E THICAL C ONSIDERATIONS

When preparing the design and the ethical protocol for this study, I explored the ethical principles behind performing research in the field of health science. The study plan has been approved by the North Denmark Regional Research Council (Data Protection Agency Journal, no. 2008-58-0028). No sensitive personal data concerning patients has been recorded or stored. The study plan has also been sent to the North Denmark Regional Ethical Review Board, although that was not demanded, since the study did not directly involve patients and patients' treatment. Furthermore, I have been guided by the Ethical Guidelines for Nursing Research in the Nordic Countries (Northern Nurses’ Federation, 2003), as well as by the Declaration of Helsinki (WMA, 2013).

These guidelines are consistent with ethical guidelines from other research areas involving human subjects, although the medical researcher's responsibility for the protection of vulnerable patients is particularly emphasized in these guidelines. In order to capture the ethical issues surrounding this mixed methods study, I have been inspired by the considerations relevant to ethical issues in qualitative research presented by Hammersley and Atkinson (2007) and Brinkmann and Kvale (2015).

More specifically, I have been inspired by their assumptions regarding ethical issues in ethnography and qualitative research interviewing, which can be grouped under the following headings: informed content, confidentiality, consequences for participants, and the role of the researcher.

5.6.1 Informed Consent

To meet the ethical demands of informed consent, the participants were informed about the study and the consequences of their participation during meetings prior to the fieldwork. During the meetings, the study was presented, and questions were answered. In terms of the presentation of the study, the participants were told what to expect from my presence in the operating room. They were also told about the purpose of the study being to explore the interdisciplinary collaboration in surgical teams by observing what is going on, listening to what is talked about, asking questions, and writing fieldnotes. The theoretical framework of the study, that is, the theory of relational coordination, was presented, as was the intention of using the findings from the fieldwork in the latter interventions within the surgical unit. In addition, the participants were informed by a written statement in which the study was described, and they were told about anonymity and their right to withdraw at any time (Appendix 5). Afterwards, the participants were asked to sign a letter of agreement to participate (Appendix 6).

Prior to the interviews, the participants were informed about the purpose of the interviews and their right to anonymity.

Despite my intention to provide the participants with the possibility to make decisions regarding their participation based on comprehensive information, I am aware of the fact, highlighted by Hammersley and Atkinson (2007), that not everything about the study has been told to them. First, as a field researcher, I wanted to go into the operating room with an open, curious, and humble mind, and therefore I had little

knowledge of how the observations and the interviews would proceed in advance.

Second, I did not want detailed information to affect the behavior of the participants and thereby to invalidate the conclusions derived from the fieldwork. Throughout the period of observations, I attempted to be as well-known as a person as possible, and I endeavored to build a rapport in order to minimize the behavioral changes due to my presence in the operating room. Despite my intention to provide all the participants with all the necessary information, it has not always been possible. For example, one day, when I was following a coordinating nurse, I participated in the daily surgeons’

conference in the morning. During these conferences, surgeons from all the different orthopedic specialties where meet, including surgeons from other specialties than the hip and knee specialty. These other surgeons were not informed about the study or the purpose of my presence in the conference. It also happened that on another occasion one of these surgeons was called to supervise during surgical procedures in the operating room when I was observing. In these cases, I contacted the surgeon directly immediately after the surgery was over, explained the reason for my presence in the OR, and invited questions to be asked if needed.

The respondents to the surveys in PHASE III were informed about them prior to receiving an email containing a link to the surveys. This information was given verbally by their managers, as well as by handing out a written description of the survey.

5.6.2 Confidentiality

The participants who were observed and interviewed during the fieldwork were assured about their right to anonymity, and they were told that the interpersonal communication and relationship dynamics between team members in surgical teams were the focus of the study. This assurance was given to help build a rapport, create confidentiality, and address any suggestions that the observation was intended to evaluate the individual's performance. The participants were also assured that any data arising from their participation would be anonymized and precautions would be taken to protect the participants’ privacy. The respondents to the surveys were assured that their responses would be treated anonymously. In order to minimize the recognition of the answers given by respondents in the small workgroups, an analysis will only be presented of the surveys obtained from workgroups larger than five people.

In the operating room, contact between patients who were awake and me as a researcher was avoided. This decision was based on a professional assessment of how best to protect patients undergoing surgery. Such patients are considered to be in a particularly vulnerable position in the minutes leading up to the administration of anesthesia and surgery. The professional assessment was derived from my experiences, knowledge, and preunderstandings due to working as a critical care nurse for several years. When the observations were carried out in a preparation room where the patients were prepared for surgery, an introduction was needed, since these rooms were very small, and it was impossible to remain out of sight. I introduced myself very briefly by saying: “Hey, my name is Birgitte Tørring, I am a nurse and a researcher

in the hospital”. I intended the contact between the patient and me to be minimized, and the contact between the patient and the AN nurses to be the focus of the patient’s attention.

5.6.3 Consequences for the Participants

Generally speaking, throughout the phases of the study, I have sought to minimize the risk of harm to the participants by informing, securing, and being aware of my responsibility as a researcher. It was important to be aware of that open and close relationships with the participants, would also enable them to be placed in vulnerable situations. I also had to be aware that the participants being observed in the operating room could be worried about doing something wrong in difficult situations, as well as that questioning the interviewees could lead them to reveal information they might later regret having shared.

Finally, I had to recognize the exploitative potential of ethnographic research, as mentioned by Hammersley and Atkinson (2007). I have hence been concerned about the possibility of giving something back to the participants and the surgical teams by taking advantage of the findings derived from PHASE I during PHASE II and PHASE III.

5.6.4 Reflections on the Role of Researcher

The role of the researcher during the ethnographic field study in PHASE I has been described previously (p. 57-59). In the following, I will add some ethical reflections concerning my role as a researcher. Traditionally, ethnographic methodological discussions have highlighted the challenges involved in conducting ethnographic fieldwork due to the researcher's prior deep knowledge of the field and the researcher's active involvement in the field (Hammersley and Atkinson, 2007; Borbasi et al., 2005;

Uhrenfeldt et al., 2017). A deep knowledge and understanding of the field could lead to researcher presenting the field in an unrealistically positive light (insider myths). Yet, the methodological discussions also emphasize other challenges that derived from the researcher having no prior knowledge about the field, since such a researcher could be incapable of understanding and appreciating the true character of the everyday life of the group being studied (outsider myths). Having these perspectives about the insider and outsider distinctions in mind, I have endeavored to balance my role as a researcher in the surgical units between being an insider and an outsider. To do so, I have had to strike a balance between being an experienced nurse with professional knowledge about anesthesia and critical care nursing, as well as experiences derived from being employed in the hospital for several years (insider), and being a curious, reflective, and analytical observer in the field of orthopedic surgery without knowledge and experience of being a member of a surgical team in the OR (outsider). In order to balance these ways of being a researcher in the field, I have drawn on my experiences as a supervisor. In particular, my knowledge and experiences concerning how to ask

lineal, circular, reflexive, wondering, and strategic questions have been a great benefit to my role as a researcher in the surgical units.

During PHASE II, the role of the researcher was different. Here, a more direct involvement in the planning, monitoring, and evaluating of the interventions was characteristic. Alongside my Ph.D. education, I have continued teaching and undertaking consultancy tasks in primary and secondary health care with a focus on communication, patient safety, interdisciplinary collaboration, and organizational development. I have therefore fulfilled different roles during these years. In the following, I will reflect on how my background as a nurse, teacher, and consultant impacted the researcher's role during PHASE II.

During the initiation phase of the intervention process in PHASE II, my role and engagement were discussed with the management group. The role of the researcher was clarified and described. I was offered the chance to participate in meetings with the change team, and I was asked to present the preliminary results of PHASE I, so they could be used in the planning of the interventions. Finally, I was invited to facilitate workshops intended to customize the RC Survey, as well as to evaluate the intervention process. As a result, my experience as a consultant during previous organizational development projects was not included in the organizational intervention process in Surgery Unit II. This would otherwise have been an obvious choice. I had to accommodate methodical considerations concerning how the dual roles as of researcher and consultant in the intervention process could be balanced. The roles needed to be balanced, so that the consultant's necessary and strong involvement in the intervention process did not color and impact the researcher's necessary curiosity and analytical interpretation of the process. In addition, the management group had previously used consultancy assistance for various improvement initiatives, which did not yield the desired results. These experiences led to certain perceptions regarding the improvement process, which were exchanged during the change team meetings, as: “We are the ones who know what is needed, and those who know best what can be done in this unit. We do not need help from the outside to solve these challenges.”

Therefore, it was not difficult to decide that I, as a researcher, should adopt a traditional researcher role, being more distant, observing, and asking questions about the process – instead of being directly involved in the development and implementation of the organizational interventions.

During PHASE III, the role of the researcher was distanced through email contact to with the participants concerning invitations and a link to participate in the survey, as well as follow-up invitations to participate in the survey sent every eight days for a period of three weeks to those participants who had not yet responded. I intended to establish a relationship of trust built on distance in these emails by securing the anonymity of the responses and inviting the respondents to ask questions if needed.

Finally, I signed the email with my name, title, and contact address.