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Nurse Researcher

Interviewing people about potentially sensitive topics

Correspondence to

Rakime Elmir

Email: r.elmir(Suwa.edu.au

Rakime Elmir RN, R M ,

BN(Hons), Graduate Certificate

in Clinical Teaching is a

registered midwife and

doctoral student

Virginia Schmied RN, PhD is a

professor of midwifery

Debra Jackson, RN, PhD is a

professor of nursing

Lesley Wilkes, RN, PhD is a

professor of nursing

All at the School of Nursing and

IVIidwifery, University of Western

Sydney, Australia

Cite this article as: Elmir R, Schmied V, Jackson D, Wilkes L (2011) Interviewing people about potentially sensitive topics. Nurse Researcher. 19, 1, 12-16.

Received December 22 2009; accepted September 9 2010

Abstract Aim This paper explores the challenges of

interviewing people about sensitive topics. It uses

existing literature and the first author's experience

of interviewing women traumatised by having

an emergency hysterectomy following a severe

postpartum haemorrhage. It also highlights the

strategies that can assist interviews.

Background Interviewing participants about sensitive

topics requires skill and special techniques. Certain

research topics have the potential to cause participants

and researchers distress and discomfort. Identifying

ways to prevent vicarious traumatisation and

researcher burnout is imperative to the integrity

of the research.

Data sources Twenty one Australian women took part

in in-depth, tape-recorded, face-to-face, email, internet

and telephone interviews.

Review methods This is a methodology paper on the

first author's experience of interviewing women on

potentially sensitive topics.

Conclusion Some participants may find telling their

stories to be cathartic, providing them with a sense of

relief. Implementing techniques that may be helpful in

initiating the interview process can be challenging.

Keywords Qualitative research, sensitive, interviews,

therapeutic, hysterectomy, lived experience

Introduction ALTHOUGH THERE is some controversy regarding the definition or identification of what constitutes a sensitive research topic, much nursing and health research focuses on aspects of Ufe that may be considered sensitive (Enosh and Buchbinder 2005). Lee and Renzetti (1990) argued that it is possible for any topic to be sensitive, although some topics may be more likely to cause distress than others (Lee and Renzetti 1990, Corbin and Morse 2003). Cowles (1988) said that sensitive topics are those that have the potentiell to cause harm to participants, eliciting powerful emotional responses such as anger, sadness, embarrassment, fear and anxiety. Sieber and Stcinley (1988) commented that sensitive research also includes topics that may cause distress to the research team involved in the inquiry. Some authors , are more specific in their definition of sensitive research, referring to the subject or the topic under investigation. These topics may include HIV/AIDS (Davis et al 2004), mental health issues, death and

bereavement, fertility, abortion, miscarriage, and terminal illnesses such as cancer (Alty and Rodham 1998, Davis effl/2004).

This paper draws on nursing and early feminist literature to explore the main elements of conducting research into sensitive topics. We will use the experience of the first author [RE], who, as part of her doctoral studies, interviewed women who had emergency hysterectomies following severe postpartum haemorrhages (PPH), to illustrate these elements. The study was sensitive as it involved women («=21) talking about their lived experiences of having hysterectomies following severe postpartum haemorrhages. For the purpose of this paper, we wiU use the work of Cowles (1988) and Sieber and Stanley (1988) to define a sensitive topic as one having the potential to cause physical, emotional or psychological distress to participants or the researcher. This paper reflects on the literature and the decisions made in the design phase of the study, as well as on the experience of collecting data

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Qualitative research

regarding this potentially sensitive topic. We will also discuss key issues cind challenges.

Data collection methods Qualitative methods, such as in-depth semi-structured or tmstructured interviewing, are best suited to investigating sensitive topics (Elam and Fenton 2003). The decision to interview people about sensitive topics stems from the epistemological and ontological stance that knowledge and reality can only be sought from those who experience it (Crotty 1998), Knowledge about a particular phenomenon may be gained throtigh face-to-face interviews. Face-to-face interviewing involves hxmian interaction and is a way of exchanging information that can be difficult to obtain through other methods of data collections such as questionnaires or surveys (Kvale 1996, Creswell 2007).

In addition, researchers can also draw oh technologies known as computer mediated communication (CMC) - such as emáü, instant text messaging and online social networking forums - to collect data on sensitive topics. This technique can be advctntageous for collecting data on sensitive topics, as some participants may consider disclosing intimate and personal experiences to be embarrassing, humiliating and awkward (Davis et al 2004, East et al 2010), Participants may feel more comfortable using CMC, as opposed to face-to-face interviews, to participate in research, so its use may increase participant recruitment (Mann and Stewart 2000, East et al 2008, 2010). Using CMC to interview pctrticipants who Uve far away saves time on travel. Additionctlly, using CMC means there is no need as with oral interviews to transcribe narrative data (MinicheUo et al 2008, East, et al 2008, 2010),

Despite the various benefits associated with CMC, some argue that data collected using this • method may be viewed as 'face-less and 'body-less' (Ison 2009). However, to the contrary. East et al (2010) highlighted the possibility of supportive participant-researcher relationships developing as participants value the opportunity to talk and receive support. CMC is therefore as 'real' as face-to-face interviewing (East et al 2010).

Telephone interviews may be well-suited to potentially sensitive topics because this technique provides participants with the opportunity to disclose intimate and closely held experiences without feeling uncomfortable (Sturges and Hanrahan 2004), Similar to internet interviewing, telephone interviews provide an opportunity for potential participants who Uve at a distctnce from the researcher to participate in research endeavours (Sturges and Hanrahan 2004, Opdenakker 2006).

Early in our study of women's experiences of hysterectomy foUowing PPH, it became evident that it would be necessary for us to use a range of approaches to collect data, including face-to-face, telephone and email interviews. The phenomenon under investigation is relatively a rare occurrence: Haynes et al (2004) indicated that between 1999 and 2002 in Victoria, Australia, five out of 1,000 women giving birth experienced hysterectomy foUowing PPH (0,05 per cent). To increase participation, we invited aU women who expressed an interest to participate in the study, even if they Uved far away. Some participants in our study who Uved locally also chose to be interviewed by email or over the phone for convenience; however, it was also apparent that these participants felt more comfortable discussing the sensitive topic in this manner.

Issues and challenges QuaUtative interviewing involves entering the Ufe-world of participants (Opdenakker 2006, Dickson-Swift et al 2008), One of the most important elements of data collection during in-depth interviewing on a sensitive topic is the ability for the researcher to develop a rapport with participants (Uamputtong 2007, KamieU-Müler et al 2009). Dickson-Swift ef a/(2007) suggested that developing a rapport with participants in quaUtative interviews will enhance the researcher's access to the interviewees' Uves. Booth and Booth (1994) beUeved that the way to develop a good rapport involves giving as weU as receiving information in a two-way process between participant and researcher. Through this, the researcher can better form a trusting connection with participants, helping them to share their experiences (Seidman 2000).

In our study, the process of building rapport started with recruitment. In some cases, two to three phone conversations or emau discussions occurred with women before meeting them for interviews, and they began to disclose their experiences, which initiated the building of rapport.

One way of judging the success of biulding rapport is the deptii and quaUty of information and experiences revealed by participants (KamieU-MiUer et al 2009). Lee (1993) warned that conducting research into sensitive topics can result in the researcher developing a closeness to participants that confuses the roles of friend and researcher. This could be an issue if data coUection involves repeated rather than single contacts between the researcher and the participants.

A major concern when undertaking qualitative interviewing is to minimise the power imbalances

Nurse Researcher

between the researcher and the participant (Enosh and Buchinder 2005, Peters et al 2008). Reciprocity involves a mutual exchange of irrformation and contributes to establishing rapport (Peters et al 2008). Eeminist literature (Stanley and Wise 1983, Reinharz 1992) has highlighted the significance of building rapport in research, while others argue that efforts to build rapport may be seen as coercive or a form of surveillance rather than support (Peckover 2002). Participants may feel they are imder 'examination' or 'scrutiny' and so not feel comfortable in relaying their experiences or telling their stories to researchers.

In our study, the interviewer [RE] endeavoured to minimise potential power imbalances and build rapport through small talk about the weather, work, participants' children and how their days had been ' progressing, for example. The women noticeably became less anxious, more relaxed and more inclined to talk about their experiences of PPH and their subsequent hysterectomies during the conversation.

Sensitive and open questioning When posing interview questions, it is important to allow participants adequate time to respond fuUy (Nieswiadomy 1998). In qualitative inquiry, good interview questions are open-ended, clear and aimed at eliciting responses that reflect the participants' experiences (Patton 2002), while simultaneously being mindful of, and sensitive to, the needs of participants (Dickson-Swift et al 2007). In our study, we asked open questions such as 'Can you describe your thoughts when you were experiencing the haemorrhage or heavy bleeding?' and 'Can you describe the relationship you developed with your baby in the first few weeks and months?' to grasp the entirety of women's experiences. These questions elicited strong responses from the women and we allowed time during the interviews for the women to express their feelings, as well as to remain silent for fairly lengthy periods.

Demonstrating care and empathy during research is essential in eliciting information from participants (Cowles 1988, Dickson-Swift et al 2007). This is particularly important when studying vulnerable participants and sensitive topics (Kavanaugh et al 2006). In our study, I [RE] engaged with the women sensitively, respecting periods of silence and their readiness to continue with the interviews. Women made comments such as 'Sorry,' 'I'm alright to continue,' or 'I said to myself I wouldn't cry.' In spite of the sometimes strong emotions the women demonstrated, they wanted to continue and later disclosed that they were pleased to have had the opportunity to discuss their experiences.

Appropriate use of self-disclosure Researcher self-disclosure is the process of revealing information about self to the participant (Peters et al 2008). Feminist researchers advocate this, highlighting the possibility for greater engagement by participants during the interview process; however, it can potentially lead to researcher vulnerability and scrutiny, depending on what the researcher has divulged (Reinharz 1992).

In our study, I shared thoughts and information with participants when appropriate. Women would often ask 'What interested you in this topic?' or 'What is the incidence of women having a hysterectomy following chQdbirth?' I answered questions honestly, which assisted in reaffirming to them that others had also experienced this phenomenon, as many described their experience as 'isolating'.

Self-disclosure during the ihterviews created a less intimidating environment cind enhanced the reciprocal nature of interviewing. Although self-disclosure can enhance interviews, it also has the potential to cause confusion about the role of the researcher - what Dickson-Swift et al (2008) termed 'blurred boundaries' between the dual roles of healthcare professional and researcher. This CEin often occur as a result of the sensitive nature of the topic and prolonged contact with participants.

Creation of a comfortable interview environment Environmental considerations and appropriateness of venue need to be thought through carefully. It is importcint for the participemt and the researcher to feel safe (McCosker et al 2001). Interviews should be conducted at the times most convenient for participants and at places agreed by the participants and the researcher. Participant privacy and, convenience are paramount, according to Speziale and Carpenter (1999): the more comfortable participants are, the more likely they are to disclose information and reveal the nature of their lived experiences.

To reduce the participants' sense of vulnerability, they were asked to choose places where they could. most comfortably participate in an interview. Ensuring a private environment was also important. Most opted to be interviewed in their homes when other fcimñy members would not be present; only four had young infants or children with them. Three chose to come to the university for the face-to-face interviews. These were conducted in a private and quiet room with soft lighting. A sign was placed on the door to avoid any interruptions. Comfort was a priority to ensure women were at ease during the interview. I offered breaks, tissues and refreshments, ensured privacy and temporarily terminated interviews when participants were distressed or emotional.

October 2011 I Volume 19 I Number 1 © RCN PUBLISHING / NURSE RESEARCHER

Qualitative research

Consideration of the timing of interviews There are varying views about timing and the optimum time to coUect qualitative data after a traumatic personal experience (Cowles 1988, Enosh and Buchinder 2005). Researchers need to be mindful of participants' recent experiences and how these can influence their immediate responses to questions. According to Porter and Birt (2001), it is important to capture experiences close to the traumatic event as the memory is resolved, becoming less detailed, less vivid and more distant over time. However, other authors disagree, PioUno et al (2006), for example, commented that an individual is able to recall memories relevant t:o their personal Uves despite the time period.

We interviewed women between five weeks and 28 years after they had a hysterectomy after birth. Despite the different time periods, all 21 participants had shared experiences of grief, loss and trauma. However, there were noticeable differences among the narratives, particularly with one woman who had her hysterectomy five weeks before the interview. It was difficult to interpret the complexity of her experience during the interview and transcription processes. Frank (1995) termed the difficulty in interpreting or understanding the narrative because the storyteUer is still distressed and traumatised by the experience 'chaos netrrative'.

Risks to the researcher Conducting research into sensitive topics can be challenging, especiaUy if the researcher is a novice and has limited expertise in interviewing about topics of a sensitive nature (Anderson and Hatton 2000). QuaUtative research is the study of subjective experience, so it is cUfficult for researchers to distance themselves from studies. They cannot remain 'faceless' interviewers (Dickson-Swift et al 2008). Researching in sensitive areas has the potential to pose a threat to' researchers' weUbeing, particularly if they have strong feeUngs or have Uved experiences of the phenomena under investigation (Lee 1993).

Ui our study, we were aware of the potential for 'vicarious traumatisation'. Vicarious traumatisation occurs when the researcher engaging with the traumatised women begins to develop feeUngs of fear, grief and intrusive thoughts (Dunkley and Whelan 2006). Researcher 'burnout' (Dunkley and Whelan 2006) was another issue that concerned the researchers. In our study, we estabUshed processes to ensure that I had time between interviews to reflect on what had been Sciid and what had occurred. I conducted at most two interviews per week and I met regularly with other members of the team to 'debrief.

Potential benefits of interviewing Uidividuals sharing their Ufe experiences and teUing their stories to ctn interested Ustener can experience positive and therapeutic effects from participation (Corbin and Morse 2003, Ison 2009, East et al 2010). Participants may find teUing their stories to be cathartic (East et al 2010), since participants tmdergo a reflective process, which is a possible way of gaining closure (CarUck and Biley 2004). Reflecting during interviews has also generated some positive outcomes for women participating in research: for example, breast cancer survivors (EUnir 2006, EUnir et al 2010), women with sexuaUy transmitted infections (East et al 2010) and women with postnatal depression (Beck 2005). This is because teUing someone your experiences and sharing your story can.contribute to heaUng (Leseho and Block 2005, Supporting and encouraging individuals to unveil their experiences wiU help reduce any insecurity they foresee in the future and in their Ufe (Duffy 2002), The therapeutic effect of catharsis occurs when participants express deeply held personal feeUngs and thoughts, generally projecting a sense of reUef (East ef a/2010).

In our study, six women reported a perceived cathartic effect for telling their stories, 'GüUan' (a pseudonym) participated in a face-to-face interview. Following the interview, she sent an emau stating: 'Just a note to thank you for coming round to interview me the other day. I found that a very positive experience and it was good to talk about my feeUngs, Thank you for all the work you ctre doing on the study which I'm sure wiU produce some very helpful information. If there is any way I can help in future, please don't hesitate to let me know, I would be very willing to offer support to others or to be involved in a support group.'

East et al (2010) noted that participants in their study also express a sense of empowerment from being Ustened to and heard. This also concurs with Beck (2005) who interviewed women by emau about their traumatic birth experiences and revealed that participants found it particularly empowering and therapeutic to have someone Usten to and respond to their stories even if that was over the internet. Ui our study, 'Louise' felt a sense of reUef from talking about the trauma she experienced as a result of having the hysterectomy. She said: 'I know my family and friends are sick of me talking about it. It has been so good speaking to someone who is genuinely interested,' Similarly, 'Marie' and 'Mia' conveyed their wilUngness to participate in the study to have the opportunity to share their stories with an interested Ustener,

Marie said she 'had to have a hysterectomy as I was unknowingly a victim of placenta accreta, I am

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happy to participate and I definitely have observed differences in my post birth experience compared with my first baby... It would be wonderful to speak to someone about this...'

Mia had a hysterectomy five weeks before the interview. She explained how talking about her experience had been therapeutic. 'I think what you doing is fantastic... it has been therapeutic talking about it... Every time you talk about it, it helps and makes it easier, and for a week I've been psyching myself up thinking, "Don't be an idiot and cry, don't be an idiot and cry," and ciU morning I've been thinking, "Yeah, I feel really good today," and as soon as I start talking about it, I start crying.'

Peters et al (2008) noted that participants who tell their story as part of qualitative research may have a sense of being 'valued' or of 'being'. Participants may also be inclined to share their experiences to gain a

References

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Conclusion Employing strategies, such as building rapport, reciprocity, appropriate and sensitive use of open questions, self-disclosure, ensuring a comfortable environment and appropriate timing, helped with the interviews in this study of a sensitive topic. These measures were aimed at achieving trust between participant and researcher to enhance spontaneous exchange of information in a warm and supportive environment. Although interviewing pcirücipants about sensitive topics has the potential to cause a degree of discomfort, talking about an experience in a safe and respectful environment can help with gaining closure and personal control or efficacy over the event or situation.

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