3, 238-255.
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Scott SD, Hirschinger LE, Cox KR et al (2009) The natural history of recovery for the healthcare provider ‘second victim’ after adverse patient events. Quality & Safety in Healthcare. 18, 5, 325-330. Sheeran T, Zimmerman M (2002) Screening for posttraumatic stress disorder in a general psychiatric outpatient setting. Journal of Consulting and Clinical Psychology. 70, 4, 961-966. Tahan HA, Sminkey P (2012) Motivational interviewing: building rapport with clients to encourage desirable behavioural and lifestyle changes. Professional Case Management. 17, 4, 164-172. Taylor AW, Martin G, Dal Grande E et al (2011) Methodological issues associated with collecting sensitive information over the telephone – experience from an Australian non-suicidal self-injury (NSSI) prevalence study. BMC Medical Research Methodology. 11, 20, 1-7.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
Thomas DR (2006) A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation. 27, 2, 237-246. Toomey R, Kang HK, Karlinsky J et al (2007) Mental health of US Gulf War veterans 10 years after the war. The British Journal of Psychiatry. 190, 385-393. Trier-Bieniek A (2012) Framing the telephone interview as a participant-centred tool for qualitative research: a methodological discussion. Qualitative Research. 12, 6, 630-644. Von Rueden K, Hinderer KA, McQuillan KA et al (2010) Secondary traumatic stress in trauma nurses: prevalence and exposure, coping, and personal/environmental characteristics. Journal of Trauma Nursing. 17, 4, 191-200. Yehuda R (2002) Post-traumatic stress disorder. New England Journal of Medicine. 346, 108-114.
Thorne S (2008) Interpretive Description. Left Coast Press, Walnut Creek CA.
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Methodological and ethical issues related to qualitative telephone interviews on sensitive topics Cite this article as: Mealer M, Jones J (2014) Methodological and ethical issues related to qualitative telephone interviews on sensitive topics. Nurse Researcher. 21, 4, 32-37. Date of submission: February 26 2013. Date of acceptance: June 4 2013. Correspondence to Meredith Mealer [email protected]
Abstract
Meredith Mealer MSc, PhD is a research instructor at the University of Colorado Denver, United States
Aim To explore the methodological and ethical issues of conducting qualitative telephone interviews about personal or professional trauma with critical care nurses.
Jacqueline Jones RN, PhD is an associate professor at the University of Colorado Denver, United States Peer review This article has been subject to double-blind review and checked using antiplagiarism software. Author guidelines nr.rcnpublishing.co.uk
Background The most common method for conducting interviews is face-to-face. However, there is evidence to support telephone interviewing on a variety of sensitive topics including post-traumatic stress disorder (PTSD). Qualitative telephone interviews can limit emotional distress because of the comfort experienced through virtual communication. Critical care nurses are at increased risk of developing PTSD due to the cumulative exposure to work-related stress in the intensive care unit. We explored the methodological and ethical issues of conducting qualitative telephone interviews, drawing on our experiences communicating with a group of critical care nurses. Data sources Qualitative research interviews with 27 critical care nurses. Fourteen of the nurses met the diagnostic criteria for PTSD; 13 did not and had scores consistent with high levels of resilience.
Introduction ‘SENSITIVE’ RESEARCH topics include a variety of issues, such as those that may damage an individual’s financial standing, employability or reputation in a community, or that contain information about personal use of drugs and alcohol, information about illegal activity or sexual attitudes, and/or information that may lead to social stigmatisation or discrimination, such as research related to psychological wellbeing and mental health (Bankert and Amdur 2006). When sensitive topics are the focus of research, there should 32 March 2014 | Volume 21 | Number 4
Review methods This is a methodology paper on the authors’ experiences of interviewing critical care nurses on sensitive topics via the telephone. Discussion The authors found that establishing rapport and connections with the participants and the therapeutic use of non-verbal communication were essential, and fostered trust and compassion. The ethical issues of this mode of communication include protecting the privacy and confidentiality associated with the disclosure of sensitive information, and minimising the risk of psychological harm to the researcher and participants. Conclusion Qualitative telephone interviews are a valuable method of collecting information on sensitive topics. Implications for research/practice This paper explores a method of interviewing in the workplace. It will help inform interventions to promote healthy adaptation following trauma exposure in the intensive care unit. Keywords Critical care nursing, interpretive analysis, theory, resilience, telephone interviews be reasonable and appropriate safeguards to minimise the risk associated with invasion of privacy and breach of confidentiality. There is evidence in the literature about qualitative interviews being used to explore sensitive topics (Elmir et al 2011, Taylor et al 2011). Qualitative interviews of individuals diagnosed with posttraumatic stress disorder (PTSD) have been conducted with rape survivors (Campbell et al 2001, Koss et al 2003, Jenkins et al 2000), war veterans (Toomey et al 2007, Sayer et al 2009) and survivors of natural © RCN PUBLISHING / NURSE RESEARCHER
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Virtual communication disasters (Green et al 2006, Lowe et al 2011). The most common form of interviewing is the face-toface interview and there is little discussion about telephone interviewing and the methodological and ethical issues involved (Novick 2008). Qualitative telephone interviews can limit the emotional distress experienced by participants because of the comfort afforded by a virtual communication forum (Trier-Bieniek 2012) and we contend that they are an effective way to explore sensitive topics. Critical care nurses are at an increased risk of psychological distress due to the stressful work environment. Cumulative exposure to work-related stress in the intensive care unit (ICU), such as end of life issues, post-mortem care, performing cardiopulmonary resuscitation and prolonging life in terminally ill patients, has been associated with an increased prevalence of PTSD, anxiety, depression and burnout syndrome (Mealer et al 2007, Mealer et al 2009). PTSD is a psychiatric disorder that results from direct or indirect exposure to a traumatic event that is responded to with extreme fear, helplessness and horror (Yehuda 2002). To meet the diagnostic criteria for PTSD, an individual must have (Sheeran and Zimmerman 2002): ■■ Had exposure to a traumatic event, felt helpless or terrified during the event and have had at least one episode of a ‘re-experiencing’ symptom – for example, nightmares or reliving the traumatic event, ■■ Three ‘avoidance’ symptoms – trying to avoid activities or places that remind him or her of the traumatic event and not being able to remember important parts of the event, ■■ Two ‘arousal’ symptoms – being overly alert, jumpy or easily startled. The lifetime prevalence of PTSD in the general population is approximately 8-10% (Breslau et al 1997, Yehuda 2002, Baxter 2004), but it has been reported as being as high as 33% in critical care nurses (Mealer et al 2009). It is therefore important to understand the contextual perspectives of nurses traumatised by the work environment as well as of those who are able to adapt using positive coping skills, with the hope of developing strategies to improve nurses’ capacity to function in the ICU and improve their work environment through organisational changes. The purpose of this paper is to explore the methodological and ethical issues of conducting qualitative interviews over the telephone, drawing on our experience communicating with these critical care nurses (Mealer et al 2012b). Half the nurses in the study (n=14) met all the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for a diagnosis of PTSD and the other half (n=13) were © RCN PUBLISHING / NURSE RESEARCHER
highly resilient and did not have symptoms of PTSD. Telephone interviews were chosen for this cohort of critical care nurses because of convenience related to geographical considerations and the highly technical environment that these nurses had been accustomed to communicating in.
Methods Surveys were sent to a randomly selected mailing list of 3,500 registered critical care nurses in the United States who were members of the American Association of Critical-Care Nurses (AACN). The first section of the survey included the following demographic questions: marital status, age, race, ethnicity and highest nursing degree earned. The second part of the survey included questions related to the work environment, such as primary shift, nurse-patient ratio, type of ICU and years practising as a nurse. The survey also included well-validated PTSD and resilience measures. The Post-traumatic Diagnostic Scale (PDS) is a validated, self-report tool that yields a PTSD diagnosis according to DSM-IV criteria and a measure of the severity of PTSD symptoms. While the gold standard for diagnosing PTSD is the Clinician-administered PTSD Scale (CAPS), the PDS is highly correlated with the clinician-rated measures diagnosing PTSD (Foa et al 1997, Mueser 2001, Sheeran and Zimmerman 2002). It consists of a screener for criterion A – a checklist of 12 traumatic events (including an ‘other’ category) – and criteria B, C and D, which assess the 17 DSM-IV symptoms by using a four-point scale, with zero equivalent to ‘not at all’ or ‘only one time’ and three equivalent to ‘five or more times a week/almost always’. A positive diagnosis for PTSD is determined if the following criteria are present: having experienced a traumatic event and felt helpless or terrified during that event (criterion A), and at least one episode of a ‘re-experiencing’ symptom (criterion B), three ‘avoidance’ symptoms (criterion C) and two ‘arousal’ symptoms (criterion D). Symptom severity can be calculated by adding up the scores of the 17 items addressed in criteria B, C, and D (Mealer et al 2009). The PDS also has a section that asks how the problems rated in criteria B, C, and D have interfered with any of the following areas of life in the previous month: work, household chores and duties, relationships with friends, fun and leisure activities, schoolwork, relationships with family, sex life, general satisfaction with life, and overall level of functioning in all areas of life. The PDS is a well accepted and validated survey instrument for diagnosing individuals with PTSD (Foa et al 1997, March 2014 | Volume 21 | Number 4 33
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Nurse Researcher Mealer et al 2009), with high internal consistency reliability (Cronbach’s alpha range 0.78-0.92). In this study, nurses were asked to complete criterion A by focusing only on traumatic events that were experienced in the ICU environment, and to fill out criteria B, C, and D for only those. Test-retest reliability coefficients of the total PDS score in our study demonstrate satisfactory reliability: 0.83 for total symptom severity, 0.77 for re-experiencing, 0.81 for avoidance and 0.85 for arousal (Foa et al 1997, Mealer et al 2009). The Connor-Davidson Resilience Scale (CD-RISC) was used to assess resilience (Connor and Davidson 2003). The CD-RISC was developed as a short, self-report assessment to quantify resilience and as a clinical measure to assess treatment response. The CD-RISC is copyright-protected and permission was obtained before mailing out the surveys. It is a 25-item, self-report scale with total score ranges from zero to 100. Higher scores reflect greater resilience. Resilience is defined as a CD-RISC score of more than 80, with a median score of 82. Highly resilient is defined as one standard deviation greater than the mean, and therefore a score of 92 or greater is defined as a positive score for being highly resilient (Connor and Davidson 2003, Campbell-Sills et al 2009). The CD-RISC has been extensively used in community samples, primary care outpatients, general psychiatric outpatients, a clinical trial of generalised anxiety disorder and two clinical trials of PTSD. The CD-RISC maintains excellent reliability (Cronbach’s alpha of 0.89) and a test-retest reliability correlation of 0.87 (Connor and Davison 2003). For our analysis, the Cronbach’s alpha for CD-RISC was 0.92 (Mealer et al 2012a).
Qualitative research interviews Qualitative research interviews are differentiated from everyday conversations as social and emotional encounters by the relationship between the researcher and participant. We adopted a ‘social constructivist’ approach to understanding reality (Charmaz 2004, Mayan 2009). ‘Symbolic interactionism’ (Blumer 1969) helps us to understand how people act towards situations based on the meanings they give them. Such meanings are derived from social interactions with others and their context, modified by interpretation. The telephone provides a virtual space for communication in which we used inductive, interpretive techniques to generate research data with the participant through language and reflection (Prasad 2005). Rubin and Rubin (2012) called this ‘responsive interviewing’: healthcare workers and researchers accept the ‘complexity and ambiguity of real life’ 34 March 2014 | Volume 21 | Number 4
and engage the participants as partners rather than the subjects of our research.
Methodological issues The most important methodological issues associated with telephone interviewing are: establishing rapport and connections between the researcher and participant, and the therapeutic use of non-verbal communication. Establishing rapport It is paramount to establish a trusting relationship with research participants to overcome the barriers and fears that would prevent honest disclosure yet enhance the participants’ willingness and desire to share feelings related to sensitive issues (Elmir et al 2011, Tahan and Sminkey 2012). Through effective rapport, an individual may be more willing to exchange personal and sensitive information (Trier-Bieniek 2012). In our study, one author (MM) called each of the nurses who had expressed an interest in using in-depth interviews about traumatic exposures. This initial call was to introduce the researchers and to obtain verbal consent for the interview. Verbal consent was essentially a waiver of documented consent and had all the elements of informed consent, including: the purpose of the study, the time needed for the interview, the types of questions that would be asked, the voluntary nature of participation, potential risks and benefits, and contact information for questions and/or concerns about the study. The interviews were scheduled for a time that was convenient for the participants and they were asked to choose environments that would allow them to speak freely about their traumatic experiences. The interviews were semi-structured with a script of questions intended to explore the traumatic ICU experiences of each of the nurses, personal traumatic experiences that may have influenced further traumatisation at work and coping mechanisms used to ameliorate psychological distress caused by these experiences. Both authors conducted the first five interviews to enhance the credibility of the questioning framework (Thomas 2006). The script then underwent iterative changes based on common themes that developed over the course of the interviews that were relevant to a deeper understanding of the lived experiences of these nurses (Thorne 2008). All subsequent interviews were conducted by MM. During the second call, and before the semistructured interview, rapport was further established by asking innocuous questions related to where the participants lived, the types of hospital they worked in, the types of ICU that they worked in and the years © RCN PUBLISHING / NURSE RESEARCHER
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Virtual communication of experience they had in nursing. This was also a time for us to disclose as necessary, by sharing experiences of being ICU nurses and our research interests. This allowed us to connect by sharing our similar work backgrounds and to further support collegial rapport. The geographic distance also served to promote rapport and allow honest communication because the subjects did not work in the same institution as we did, thus eliminating the fear of breaches in confidentiality and privacy. Rapport was further supported by the use of nonverbal communication. Non-verbal communication The four types of non-verbal communication are: ■■ Proxemics. ■■ Kinesics. ■■ Chronemics. ■■ Paralinguistic. Proxemics is the way in which an individual communicates attitudes and trust by controlling his or her personal space (Adler and Towne 2003, Fontana and Frey 1994). Kinesics is the use of posture, gestures and facial expressions to communicate rapport and relationships among individuals. Chronemics relates to the use of time, such as the length of silence in conversations and the pacing of speech. Paralinguistic communication is the way our voice communicates through its tone, speed, pitch and volume, which also lends support to rapport during interviews as it can reinforce the message that the words convey (Adler and Towne 2003, Onwuegbuzie et al 2012). It is the first two types of conversation that are lost in telephone interviewing and it has been argued that this is a disadvantage (Novick 2008). However, our experience suggests that this loss may be an advantage when interviewing individuals exposed to trauma. The lack of visual cues allows emotional distance, which is perceived as removing judgment and provides the subjects with an environment to engage with their reality. There is a difference in power between researcher and participant that can be ameliorated through virtual space. While protecting emotional distance, the use of chronemics and paralinguistics can be a powerful tool for eliciting rich contextual information. At times, the intensity of an experience was echoed in the fast pace or sombre tone used by the participant in recounting it. Silence during a phone conversation is often awkward but in this study it allowed the participant the necessary time to complete a thought or to regain composure when describing a very emotional and traumatic memory. Since there were no visual cues to validate active listening, it was important to convey compassion and empathy by occasionally interjecting phrases such as © RCN PUBLISHING / NURSE RESEARCHER
‘Please continue’ and ‘Take all the time that you need’. We also found that it was well received, after listening to a nurse’s traumatic story, to acknowledge how difficult it must have been to share the information and how appreciative we were that the nurse was able to share this information with us. However, the researcher must take a more active and engaged stance towards the participant and not allow extraneous events to cause distractions. Some of the traumatic events that were shared in the interviews were uncomfortable to listen to and the lack of visual cues helped promote discussion, since the response to what was being said could not be seen. The participants benefited from the disclosure of their traumatic experiences and the intimacy achieved through rapport, which were further supported by the virtual space of the phone conversation and the opacity of interpreted meaning by the researchers. Vicarious traumatisation – being indirectly traumatised by listening to someone describe their own personal trauma – did occur at times, so both researchers needed debriefing with one another and others. It prompted deeper reflection on trauma and personal or professional experiences that we had encountered ourselves.
Ethical issues The main ethical considerations encountered in our experience with this group of traumatised nurses were protecting the privacy and confidentiality associated with the disclosure of sensitive information, and the efforts needed to prevent psychological harm to the researchers and participants. Research that involves sensitive topics, such as exposure to trauma, can provoke emotional responses and place participants at risk of discrimination, recrimination or other harm (Bankert and Amdur 2006). The process of obtaining informed consent does tell participants about these risks and the individual should therefore have control over what information is disclosed (Corbin and Morse 2003). However, once participants begin to express feelings and emotions, they may find this therapeutic and choose not to withdraw from the interview because they want to co-operate, be heard and be understood. Clinicians and researchers working with individuals who are traumatised or experience physical or psychological distress can develop the same psychological responses as the victims themselves (Argentero and Setti 2011). There are many reports of healthcare professionals with compassion fatigue (Meadors and Lamson 2008, Dominguez-Gomez and Rutledge 2009), secondary traumatic stress (Quinal et al 2009, Robins et al 2009, Von Rueden et al March 2014 | Volume 21 | Number 4 35
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Nurse Researcher 2010) and PTSD (Mealer et al 2007, Mealer et al 2009, Mealer et al 2012a). Developing a plan to protect researchers from this type of distress is therefore necessary before conducting in-depth interviews with a traumatised group. Self-reflection through writing journals and debriefing was one method used in our study. This involves making oneself aware of uncomfortable feelings and thoughts, critically analysing those thoughts, and developing a new perspective that allows cognitive, affective and behavioural changes (Freshwater et al 2008). Self-reflection helps to mitigate adverse psychological outcomes (Scott et al 2009) and participants were encouraged to use this strategy when discussing their traumatic events. Another ethical consideration is the protection of privacy and maintaining confidentiality related to the information shared during interviews. Privacy refers to ‘having control over the extent, timing, and circumstances of sharing oneself (physically, behaviourally, or intellectually) with others’ (Bankert and Amdur 2006). To ensure privacy, nurses were asked during the introductory telephone calls to
schedule their interviews for a time when they would not be disturbed, preferably when they were not working or caring for children at home, for instance. They were also asked to choose an environment in which they were comfortable talking about the traumatic experiences they have had in the ICU. For some, this was their home but others chose to sit in their cars before going to work or coming home from work. Since the interviews were conducted over the phone from a work office, MM ensured that participants’ privacy would be respected by keeping the door closed and hanging up a sign that she was not to be disturbed. Confidentiality of research interview information is concerned with the secure storage of research data on paper or electronically, so anonymising data and destroying them after the analysis is complete eliminates the potential for inadvertent disclosure (Bankert and Amdur 2006). For this study, the telephone interviews were recorded so that they could be transcribed at a later time. Notes regarding the conversations were taken at the time to serve as
References Adler R, Towne N (2005) Looking Out, Looking In. Thomson Wadsworth, Boston MA.
Journal of Interpersonal Violence. 16, 12, 1239-1259.
Argentero P, Setti I (2011) Engagement and vicarious traumatization in rescue workers. International Archives of Occupational and Environmental Health. 84, 1, 67-75.
Campbell-Sills L, Forde DR, Stein MB (2009) Demographic and childhood environmental predictors of resilience in a community sample. Journal of Psychiatric Research. 43, 12, 1007-1012.
Bankert EA, Amdur RJ (2006) Institutional Review Board: Management and Function. Jones and Bartlett, Boston MA. Baxter A (2004) Posttraumatic stress disorder and the intensive care unit patient: Implications for staff and advanced practice critical care nurses. Dimensions of Critical Care Nursing. 23, 4, 145-150. Blumer H (1969) Symbolic Interactionism: Perspective and Method. University of California Press, Berkeley CA. Breslau N, Davis GC, Peterson EL et al (1997) Psychiatric sequelae of posttraumatic stress disorder in women. Archives of General Psychiatry. 54, 1, 81-87. Campbell R, Wasco S, Ahrens C et al (2001) Preventing the ‘second rape’: rape survivors’ experiences with community service providers.
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Charmaz K (2004) Premises, principles and practices in qualitative research: revisiting the foundations. Qualitative Health Research. 14, 7, 976-993. Connor KM, Davidson JR (2003) Development of a new resilience scale: the Connor-Davidson resilience scale (CD-RISC). Depression and Anxiety. 18, 2, 76-82.
Elmir R, Schmied V, Jackson D et al (2011) Interviewing people about potentially sensitive topics. Nurse Researcher. 19, 1, 12-16. Foa E, Cashman L, Jaycox L et al (1997) The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale. Psychological Assessment. 9, 4, 445-451. Fontana A, Frey JH (1994) The art of science. In Denzin NK, Lincoln YS (Eds) The Handbook of Qualitative Research. Sage Publications, Thousand Oaks CA. Freshwater D, Taylor BJ, Sherwood G (2008) International Textbook of Reflective Practice in Nursing. John Wiley & Sons, New York NY.
Corbin J, Morse JM (2003) The unstructured interactive interview: issues of reciprocity and risks when dealing with sensitive topics. Qualitative Inquiry. 9, 3, 335-354.
Green J, Gill D, Kleiner A (2006) From vulnerability to resiliency: assessing impacts and responses to disaster. Southern Rural Sociology. 21, 2, 89-99.
Dominguez-Gomez E, Rutledge DN (2009) Prevalence of secondary traumatic stress among emergency nurses. Journal of Emergency Nursing. 35, 3, 199-204.
Jenkins MA, Langlais PJ, Delis DA et al (2000) Attentional dysfunction associated with posttraumatic stress disorder among rape survivors. The Clinical Neuropsychologist. 14, 1, 7-12.
Koss MP, Bailey J, Yuan N et al (2003) Depression and PTSD in survivors of male violence: research and training initiatives to facilitate recovery. Psychology of Women Quarterly. 27, 2, 130-142. Lowe SR, Chan CS, Rhodes JE (2011) The impact of child-related stressors on the psychological functioning of lower-income mothers after Hurricane Katrina. Journal of Family Issues. 32, 10, 1303-1324. Mayan J (2009) Essentials of Qualitative Inquiry. Left Coast Press, Walnut Creek CA. Meadors P, Lamson A (2008) Compassion fatigue and secondary traumatization: provider self care on intensive care units for children. Journal of Pediatric Health Care. 22, 1, 24-34. Mealer ML, Shelton A, Berg B et al (2007) Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. American Journal of Respiratory and Critical Care Medicine. 175, 7, 693-697. Mealer M, Burnham EL, Goode CJ et al (2009) The prevalence and impact of post traumatic
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Virtual communication a reminder of the nonverbal communication that was taking place. The participants were informed that the interviews were being recorded and, after the interviews were complete, they were given the opportunity to ask for all or a portion of the interview to be deleted. The interviews were later uploaded to a secure and encrypted repository for digital audio files so they could be transcribed by a medical transcriptionist hired for the study. The transcription was then uploaded to a secure, password-protected server for review and the audio file deleted. Any paper documents collected were stored in a locked file cabinet and only referred to the participant by study number.
Conclusion Based on the literature, and from our perspective of interviewing traumatised nurses, qualitative telephone interviews are a valuable way of collecting information on sensitive topics. Telephone interviews offer an avenue for rich, in-depth exploration of meaning in the context of vulnerability that should be considered a primary rather than additional approach for qualitative
study. Thoughtful consideration should be given to the ethical and methodological issues of exploring sensitive topics through this mode of communication. This would include the ability of the researcher to establish rapport in the hopes of enhancing authentic communication, as well as the therapeutic use of non-verbal communication to convey compassion and empathy during interviews. The ethical issues include the protection from psychological harm of participants and researchers, and protecting privacy and confidentiality. The use of critical reflection and rigour in generating qualitative data was emphasised. In addition to the value of telephone interviewing on sensitive topics, this research holds important implications for nursing practice by elucidating the specific mechanisms by which resilient ICU nurses are able to positively adapt to the stressful work environment and the triggering events that cause the most distress to those with a diagnosis of PTSD. These insights may allow for the development of interventions to improve the psychological health and satisfaction of ICU nurses, as well as organisational improvements to the work environment.
stress disorder and burnout syndrome in nurses. Journal of Depression and Anxiety. 26, 12, 1118-1126.
Prasad P (2005) Crafting Qualitative Research: Working in the Postpositivist Traditions. ME Sharpe, New York NY.
Mealer M, Jones J, Newman J et al (2012a) The presence of resilience is associated with a healthier psychological profile in intensive care unit (ICU) nurses: results of a national survey. International Journal of Nursing Studies. 49, 3, 292-299.
Quinal L, Harford S, Rutledge DN (2009) Secondary traumatic stress in oncology staff. Cancer Nursing. 32, 4, E1-E7.
Mealer M, Jones J, Moss M (2012b) A qualitative study of resilience and posttraumatic stress disorder in United States ICU nurses. Intensive Care Medicine. 38, 9, 1445-1451. Mueser KT, Salyers MP, Rosenberg SD et al (2001) Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness. Psychological Assessment. 13, 1, 110-117. Novick G (2008) Is there a bias against telephone interviews in qualitative research? Research in Nursing and Health. 31, 4, 391-398. Onwuegbuzie AJ, Leech NL, Slate JR et al (2012) An exemplar for teaching and learning qualitative research. The Qualitative Report. 17, 1, 16-77.
Robins PM, Meltzer L, Zelikovsky N (2009) The experience of secondary traumatic stress upon care providers working within a children’s hospital. Journal of Pediatric Nursing. 24, 4, 270-279. Rubin HJ, Rubin IS (2012) Qualitative Interviewing: The Art Of Hearing Data. Third edition. Sage Publications, Thousand Oaks CA. Salmons J (2009) Designing and Conducting Research with Online Interviews. Sage Publications, Thousand Oaks CA. Sayer NA, Friedemann-Sanchez G, Spoont M et al (2009) A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry. 72, 3, 238-255.
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Scott SD, Hirschinger LE, Cox KR et al (2009) The natural history of recovery for the healthcare provider ‘second victim’ after adverse patient events. Quality & Safety in Healthcare. 18, 5, 325-330. Sheeran T, Zimmerman M (2002) Screening for posttraumatic stress disorder in a general psychiatric outpatient setting. Journal of Consulting and Clinical Psychology. 70, 4, 961-966. Tahan HA, Sminkey P (2012) Motivational interviewing: building rapport with clients to encourage desirable behavioural and lifestyle changes. Professional Case Management. 17, 4, 164-172. Taylor AW, Martin G, Dal Grande E et al (2011) Methodological issues associated with collecting sensitive information over the telephone – experience from an Australian non-suicidal self-injury (NSSI) prevalence study. BMC Medical Research Methodology. 11, 20, 1-7.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
Thomas DR (2006) A general inductive approach for analyzing qualitative evaluation data. American Journal of Evaluation. 27, 2, 237-246. Toomey R, Kang HK, Karlinsky J et al (2007) Mental health of US Gulf War veterans 10 years after the war. The British Journal of Psychiatry. 190, 385-393. Trier-Bieniek A (2012) Framing the telephone interview as a participant-centred tool for qualitative research: a methodological discussion. Qualitative Research. 12, 6, 630-644. Von Rueden K, Hinderer KA, McQuillan KA et al (2010) Secondary traumatic stress in trauma nurses: prevalence and exposure, coping, and personal/environmental characteristics. Journal of Trauma Nursing. 17, 4, 191-200. Yehuda R (2002) Post-traumatic stress disorder. New England Journal of Medicine. 346, 108-114.
Thorne S (2008) Interpretive Description. Left Coast Press, Walnut Creek CA.
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