THE IMPACT OF LOCAL RESEARCH ETHICS COMMITTEES ON THE DEVELOPMENT OF NURSING KNOWLEDGE
There can be few nurse researchers in the United Kingdom (UK) who have not had a rejection letter from a local research ethics committee at some point in their careers. Of course, the rejection may be for entirely legitimate reasons, such as an ill-thought out design, or poorly focused research questions which could cause potential harm to the research participants. Ominous for nursing, however, is the ethics committee submission which is rejected because it is not understood by the committee members (as opposed to not being understandable), or worse because those on the committee do not like the research method adopted.
While ethics committees play a critically important role in protecting patients from researchers who might naively or wilfully harm them, when these committees result in a stranglehold on the development of nursing (or other) knowledge then questions should be raised about their function.
In the UK, the majority of research ethics committees have historically had a strongly medical dominance by professional composition and a positivist outlook by philosophical stance. The longstanding medical perception of nursing as a subordinate profession with a lower standard of educational preparation has, on a number of occasions, in my experience led to the assumption by doctors that they alone have the intellectual and professional training to undertake research that is valid and worthwhile.
To be blunt, medical research is seen as more important and of greater value than nursing research and thus more likely to be funded ( Lorentzen 1995).
The inculcation of positivist ideology begins in medical school curricula where students are forcefully told that the so-called ‘hard sciences’, such as biochemistry and physics, are not only the foundations, but the supporting infrastructure and building blocks of their practice. Softer disciplines, such as sociology, social policy and philosophy, are considered little more than expensive decorations to be added when time and inclination allow. Positivism becomes the dominating paradigm in most subsequent medical research, for which medical students actually have little formal training.
This paradigm is further reinforced by the fact that randomised controlled trials are considered to be the ‘gold standard’ of research against which all other research must be measured. Indeed, Luker (1999 p. 85) observes that well conducted randomised controlled trials are considered by many to be more worthy in terms of the contribution they make to the British National Health Service (NHS) research agenda than well conducted qualitative studies.
My comments should not be construed as a criticism of quantitative research which serves a valuable purpose and produces much useful information for patients and practitioners in all disciplines. Nursing, which does not have a strong research tradition, has acknowledged and even embraced nonpositivist paradigms which have developed over the latter half of the twentieth century to become the dominant force in social sciences research. Nursing has drawn on both world views to provide it with a wide range of methodologies and tools to address questions of relevance to nursing.
Medicine, however, has tended to remain reliant on its tried and trusted methods, denigrating any other which does not fit into its own narrow definition of research. The whole two paradigm debate is becoming rather tired as both sides appear to argue in a war of semantics and linguistic attrition. But the debate has a direct impact on the development of nursing knowledge. The traditional approach of ethics committees too often leads to the denigration of nonpositivist research approaches which are considered to be neither rigorous nor valuable, when, in fact, they may be only poorly understood.
Many nursing research studies attempt to discover meaning in the patient’s experience of care. This often requires the use of qualitative methodologies, which may be best suited to exploring these experiences by using small local samples and research instruments that aim to uncover depth rather than breadth. So how do the esoteric arguments, noted above, impact on the development of nursing knowledge? The answer lies in the strategies adopted by nurse researchers to obtain research ethics committee consent for their proposed research projects.
In order to gain approval to undertake a study, a nurse researcher seeking to explore, for example, the patient’s experience of emergency care, will include quantitative measurement instruments in the study to suggest to the research ethics committee that the subsequent findings may be replicable and generalisable. In reality, the nurse researcher may be far more interested in gaining a depth rather than breadth of understanding, but frequently he/she recognizes that suggesting to the research ethics committee that quantitative instruments will be used may be the only way to gain ethics committee approval.
Research is compromised
The outcome is that precious research time that could have been spent in gaining insights, understanding and exploration of previously hidden themes in patients’ experiences of care, is compromised by the pragmatic imperative to analyse the quantitative data, which, while of interest, is not really the prime concern of the researcher.
The end result is that the body of nursing knowledge remains relatively anorexic as nurse researchers are steered away from fleshing out the conceptual and philosophical dimensions of what nursing is and instead add further bulk to the understanding of what nurses do. As Savulescu et al. (1996 ) note, research ethics committees have a wider responsibility to promote the public interest by helping to ensure that relevant research is done. This, by definition, must mean fostering a climate in which qualitative approaches to knowledge generation are seen as just as valid as other, more traditional, approaches.
In addition, research ethics committees must accept that challenging legitimate methodological approaches is beyond their remit. There have been calls in the UK for almost 20 years for greater accountability of research committees to justify their decisions ( Lancet 1980; Gilbert et al. 1989 ; Garfield 1995). Yet, by inappropriately challenging the methodology rather than concentrating on the ethics of research, the research ethics committees serve to undermine their own authority and occasionally lead to the questionable practice of researchers calling their studies ‘audits’ in order to circumvent the vagaries and inconsistencies of research ethics committees.
While the growing number of nurses and social scientists as members of research ethics committees is to be welcomed, as are the increasing numbers of doctors with an interest in qualitative research, the prevailing culture needs to be challenged. This should also include reviewing the format of research ethics committee application forms, many of which still tend to assume that the proposed research will be quantitative by asking questions about sample sizes and statistical advice taken, and describing participants as subjects, etc.
Nursing remains in the adolescent phase of its development; constantly seeking to test the boundaries of its knowledge and clinical practice. If it is artificially constrained, it will, like most adolescents, eventually rebel in ways that may not always appear to be constructive. To draw a parallel from another discipline, Richard Feynman, the Nobel Prize winning physicist, once observed that relations among early scientists were very argumentative, but today they are very good.
In a series of lectures given in 1963 he noted, ‘a scientific argument is likely to involve a great deal of laughter and uncertainty on both sides…if you get anything new from anyone, anywhere, you welcome it, and you do not argue about why the other person says it is so’ ( Feynman 1998 pp. 21–22). In some respects more and not less uncertainty is needed in nursing because what we do not know we will hopefully want to find out.
But if nurse researchers are prevented from asking the relevant questions merely because the research ethics committee do not like them, they might end up losing interest in the questions themselves. And that would certainly be to the detriment of the development of nursing knowledge.