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The Researcher as an Instrument

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In qualitative research, there are many different sources of data. Qualitative research data are collected using many different methods. Interestingly, one of these data collection methods is the researcher himself or herself. This is the reason why most experts consider the researcher as an instrument. The question always asked is “What does it really mean?” This chapter explains what it is and what is expected from the researcher in his or her role as an instrument throughout a qualitative research study. The ethical considerations pertaining to this important role are also discussed. This chapter is meant to bring this important role to everyone’s awareness so that rigor in qualitative research can be fostered.

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Wa-Mbaleka, S. (2020). The Researcher as an Instrument. In: Costa, A., Reis, L., Moreira, A. (eds) Computer Supported Qualitative Research. WCQR 2019. Advances in Intelligent Systems and Computing, vol 1068. Springer, Cham. https://doi.org/10.1007/978-3-030-31787-4_3

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Researcher–researched relationship in qualitative research: Shifts in positions and researcher vulnerability

Målfrid råheim.

1 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway

Liv Heide Magnussen

2 Department of Occupational Therapy, Physiotherapy and Radiography, Bergen University College, Bergen, Norway

Ragnhild Johanne Tveit Sekse

3 Department of Obstetrics and Gynecology, Haukaland University Hospital, Bergen, Norway

4 Department of Clinical Science, University of Bergen, Bergen, Norway

5 Haraldsplass Deaconess University College, Bergen, Norway

Åshild Lunde

Torild jacobsen.

6 DIALOG, Bergen, Norway

Astrid Blystad

The researcher role is highly debated in qualitative research. This article concerns the researcher-researched relationship.

A group of health science researchers anchored in various qualitative research traditions gathered in reflective group discussions over a period of two years.

Efforts to establish an anti-authoritarian relationship between researcher and researched, negotiation of who actually “rules” the research agenda, and experiences of shifts in “inferior” and “superior” knowledge positions emerged as central and intertwined themes throughout the discussions. The dual role as both insider and outsider, characteristic of qualitative approaches, seemed to lead to power relations and researcher vulnerability which manifested in tangible ways.

Shifting positions and vulnerability surfaced in various ways in the projects. They nonetheless indicated a number of similar experiences which can shed light on the researcher-researched relationship. These issues could benefit from further discussion in the qualitative health research literature.

This article begins and ends in the reflexive turn of qualitative research (Altheide & Johnsen, 1994 ). Reflexivity concerns thoughtful, analytic self-awareness of researchers’ experiences, reasoning, and overall impact throughout the research process. Pre-understanding and openness, closeness and distance, the co-construction and situating of knowledge, trustworthiness and integrity, power relations, and ethical dilemmas are given primacy in the qualitative methodology (Dahlberg, Dahlberg, & Nyström, 2008 ; Finley, 2002 ; Gergen & Gergen, 2000 ; Kvale & Brinkmann, 2009 ; Lincoln & Guba, 1985 ). In this article, we reflect on the role of the researcher in the process of knowledge production as it emerged in a series of reflective group discussions between researchers based in the health sciences. Focusing on our own research experiences, our aim was to explore systematically our experience of fluctuations in “superior” and “inferior” knowledge positions and the related researcher vulnerability that emerged.

The relation between researcher(s) and researched has been a recurrent concern in the methodology literature. The privileged position of the researcher vis à vis the researched has been strongly emphasized. The inherent power imbalance between the parties and the ethical concerns pertaining to this imbalance are commonly dwelled upon, with particular attention to the predetermined asymmetric roles between the researcher and the researched. However, the literature simultaneously emphasizes that qualitative traditions all have “…a common epistemological ground: the researcher determination to minimize the distance and separateness of researcher-participant relationships,” as phrased by Karnieli-Miller, Strier, and Pessach ( 2009 , p. 279). Furthermore, it is argued that defining what knowledge is to count in a concrete researcher–researched encounter is not necessarily the sole privilege of the researcher because participants bring their own agenda to the research situation (Karnieli-Miller et al., 2009 ). In the ethnographic literature, much attention is paid to the complexity of the role of the researcher as observer, as well as the contextual understanding of potentially opposing perspectives between the researcher and researched (Adler & Adler, 2002 ; Angrosino & Mays De Pérez, 2000 ; Hammersley & Atkinson, 1983/1992 ; Vitus, 2008 ). Role conflict related to being both an insider and an outsider, and the experience of resistance from the research participant are related themes that seem to call for further nuancing of the representations of inherent asymmetric relations (see, for instance, Burns, Fenwick, Schmied, & Sheenan, 2012 ; Dwyer & Buckle, 2009 ; Jack, 2008 ; Lalor, Begley, & Devane, 2006 ; Lee, 1993 ; Malacrida, 2007 ).

The insider-outsider perspectives are not new, but have been hotly debated for decades (see for example, Emerson & Pollner, 1988 ; Garfinkel, 1984 ; Lynch & Woolgar, 1988 ; Pollner & Emerson, 2001 ). The debates revolve around researcher positionality, what it means to be an insider or outsider in a given study setting, and how the researcher's status is negotiated throughout the research processes. Laura Nader ( 1969/1972 ) launched the dichotomy of studying up/studying down pertaining to researcher positionality in her classical work, holding that studying up contributes in vital ways to an understanding of the processes by which power and responsibility are exercised. Beyond informing our understanding of patterns of distribution, value, and power, Nader's call for studying up has posed new questions pertaining to the research relationship, and has been widely drawn upon. The researcher “studying up” may experience him- or herself moving into a research field of less “control” or “power,” so the approach calls for new reflections on the issues of access, methodology, attitudes, and ethics (Nader, 1969/1972 , p. 301). Reflections on studying up or down may enhance the understanding of researcher experiences in our article.

We should emphasize that we fundamentally acknowledge the existence of an inherent imbalance in the relation between the researcher(s) and the researched in qualitative health research. Despite this, we will make a modest attempt to add to the debate about whether the researcher is by definition located in a privileged and superior position vis-à-vis the research subjects. Our aim is to use examples from our own research projects to reveal shifts in “superior” and “inferior” positions in researcher–researched relationships, in which ethical dilemmas and vulnerability surface on the part of the researcher. A further aim is to explore whether experiences from projects based in different qualitative traditions can shed additional light on the researcher–researched relationship.

Reflective group discussions

The authors of this article are senior researchers (two professors, four associate professors), all women, who gathered in six reflexive group discussions over a period of 2 years. The group participants had backgrounds in nursing (two), physiotherapy (two), genetic counselling (one), and in acting/drama as a pedagogical tool (one). One of the nurses also held a PhD in social anthropology. They were colleagues in research and/or in the running of a master's programme in health science. The participants reflected on their role as researchers in their earlier research projects. The reflective group discussions took the form of dialogues, aimed at letting multiple voices surface.

The first author developed the project idea, invited the participants, and moderated the group discussions. In order to delve deeper into methodologically important aspects of the researcher role in qualitative health research, it was deemed important that all the group participants were anchored in health science and experienced in traditions in which qualitative approaches are highly valued. Representing a diversity of research designs and traditions was also deemed important, as methodological challenges may surface differently in different designs (see Table I ).

Overview of research projects, which worked as empirical examples in the reflective group discussions, including methods, traditions, and authors.

Complete references are included in the list at the end of the article.

In the first group discussion, we openly shared our experiences as researchers in our own projects. No specific themes were introduced by the moderator, but the participants were encouraged to spontaneously bring up themes they considered important. Each participant then chose one research project/empirical example from which she made drawings revealing important topics of her own experience as a researcher. We did not put any restrictions on ourselves as to the drawings, which were meant as a creative way to come up with preliminary discussion themes. The participants worked in pairs to consider at some length what was communicated in the drawings about the researcher role. The crux of the content was later shared and discussed collectively. The discussion was recorded and transcribed. A preliminary analysis of the concrete researcher experiences and meta-reflections from the discussion was performed by the first author. The transcripts and the drawings were circulated to the group participants before the second group discussion, together with preliminary themes and emerging patterns based on the first author's readings of the transcript. Already, at this stage, shifts in the dynamics of the relations between interviewer and interviewee, and researcher vulnerability, were emerging as preliminary themes.

During the second group discussion, based on the preliminary themes deemed most interesting, a decision was reached to deepen our knowledge about the ways in which our own experiences of research-related relations seemed to move us beyond established knowledge of the imbalance in which the researcher holds a privileged position.

Between the second and third group discussion, transcripts from the first two group discussions were read and analysed by first and last authors, looking for concrete examples and meta-reflections that deepened the key issues chosen by the group. The different examples of researcher experiences revolved around more or less explicitly emerging shifts and ambivalence related to knowing and non-knowing positions of the parties in the phase of co-producing the research material. Examples of negotiations, related to whose agenda was directing the production of the research material, emerged in diverse ways. The examples were categorized under headings highlighting the social status of the participants and the researchers, as well as the knowledge positions of the different parties pertaining to the phenomena under study.

During the third group discussion, the analysis was discussed and key issues further developed. This included discussions pertaining to problematizing the notions of “studying up and down” on the basis of the empirical examples. Literature on researcher reflexivity in qualitative health research was familiar to the participants at the outset of the reflexive group discussions, but a fresh literature search was undertaken at this stage, focusing on themes related to the imbalance in the researcher–researched relationship in qualitative research, and researcher vulnerability.

In the fourth group discussion, we once more worked in pairs to develop our meta-reflections around our own experiences as researchers in the six chosen research projects, summing up and discussing the key issues. Notes were taken during this session as well, and a post-group summary was written.

Between the fourth and the fifth group discussion, the participants worked in pairs or separately to write up their researcher experiences, based on the concrete projects. Drafts of textual presentations were sent to the first author, who wrote a comprehensive preliminary paper that was circulated to the participants.

Discussions during the fifth and the sixth group gatherings concerned revision and refinement of the text. The first and the last author had continuous discussions during the writing process.

The research projects—Differences and common ground

The projects from which the meta-reflections about experiences were drawn were different with regard to aims, research tradition, and research design. However, as stated above, they were all located within the qualitative research tradition of the health sciences, and were epistemologically grounded in the humanistic or social science traditions, as can be seen in Table I .

Two projects (empirical example 1 and 2) were anchored in a phenomenological life-world perspective, and were based on research material produced through in-depth interviews. The projects shared a common interest in exploring phenomena concerning living in “a changed world” related to profound changes in health condition. Both studies involved reflexive practices to create an awareness of the researchers’ pre-understandings. In the first study (Råheim & Håland 2006 ), women with fibromyalgia were interviewed about living with chronic pain. The second study (Sekse, Råheim, Blaaka, & Gjengedal, 2009 ; Sekse, Gjengedal, & Råheim, 2012 ) focused on the experiences of long-term survivors of gynaecological cancer. The researcher–participant relationships in these two projects might be characterized as essentially asymmetrical and “studying down.” Nevertheless, important shifts in who defined the relevant body of knowledge were experienced.

Two studies produced data through focus group interviews (empirical example 3 and 4), research material substantially depending on the interaction within the groups. Both projects aimed to gather knowledge about how to handle challenging cases and ethical dilemmas in professional practice, and they were both anchored in a hermeneutic tradition. One project focused on challenges and problematic aspects of genetic counselling practice (Lunde, Nordin, & Strand, 2014 ). The second (Nilsen, Werner, Maeland, Eriksen, & Magnussen, 2011 ) focused on sick-leave decision-making based on general practitioners’ (GPs’) consultations with patients who have complex health issues. In both studies, the researcher was the group moderator. The relationship between researcher and researched in these two studies can be characterized as asymmetrical, such that the asymmetry worked both ways: the researchers held a “superior” position in relation to the participants in terms of planning and leading the project, while the participants/professionals held a “superior” position pertaining to professionally based knowledge within the actual field of research. These studies also actualize studying the privileged, the experts in the field, or “studying up.”

The fifth study (empirical example 5) was a classical field study anchored in ethnography (Blystad, 1999 ; Blystad & Rekdal, 2004 ). The researcher lived in a Tanzanian pastoral community for a period of more than 2 years, exploring maternal practices related to pregnancy, childbirth, and infant feeding. The aim was to generate knowledge on the perceptions and practices related to the reproductive process in a community with substantial cultural emphasis on fertility but in a context of extreme marginality and a high prevalence of infant death. Shifting between positions in this project is based on experiences with the participant observer role, a role located at the heart of ethnography. That implied continuous shifts between “inferior,” non-knowledgeable, insider positions and “superior,” knowledgeable outsider positions.

The last study (empirical example 6) was a pedagogical project anchored in the context of health education. A model of group-based communication training for medical students was developed with the help of simulated patients (SP) and theatrical devices. Theoretical perspectives were grounded in pedagogy and in theatre science. In the sub-study referred to below (Jacobsen & Baerheim, 2005 ), the researcher simulated a particular patient during the training session while medical students acted as the patient's GP. How the students experienced the communication training and what they learnt was evaluated afterwards. The dual role as researcher and SP provides the starting point for reflections on researcher vulnerability from this project.

Knowledge positions and researcher vulnerability—Shifts and ambivalence

In the following, we will highlight and reflect on shifts related to knowing and not-knowing positions between the researcher and the researched that emerged during discussions. These shifts were intertwined with the power of defining the relevant body of knowledge. In particular, we discuss transitions in terms of who appears to set the agenda or define the terms, and we discuss the vulnerability inherent in the researcher role during the co-production of research material.

Distracted by illness stories

A prime example of partly losing control of the research agenda from the in-depth interview studies (empirical example 1 and 2) was related to an experience of being diverted by stories of illness. Of interest from the researchers’ points of view was the current experience of living with chronic muscle pain (example 1) and living as a long-term survivor of gynaecological cancer (example 2). The study participants, however, seemed to seize the opportunity to tell their “full” illness stories to someone who had the time to listen, stories that were accompanied by strong emotions. The emotions were vital in this context and made it difficult to interrupt participants. It was unclear whether or not the illness stories had been accepted in the participants’ many encounters with health care workers; for some, their illness stories had been ignored. The context of encounters with health care workers in the actual projects seemed vital. Both researchers were experienced qualitative researchers. Nevertheless, the subjects’ wish to reveal a high level of suffering, and the intensity of the illness stories took the researchers by surprise. The researchers felt ambivalent because the lengthy illness stories occupied more time than had been initially planned. These stories moved the focus of the interviews beyond the research agenda, but the ambiguity about when and how to interrupt the interviewees was experienced as challenging.

This illustrates a particular challenge of participants’ bringing their own agenda into the interviews (Karnieli-Miller et al., 2009 ). The narrators in these cases talked about what they felt most strongly, including experiences more or less relevant to the study in question. A need to get the illness story off one's chest, finally to be listened to, might indeed have been a factor motivating the patients to take part in the studies. If the researcher is also a health care worker, this knowledge can further fuel the fire of disclosure. The researcher and health care worker roles can become blurred in the research interview situation (Hewitt, 2007 ; Jack, 2008 ; Tee & Lathlean, 2004 ). The participants’ perceptions of the interviewer, including her professional role, can influence the interaction, and hence the information that is revealed (Richards & Emslie, 2000 ). In one of the projects referred to above, the women who participated did not know about the researcher's professional role as a physiotherapist. In the other, the participants did know that the researcher was also a nurse. The fact that the studies were based in the health care establishment (University Hospital, Faculty of Medicine) might have influenced the participants’ conduct in both studies. Furthermore, the participants could have been motivated to elaborate on the suffering during the interview, as encouragement to reveal personal experiences could have a potential “therapeutic” dimension. Similarities between research interviews and therapeutic encounters have been recognized (Kvale & Brinkmann, 2009 ). Although therapeutic effects are rarely aimed at by researchers, attentive and empathic listening, and encouraging reflections on what is being expressed might be perceived by the participants as encouragement to narrate detailed tales of illness (Hewitt, 2007 ; Hutchinson, Wilson, & Wilson, 1994 ; Lowes & Gill, 2006 ; Richards & Emslie, 2000 ).

During the interview stage, the researcher is dependent on the participants’ willingness not only to take part, but also to share their experiences and thoughts about the topics in question (Karnieli-Miller et al., 2009 ). The researchers considered it important to listen to the illness stories, first and foremost to show respect, but also to gain the trust of the participants, which is essential for a constructive qualitative research encounter. Besides, illness stories might well bring about contextual insights of importance to the understanding of the phenomena to be explored, in our context to the understanding of living with chronic muscle pain or as long-term survivor after cancer. However, including the “full” illness stories had not been planned and it took time away from the key focus of the research.

The balance at play between knowing and non-knowing positions illustrates several points of interest. It is claimed, for instance by Kvale ( 1996 ), Brinkmann and Kvale ( 2005 ) that the empathic, caring, and empowering atmosphere of equality aimed at in qualitative interviews may conceal power differences and hence be ethically questionable. The researcher's dependence on the trust of participants to get their stories can indicate that the dialogue taking place is used as a strategic instrument that works as a cover for the exercise of research-related power. We have indicated that listening to the illness stories of the research participants was important for establishing mutual trust, which might have been a gateway for accomplishing the researchers’ agendas. As such, listening included a strategic element, which we surely acknowledge is a part of qualitative research interviews. However, being guided by respect and ethically sound reasoning, as well as constantly operating through an open and dwelling attitude, contradicts the notion of attentive listening as “a fake.” Indeed, we will argue that it would have been impossible to gain mutual trust and rich descriptions if the researchers had not been genuinely interested in the experiences of the researched. According to phenomenological methodology, a genuine interest coupled with an attitude of openness and wonder that puts pre-understandings at risk, is essential in order to explore lived experience in any depth (Dahlberg et al., 2008 ; Van Manen, 1997 ). However, as we have seen in the cases above, genuine interest and attentive listening also risk paving the way for participants to reveal wells of sensitive information, as well as the risk of moving the interview away from the main research agenda. Difficult ethical choices had to be made during the interview situation. The challenges experienced have some general relevance for the art of in-depth interviewing.

The inherent researcher vulnerability in In-depth interviews

A common theme in the in-depth interview studies relates to researcher as well as participant vulnerability. Hewitt ( 2007 , p. 1151) underscores that moral questions can arise at any time during in-depth interviews, depending on the types of disclosure, unintended consequences of trust and emotional closeness, as well as varying competence in communication skills and ethically sound reasoning on the part of the researcher. Overly intrusive interviews mean exploitation, and might harm participants (Hammersley & Atkinson, 1983/1992 ; Kidd & Finleyson, 2006 ; Richards & Schwartz, 2002 ).

In the in-depth interview studies considered here, the researchers were involved in stories of great emotional intensity. They were challenged to catch and interpret signs and expressions, tones located beneath and between what was literally communicated in words, in order to make choices about the welfare of the woman/participant. In preparation for the interviews, raised awareness of the importance of not being intrusive was practised. However, both researchers in the in-depth interview studies were acquainted with feelings of guilt, and were touched deeply by the participants’ stories. It is claimed that it is necessary to be deeply absorbed by the participants’ expressions and empathically touched by participants’ to, at least partly, understand what might be at stake in the life-worlds of participants (Angel, 2013 ), and that such absorption is also paramount to ethically sound research (Malacrida, 2007 ). However, had we triggered reactions that could add to the women's burden in the long run? If self-disclosure meant re-opening wounds without the opportunity to work them through, it could potentially cause harm. On the other hand, sharing sensitive experiences might invoke relief, self-acknowledgement, and imply a possibility of looking at experiences anew (Hutchinson et al., 1994 ; Lowes & Gill, 2006 ). Participants who agree to take part in a study of this kind will, nevertheless, often be unprepared for what they are consenting to and what they may actually reveal (Richards & Schwartz, 2002 ). The process of qualitative health research is not always predictable for either participants or researchers (Kidd & Finleyson, 2006 ). Furthermore, what participants communicate just after the interview might later be reversed, adding to the complexity of these issues (Murphy & Dingwall, 2004 ). As stated by Hewitt ( 2007 , p. 1157), an acknowledgement of the complexities of researcher–researched relationships in in-depth interview studies implies being sensitive to the risks to participants, a continual concern. We fundamentally acknowledge this complexity, and find that enhanced ethical awareness on the part of the researcher is paramount.

Still, we will argue that there is an unsolvable dilemma implicit in in-depth interview studies, where aiming at rich descriptions is a key concern, often implying disclosure of sensitive topics, while at the same time ensuring that one does no harm to participants. We agree with Rager ( 2005 ), Lalor et al. ( 2006 ), Dunn ( 1991 ), Kidd and Finleyson ( 2006 ), and Malacrida ( 2007 ), who claim that researcher risk vulnerability regarding “compassion stress,” the danger of being emotionally drained. We will add that stress, accompanied by feelings of guilt, is underestimated in qualitative research generally. To explore knowledge about sensitive topics in peoples’ lives entails the “superiority” of the researcher position, but which pertaining to ethically demanding choices and emotional involvement nevertheless implies researcher vulnerability.

The challenge of hierarchy and status in group interviews with professionals

The participants in the group interviews (empirical examples 3 and 4) were highly qualified health professionals, indicating expert knowledge within the research topics of interest, and holding a superior social role compared to the patients in the in-depth interview studies. The researchers held a privileged position in terms of being the ones who were in charge of the research projects’ agenda. The researchers and the researched also possessed a shared body of knowledge by virtue of having similar or related professional roles. At the same time, a certain “inferiority” in terms of professional knowledge existed between the parties; a relatively newly educated genetic counsellor moderated group interviews with experienced genetic counsellors and geneticists (medical doctors specialized in genetics), and an experienced physiotherapist moderated group interviews with GPs. These studies illustrate research situations in which the challenge of interviewing peers and/or professionals enters the picture, another challenge with methodological implications (Coar & Sim, 2006 ). The two group interview studies clearly contained an element of “studying up,” moving the researchers into research fields characterized by less “control,” which again is readily related to challenging attitudes among the researched and difficulties of access to information, as noted by Nader ( 1969/1972 , p. 301). The very fact of using group interviews might, moreover, have increased this particular methodological challenge.

The researchers and moderators of the group discussions did feel that the participants questioned their expertise in the field, which primarily emerged as resistance or lack of responsiveness to some of the questions introduced. Furthermore, a hierarchy based on the classical distinction between objective, fact-related knowledge in contrast to knowledge as subjective and experience-related surfaced in both focus group studies. The researchers were interested in learning about how the informants acted and made judgments in specific challenging situations, and this involved asking for the participants’ experience-based knowledge. However, in the group discussions, the researchers and moderators found it challenging to get the participants to describe and reflect on real-life situations experienced in their own practice. Participants quickly turned to responding formally with generalized replies and fact-based knowledge such as health policy, legislation, and so forth.

It should be acknowledged that the topics of discussion in these projects imply medical assessment of substantial complexity, and to present revealing clinical examples may not be easy. Caution related to the disclosure of patient information may add to the challenge. Notwithstanding these points, the potential danger of being exposed and made vulnerable to peers is inherent in revealing subjective experience from one's own practice, a vulnerability that may be experienced as contradictory to the professional role as a doctor, a geneticist, or a genetic counsellor, and might have been important in our context. The research participants, who had expert knowledge about their professional practice (insiders), might, despite confidentiality and anonymity assertions, have felt slightly threatened by a researcher/moderator (outsider) whose intent was to explore politically and clinically potent challenges inherent in their practice. The study participants might legitimately wonder whether the researcher intended to test their professional competence, and/or place their profession in a “bad” light in the professional community. Hesitation to reveal information to colleagues, not just researchers, concerning one's own ways of solving the challenges discussed may also have been a constraint in the group discussions. In Coar and Sim's study ( 2006 ), in which both interviewer and interviewed were professionals (GPs), several participants regarded the interview as a test of their professional knowledge. Other studies have also noted that participants and professionals believe that their interests and professional identities are threatened during research (see e.g., Enosh & Ben-Ari, 2010 ). The perceptions of the researcher and the researched of the research agenda might thus not always be in harmony. Group interviews may also be challenging for the researcher because of the inherent strengths of a group of individuals, who can directly oppose the researcher's agenda.

In the studies with the GPs and genetic counsellors, minor “battles” seemed to be played out, in which the study participants alternated in terms of who was guiding or guarding the knowledge presented, including moments in which the researchers managed to move the discussion in the direction that was desired for the productive generation of knowledge. Neither the researcher in the sick-leave decision-making study (empirical example 3) nor the researcher in the genetic counselling study (empirical example 4) attempted to force the discussions in a preferred direction. Rather, the researchers repeatedly asked for concrete examples in order to gain knowledge beyond the formal, and made continuous attempts to hear participants dwell on the experienced intricacies of actual decision-making processes.

A more comprehensive understanding of the negotiations taking place about the research agenda involves insight into the context at hand and what might be at stake for both the participants and the researcher (Coar & Sim, 2006 ; Enosh & Ben-Ari, 2010 ; Vitus, 2008 ). We have indicated that the participants in both of the focus group discussion studies might have felt that their professional identities were being scrutinized. One cannot be entirely sure that the researchers and the participants were in full agreement about what the research agenda actually implied, although the aims of the research were shared before the discussions. Negotiations and resistance regarding the discussion of problematic clinical cases are, in the research literature, associated with a challenge of revelation. In such cases, the social status of the parties involved may also emerge as significant (Coar & Sim, 2006 ; Richards & Emslie, 2000 ). In the focus group studies considered here, the symmetry as well as the asymmetry in the researched–researcher relationship represented a dimension of power that the researchers experienced as challenging and as somewhat unpredictable during the course of the research encounters.

The child's role: Being at the mercy of the study participants

The next case reveals examples of researcher vulnerability experienced within a classical ethnographic study (empirical example 5). As pointed out, for instance by Hammersley and Atkinson ( 1983/1992 ), there is a substantial possibility in ethnography for informants to control the information revealed, not least when studies are carried out in foreign contexts. To illustrate the often shifting character of ethnography, Werner and Schoepfle ( 1987 ) have described the participant observer role in fieldwork as a process, starting out with descriptive observation, where taking a child's role is dominant, followed by a more “focused observation” as the cultural knowledge about the field increases, and finally moving into phases of more “selective observation.” Intertwined in such a process are changing relationships between the researcher and the researched.

A classical metaphor for the ethnographic fieldworker is the child who is to be socialized into a particular culture or subculture. As such, the researcher is from the start placed in an “inferior” position pertaining to relevant cultural knowledge. The “innocent” child and ethnographer is simultaneously a conscious and informed researcher working systematically on his or her research agenda. The agenda will be more or less transparent to the study participants, depending on how well a particular research topic can be made sensible in the research setting. An ethnographer's taking on the role of a child has its advantages, especially in the early phases of fieldwork. It allows the ethnographer to pose questions that might appear as uninformed, even naive, and might not be perceived as immediately threatening because they are coming from “a child” who is learning.

Beyond the role of the child, the role of the “insider” is sought within ethnography: being and living among the researched, becoming someone to be trusted and thus allowed access to internal matters. The attempts at gaining mutual trust and reaching a sense of or some degree of closeness to the informants lies at the heart of the ethnographic approach, and depends on considerable time being spent in the field. The “insider” role, however, is continuously articulating with the “outsider” role, which is also inherent in the participant observer role, as the researcher commonly comes from “outside” the studied field.

A particular challenge experienced in the ethnographic study we considered was the study participants’ ways of controlling information, particularly during the early phase of the fieldwork. One area that was perceived as a challenge was that of controlled exclusion: not only the careful sorting of information to be presented to the researcher, but the rigorous denial of access, the distancing or exclusion of the researcher from smaller or larger arenas defined by the researched. Dependent as the ethnographer is on guidance (and possible translation), the potential for control of information passed on to the researcher is more or less limitless, potentially jeopardizing the researcher's project. Despite the fact that the researcher in this project was invited to attend a vast number of relevant events and situations that could provide knowledge about pregnancy and birth-related perceptions and practices, she had, for months, an accompanying feeling of being guided away from core information, and even of being cheated. The experience of being part of a game was not entirely unlike what Angrosino described from his fieldwork (Angrosino & Mays De Pe'rez, 2000 ):

Even in such a highly circumscribed culture …(referring to his field site), people could experiment with styles of interaction and involve the visitor (researcher) in subtle, yet very revealingly subversive power games, games that inevitably shaped both what the ethnographer observed and how he interpreted what he saw. (p. 681)

The potential for the researched to control what a researcher is introduced to is obviously fully within the rights of the study participants, and is a principle located at the very core of any research endeavour. Nevertheless, the informants’ ability to control, deploy, and manipulate again raises questions around the notion of the researcher's exclusive power. Diverse forms of participant resistance have been described in the ethnographic literature (Adler & Adler, 2002 ). Karnieli-Miller et al. ( 2009 , p. 283) refer to the participants’ strategic use of problematic interview behaviour (such as flattery, flirting, and so forth), shift of topics, and even the decision to end the interview or cooperation altogether. On the basis of subtle or overt shifts in power relations between the parties, the awareness of the co-construction of knowledge can become more or less acute. Goodwin, Pope, Mort, and Smith ( 2003 ) write:

The community being researched is not a passive component; it also has a bearing on what the researcher is included in and excluded from. The informants were also agents in the shaping of the data, the data-collecting opportunities, and the course of the fieldwork. (p. 576)

At the same time, in the co-construction of knowledge made possible through the symbiotic relationship between researcher and researched lies one of the substantial advantages of ethnography. The closeness will often, with time, generate an openness and permissiveness, which may imply seemingly endless learning opportunities. However, the dependence on the close relationships with the informants simultaneously sheds light on the precariousness and vulnerability not only of the informants, who may have difficulties controlling the information ultimately generated from the research, but the vulnerability of ethnography as a research approach, as well as the vulnerability of the ethnographer in the process of learning.

In the current study, the researcher gradually gained access to more domains, and later fieldwork revealed the immense impact of her own position for the knowledge gained. She was provided with extensive access to the women's ritual reproductive sphere after being married, giving birth, breastfeeding etc. gaining closeness through the sharing of highly praised bodily transitions, a type of access she had not been granted while still “a girl.” The ethnographic experience also emphasized the fundamental importance of developing trust and close relationships. The potential for control of information is obviously particularly extensive at a point when the researcher knows few of her study participants, and when simultaneously the researcher is relatively uninformed about the field of study, that is, during the phase when the researcher's role as “child” is most prominent. The gaining of closeness to the field is thus part of a process of becoming more knowledgeable about culture and context, the handling of language and codes, and of the continuous building of what is often experienced as true friendship. Karnieli-Miller et al. ( 2009 ) explain that: “to gain access to the participants’ private and intimate experiences—his or her story—the researcher must enhance a sense of rapport with people and needs to build a considerate and sympathetic relationship and sense of mutual trust” (p. 282). This point pertains to all qualitative research endeavours, but is particularly pertinent in ethnography with its common demands for long-term interaction. In the study, we considered the experience of being gradually more at ease with the continued outsider role, the learning process made the researcher more of an insider. “Interaction is always a tentative process,” Angrosino and Mays De Pérez ( 2000 , p. 683) write, referring to the mutual testing out of the perceptions of one's own and the others’ roles that takes place over time in ethnography. As such, the relationship between researcher and ethnographer, and researched, and hence each person's role toward the other, is not fixed and permanent within ethnography; rather, “their behaviors and expectations of each other are part of a dynamic process that continues to grow throughout the course of single research projects” (ibid p. 683). In a similar vein, we have indicated that the role of researchers as interviewers in the in-depth interview studies and in the focus group discussion studies were not fixed during the course of the interviews. Shifts took place both in relation to definition of the relevant body of knowledge, and the particular position of the researcher in knowledge production. Partly due to the time dimension and the demands of participation, the role of the participant observer is indeed far from static or fixed, but is constantly transformed during the course of the fieldwork (Werner & Schoepfle, 1987 ).

The vulnerability in designs with especially demanding inherent dual roles

In the final example, we shed light on how researcher vulnerability seemed to be part and parcel of the dual role of the researcher. In the pedagogical study (empirical example 6), the researcher simultaneously pursued the researcher role and the actor role, portraying a patient during communication training. Two focus group interviews with medical students were conducted after the communication training. The researcher thus shifted from acting the role of a particular patient in front of a group of medical students, to moderating the focus group discussions that evaluated the training from the students’ perspective. The students who participated in the focus groups were either solely a part of the student audience, which was encouraged to comment and suggest “ways to go” in the medical encounter played out in front of them during time-outs led by a teacher and moderator, or they were also involved in the acting as GPs in the simulated encounter.

The character of the SP was a young woman. She was shy, almost nonverbal, someone who gets very easily hurt and starts crying when challenged on personal matters. The topics of the training were “the withdrawn patient” and “breaking bad news” (the patient was told that she has cancer). To portray this patient was demanding, and the actress had to use most of her proficiency and skills as an actor to create a credible character. This created an ambivalent situation; she felt emotionally drained after the performance, and found it difficult to shift from the role of the actress to the role of the researcher who moderated the group interviews. Despite the fact that she was a professional actress and well acquainted with varied responses from audiences, she felt at the mercy of the students’ evaluation in unexpected ways. She found herself wishing for the students’ approval as an actress while simultaneously wanting to be genuinely open to the students’ views of the learning potential of this particular pedagogical practice, with this latter concern demanding the distanced approach of a researcher. Role confusion of both parties could contribute to an unsharpened reflection.

As Malacrida states ( 2007 , pp. 1329–1330), engaging in emotionally challenging research topics and relationships has the potential to unsettle researchers’ well-being, and challenge their self-understanding as researchers. Being in a more emotionally charged research context than initially expected might imply underestimating the strength of the emotional reactions (Dickson-Swift, James, Kippen & Liamputtong, 2008 ; Rager, 2005 ). It puts the researcher at risk of becoming emotionally drained (Dunn, 1991 ; Lalor et al., 2006 ). To take on the dual role as researcher and SP in the development of this particular pedagogical practice exacerbated the emotional challenge, and made it difficult to find a balance between insider–outsider positions (Burns et al., 2012 ; Dwyer & Buckle, 2009 ). Parallels to the vulnerability inherent in the participant observer role in the ethnographic study are present, particularly the feelings of being at the mercy of the participants. The manner in which the researchers opened themselves to exposure placed them in a vulnerable position. In an ethnographic context, the researcher will commonly have a long-lasting relationship with the study participants, which implies opportunities to re-evaluate the course of events and modify ways of approaching demanding topics and situations. This was not the case in the pedagogical project which enhanced the sense of overall vulnerability.

Concluding remarks

In this article, we have made an attempt to shed light on the researcher–researched relationship in different qualitatively anchored studies carried out within health science. We have concentrated on the phase in which the research material is co-produced by the parties, and the researcher is highly dependent on participants’ knowledge about the phenomena under study, and on their willingness to share. Flyvbjerg, cited in Karnieli-Miller et al. ( 2009 , p. 282) argue that the study of power relations should go beyond the normative level and be anchored in the real practices of qualitative research. In this article, we have anchored our analysis of shifts and ambivalence in the researcher–researched relationship by drawing upon concrete examples from our own research. The four main qualitative approaches represented; the phenomenological in-depth interview studies, the focus group discussion studies, the ethnographic study, and the pedagogical study, held a common aim of diminishing the distance between the researcher and the researched, and creating an anti-authoritative researcher–researched relationship. This meant moving into and confronting complex negotiations about the research agenda, about which knowledge was to be counted as relevant, shifts in “inferior” and “superior” knowledge positions, as well as ethical dilemmas. The scenarios that emerged challenged the researchers partly to re-think the research agenda, but it also rendered them vulnerable to substantial emotional stress. The dual role as insider and outsider, participant and researcher, added to the challenge. “Interaction is always a tentative process that involves the continuous testing by all participants of the conceptions they have to the roles of others,” Angrosino and Mays De Pérez ( 2000 , p. 683) write, with reference to ethnography. Researchers’ and participants’ roles are not fixed, but develop during the projects. The empirical examples in this article indicate that these are points of relevance for qualitative research projects, across designs and traditions.

In order to handle shifts in positions between research parties, shifts which are intertwined with ethical dilemmas, the practice of continuous reflexive awareness is paramount. The same holds true for the context of knowledge production; scrutinizing critically what can be at stake in the encounters between researcher and researched, and one's own role in knowledge production. We argue that sharing and discussing these concerns in research teams and groups, where senior researchers as well as novices meet, should be regular practice. The value of reflexive self-awareness among researchers has been contested. Personal disclosure can fall into an infinite regress of excessive self-analysis at the expense of the research aims (Finley, 2002 ; Gergen & Gergen, 2000 ). However, along with Finley ( 2002 , p. 532), we feel that the other pitfall is to avoid reflexivity altogether. Although fraught with ambiguity, a lack of critical awareness about the impact of the research context, perspectives chosen, methodological choices made, and, in this context, the presence of the researcher, might seriously hamper the knowledge claims made. Finally, we support Malacrida ( 2007 , p. 1339) who writes that “reflexive research also should involve emotional care not only for participants but for researchers themselves.”

Authors' contributions

The first author developed the project idea, moderated the group discussions, transcribed the tape-recorded meta-reflections, produced summaries, and had overall responsibility for the project, including the production of the drafts of this article. The first and the last author planned the group discussions together and were discussion partners between the group discussions. All participants were engaged in the group discussions, contributed to developing the core topics, and took part in writing the manuscript. The last author was more involved in writing the article than the authors in the middle.

Conflict of interest and funding

The authors have not received funding or benefits from industry or elsewhere to conduct this study.

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The Role of the Qualitative Researcher

In the following, we'll explore how the researcher conducting qualitative research becomes responsible for maintaining the rigor and credibility of various aspects of the research. In a way, this is analogous to the role statistics, validated and reliable instruments, and standardized measures and methods play in quantitative research.

After reviewing this document, you will be able to:

• Compare the role of the qualitative researcher with the role of standardized instruments, measures, and methods in quantitative analysis.
• Monitoring and reducing bias,
• Developing competence in one's methods,
• Collecting the data,
• Analyzing the data, and
• Presenting the findings.

Integrity of the Research is the Issue

Recall from other qualitative courses that qualitative researchers are as concerned about the integrity of their research as quantitative researchers, but they face different challenges. Before examining how the researcher is key to research integrity in qualitative research, let's note some terminology differences between the methodologies. The below provides them at a glance. These are terms related to research integrity:

In Quantitative: designs, validity, reliability, and generalizability (or external validity) are based on the integrity of the design, and of the methods, and instruments used, and only to a lesser extent to the person of the researcher.

In Qualitative: on the other hand, credibility, dependability, and transferability rely on the person and performance of the researcher.

This is why we talk about the role of the researcher in qualitative research.

The Integrity of the Research Equals The Integrity of the Researcher

Of course, this is true of both quantitative and qualitative research. Researchers make errors, and these threaten the validity, reliability, and utility of their studies.

Qualitative researchers, however, lack many of the protections against errors that the statistical methods, standardized measures, and classical designs afford. They must rely on their own competence, openness, and honesty. That is, on their person. Thus, their role, the role of the researcher is more open to scrutiny.

Role of Researcher: Monitoring and Reducing Bias

Bias is a source of error. When a quantitative researcher administers a standardized test, bias is less a problem than when a qualitative researcher has a conversation with a participant. Why?

The researcher's ideas—about the study, her knowledge, about the topic from the literature review, hopes for the study, and simply human distractibility—crop up constantly and can distort what she hears. Confirmation bias—(the name for this) afflicts quantitative researchers, too, but more often when they are analyzing data and seeing what they are disposed to see. Qualitative researchers, whose human brains are trained to find meaning in everything, encounter confirmation bias in every interaction with both participants and data.

Therefore, monitoring and reducing one's disposition to interpret too quickly is an essential part of the researcher's role. Qualitative researchers have evolved a variety of methods for this, such as the famous phenomenological reduction and epoché, but every design within qualitative methodology requires an explicit description of how the researcher will remain conscious of his or her previous knowledge and dispositions and how he or she will control the intrusion of bias.

For example, many qualitative researchers practice mindfulness meditation as a means to become aware when their thoughts are about previous knowledge rather than open and receptive to the information from the participant.

Role of Researcher: Developing Competence in Methods

Many novice researchers think they are competent to do qualitative research. Unfortunately, they are usually wrong.

Qualitative methods, like quantitative methods, require implementing specialized skills correctly. Competence in these skills is required at all these points:

• Explaining the study without biasing the potential participants.
• Conducting interviews properly, according to the design.
• Making appropriate field observations.
• Selecting appropriate artifacts, images, journal portions, and so on.
• Handling data per design.
• Analyzing and interpreting the data per the design.

This competence is not taught in most methods courses; novice researchers are often expected to obtain training and practice on their own. What should they do?

Here are some ideas, although they are not prescriptions and you may find many other ways to develop competence.

The first step: is to self-assess your competence. Assume you do not have competence in each of the skill areas unless you have demonstrated it to someone who knows. If you perform interviews of clients, for example, but have never been taught to do interviews for research, assume you do not have the competence until a researcher who uses interviews tells you that you do.

The next step: is to talk with your mentor— about a plan to get training. For example, many learners who need to demonstrate competence in qualitative interviews do a few practice interviews and ask their mentors to critique their technique. The coaching not only amounts to a kind of training, but the mentor can then attest to the researcher's baseline competence. Another common plan is to attend training workshops in the actual design—such as grounded theory—conducted in research organizations or universities.

For each skill set your design requires you to have, including practicing the analysis methods, create a training plan that includes demonstrating competence to someone.

Is this more work? Maybe so, maybe not. If you were conducting a multiple regression analysis and did not know how to do that, you'd have to learn it, practice it, and demonstrate your competence to someone. So, it's all a matter of perspective.

Role of Researcher: Collecting and Analyzing Data

There are far too many complications in collecting and analyzing qualitative data to cover in this presentation. Have you ever:

• Wired someone with a microphone and inadvertently touched a sensitive body part?
• Sat in a schoolyard to make field observations amid the chaos and swirl of 200 hundred children at recess and known where to start?
• Been confronted with 500 pages of a single-spaced transcript and, known where to start?
• Brought a straying interviewee back to the topic in a way that not only did not offend but actually improved rapport?
• Asked questions that didn't betray what you think the answer should be?
• Sorted through 10,000 sentences or 500 pictures to identify which ones should be retained as data and which ones could be discarded?
• Recognized when you have an actual finding. In other words, can you spot a finding in qualitative analysis?

These are but a few of the challenges that the qualitative researcher faces. Are you ready? Probably not. What should you do?

• Acknowledge that you are a novice. A dissertation is an apprenticeship or internship in research. No one expects the apprentice or intern to be a master.
• Committee members.
• Other dissertators, those in your mentor's courseroom, but also others around the world. Read similar dissertations and write to their authors asking for tips and tricks. Authors love knowing that someone is reading their work.
• Professional researchers. These professionals are scholars, and they will help, at least many of them will. Two or three e-mails that yield excellent advice—and perhaps an ongoing relationship—are well worth the investment of anxiety and time.

Role of Researcher: Presenting the Findings

Most of us present findings in writing. While a few will also present their findings in posters and oral presentations, everyone in Track 3 will at least present them in writing.

Develop and demonstrate competence in writing!

Dr. James Meredith of the Capella Writing Program points out that you have to write your way out of the doctoral program.

Capella makes an extraordinary effort to provide support and instruction in scholarly writing, primarily through the Capella Writing Program and the Online Writing Center. Failing to take advantage of all these resources will result in your findings being sent back to you for revision. Why waste the time? Right now, you can and should start to make use of:

• The Scholarly Communications Guide; it's available in the Dissertation Research Seminar courseroom for you.
• Review and get familiar with the Dissertation Chapter Four Guide (qualitative or quantitative); this too is available in the Dissertation Milestone Resources area on iGuide. It offers a conventional way to structure the findings chapter of the dissertation. By learning it now, you'll have in mind a set of ideas about what sort of competence in writing and in analyzing your data you'll need at this point in the project.
• Resources for writing in the Capella Writing Program; these are broad and deep—you will be ignoring a treasure that would help you succeed if you fail to take advantage of these.
• And, perhaps most important, read dissertations and articles; read dozens in your specific methodology and design (for example, phenomenology or grounded theory). Get to know what other novice researchers are doing and how well they are doing it. Open your mind to learning from them, and remain critical of their errors and foibles: we all have them. Make it your goal to absorb the style and conventions of writers using your methodology and design.
• Learn APA style; again, Dr. Meredith reminds us that the correct use of APA format and style is an automatic claim to credibility! Remember that the converse is also true: APA errors, or even ignoring the format and style rules, automatically deprive your writing of credibility and trustworthiness.

We've covered the importance of evaluating your own role as the researcher, in the various elements of a qualitative study:

• Monitoring and reducing bias.
• Developing competence in one's methods.
• Collecting the data.
• Analyzing the data.

Doc. reference: phd_t3_u06s1_qualrole.html

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The role of the researcher in qualitative research and researcher diaries

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Nitel araştırmaların çoğalmasıyla beraber nitel araştırmacının sorumluluklarının da vurgulanması gündeme gelmektedir. Nitel araştırmacının nicel araştırmacıdan farklı rol ve sorumluluklara sahip olması beklenmektedir. Nitel araştırmanın etkin ve yararlı olması büyük ölçüde araştırmacının becerisine bağlıdır. Çünkü nicelden farklı olarak nitel araştırmalarda; araştırmacı sadece veri toplayıp çeşitli yöntemlerle analiz edip raporlama yapmamakta; araştırmanın kurgusuna dahil olup, empati kurmakta kimi zaman katılımcılarla beraber olay ve olguları deneyimlemekte ve bu sayede kazandığı bakış açısıyla sonuçları yorumlamaktadır. Araştırmacı günlüklerinin önemi tam da bu noktada ortaya çıkmaktadır. Araştırmacı, veri kaynağı ve kendisini bir üst bakışla değerlendirme kanalı olarak araştırmacı günlüklerini kullanabilmektedir. Günlüklerin, araştırma sürecinin nasıl yaşandığının bir anlamda içsel sunumunu ortaya koymaları bakımından sürece ve ürüne yönelik katkıları bulunmaktadır. Araştırmacı, çalışmasının bağlamını yansıtabilmek adına günlüğündeki alıntıları kullanarak yaşanılanların aktarımında projeksiyon görevini gerçekleştirirken; günlüğün geçmişe yönelik analize tabi tutulabilecek ürün olması önemli bir yardımcıdır. Araştırmacı günlükleri betimsel detayları yansıtmasının ötesinde, nitel araştırmalarda önemli olan “inandırıcılık” kavramının sağlanmasında da çok önemli bir veri kaynağıdır. Bu araştırmada nitel çalışmalarda araştırmacı günlüklerinin önemi ve gerekliliği tartışılmaktadır.

Alternate abstract:

With the proliferation of qualitative research, the responsibilities of the qualitative researcher are also emphasized. The qualitative researcher is expected to have different roles and responsibilities than the quantitative researcher. The effectiveness and usefulness of qualitative research largely depend on the researcher's skill. Because, unlike quantitative, in qualitative research, the researcher does not only collect data but also analyzes and reports with various methods, participates in the construction of the research, empathizes, sometimes experiences events and phenomena with the participants and interprets the results from the perspective he has gained in this way. The importance of researcher diaries emerges at this point. The researcher can use the researcher's diaries as a data source and as a channel for self-evaluation. The diaries contribute to the process and the product by revealing an internal presentation of how the research process was experienced. In order to reflect the context of his/her work, the researcher uses the quotes from his/her diary while performing the projection task in the transfer of experiences; It is an important help that the diary is a product that can be subjected to retrospective analysis. Beyond reflecting descriptive details, researcher diaries are also a very important data source in providing the concept of "credibility", which is important in qualitative research. This study discusses the importance and necessity of researcher diaries in qualitative studies.

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• Published: 08 June 2024

A multi-method exploration of a cardiac rehabilitation service delivered by registered Clinical Exercise Physiologists in the UK: key learnings for current and new services

• Anthony Crozier 1 ,
• Lee E. Graves 1 ,
• Keith P. George 1 ,
• David Richardson 2 ,
• Louise Naylor 3 ,
• Daniel J. Green 3 ,
• Michael Rosenberg 3 &
• Helen Jones 1  

BMC Sports Science, Medicine and Rehabilitation volume  16 , Article number:  127 ( 2024 ) Cite this article

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Cardiac rehabilitation has been identified as having the most homogenous clinical exercise service structure in the United Kingdom (UK), but inconsistencies are evident in staff roles and qualifications within and across services. The recognition of Clinical Exercise Physiologists (CEPs) as a registered health professional in 2021 in the UK, provides a potential solution to standardise the cardiac rehabilitation workforce. This case study examined, in a purposefully selected cardiac exercise service that employed registered CEPs, (i) how staff knowledge, skills and competencies contribute to the provision of the service, (ii) how these components assist in creating effective service teams, and (iii) the existing challenges from staff and patient perspectives.

A multi-method qualitative approach (inc., semi-structured interviews, observations, field notes and researcher reflections) was employed with the researcher immersed for 12-weeks within the service. The Consolidated Framework for Implementation Research was used as an overarching guide for data collection. Data derived from registered CEPs ( n  = 5), clinical nurse specialists ( n  = 2), dietitians ( n  = 1), service managers/leads ( n  = 2) and patients ( n  = 7) were thematically analysed.

Registered CEPs delivered innovative exercise prescription based on their training, continued professional development (CPD), academic qualifications and involvement in research studies as part of the service. Exposure to a wide multidisciplinary team (MDT) allowed skill and competency transfer in areas such as clinical assessments. Developing an effective behaviour change strategy was challenging with delivery of lifestyle information more effective during less formal conversations compared to timetabled education sessions.

Conclusions

Registered CEPs have the specialist knowledge and skills to undertake and implement the latest evidence-based exercise prescription in a cardiac rehabilitation setting. An MDT service structure enables a more effective team upskilling through shared peer experiences, observations and collaborative working between healthcare professionals.

Peer Review reports

In the UK, 26 million people live with a long-term health condition, of which 24% have two or more conditions [ 1 ]. By 2035 the UK population is estimated to grow by over four million, with a 50% increase in the over 65s, and a quadrupling of those with four or more illnesses (multi-morbidities) [ 2 ]. In recognition of this rise in both population growth and associated chronic and complex medical conditions, the National Health Service (NHS) long-term plan identified the need for clinical exercise services within acute care pathways to aid the prevention and treatment of non-communicable diseases [ 3 ]. The need for specialist exercise staff within clinical settings, primarily with higher education qualifications / backgrounds, has been frequently acknowledged [ 1 , 2 , 3 , 4 , 5 ]. Yet until recently, a lack of clarity has existed regarding what exercise services are being offered, to whom, and by whom to create an effective system-wide approach in exercise service provision for long-term health conditions [ 4 , 5 ]. We [ 5 ] reported inconsistency in UK clinical exercise service provision, notably disparities in exercise specific job titles (e.g., clinical exercise physiologist (CEP) or exercise instructor) for individuals not part of statutory regulation, leading to inconsistency in staff scope of practice, knowledge, skills, competencies and experience within services [ 1 , 2 ]. Such variances have led to a diverse workforce ranging from vocational to postgraduate master’s level qualified staff delivering exercise within clinical settings making it difficult to compare within and across services [ 1 , 2 , 3 , 4 , 5 ].

In the UK, clinical exercise service provision are most frequently available for those with cardiovascular disease ( n  = 242) or more specifically for coronary heart disease, with the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) providing guidance to standardise exercise provision [ 2 , 6 ] and the National Audit of Cardiac Rehabilitation (NACR) [ 7 ] auditing delivery. Although UK cardiac provision retains some similarities to its international peers (e.g., Australia) regarding service structure [ 8 , 9 ], there are differences in staff knowledge, skills, competencies and job titles for those delivering the exercise components [ 2 ]. Indeed, structured education and employment pathways for registered/accredited CEPs have existed internationally across long-term conditions for ~ 30 years (e.g., Australia and USA) [ 10 , 11 ]. Conversely, in the UK only 18% ( n  = 61) of exercise staff within cardiac services were postgraduate qualified CEPs [ 2 ]. This lack of consistency even in the most standardised service network is concerning when trying to regulate patient care and ensure patient safety [ 1 , 2 ]. The recognition of Clinical Exercise Physiologists (CEPs) as a registered health professional in 2021 in the UK, provided a potential solution to standardise the cardiac rehabilitation workforce.

Our recent case study examining a unique, successful and large UK cancer pre/rehabilitation service found that exercise specialists were (typically) degree qualified and possessed equivalent knowledge, skills and competency levels to apply for Academy for Healthcare Sciences (AHCS) CEP registration via an equivalency process [ 12 ]. Yet, this level of qualification is rare as 88% of exercise delivering staff in UK cancer services did not possess an undergraduate degree or higher [ 2 ]. Therefore, a purposeful case study to understand how registered CEP knowledge, skills and competencies contribute to the provision of a cardiac-based clinical exercise service is valuable to understand best practice, as job titles alone are not sufficient to judge service effectiveness or staff qualities [ 1 , 2 , 3 , 5 ]. Consequently, the service purposefully selected to be examined in this study was chosen because it was; (i) well established ( n  = 30 years) and delivered clinical exercise provision by registered CEPs as part of a multidisciplinary team (MDT), (ii) delivering exercise to wider range of patients with cardiovascular disease including high-risk cardiac and vascular conditions as well as with congestive heart failure, (iii) conducting research into enhancing exercise service provision for cardiac rehabilitation as well as other conditions, (iv) uniquely operating in a dedicated building for exercise services with use of a purpose build gymnasium for strength and conditioning, and (v) commissioned by the NHS. This purpose-built study aimed to explore how CEP staff knowledge, skills and competencies contribute to the provision of a cardiac-based clinical exercise service, how these components assist in creating effective service teams, how they differ to previously explored services, and to identify what challenges currently exist from staff and patient perspectives.

Design and theoretical underpinning

A case study format employed ethnographic principles (the exploration of peoples’ habits and beliefs) to uncover values and attitudes retained by the participants [ 13 ]. Multiple qualitative methods (online semi-structured interviews and face-to-face observation and field notes) were employed to explore the service from staff and patient perspectives both individually and collectively [ 13 ]. This qualitative multi-method approach, combined with the longevity of the study and data triangulation, was employed to reduce potential social desirability and bias from staff and patient perspectives [ 14 ]. Ethical approval was obtained from East Midlands - Leicester South Research Ethics Committee [ref: 21/EM/0227]. The lead researcher spent 2–3 days per week for 12 weeks in the service between April - July 2022. The ethnographic data via field notes and observation was the primary focus allowing rapport to be developed with both staff and patients before the completion of semi-structured interviews at the end of the 12 weeks [ 14 ].

Consolidated framework for implementation research (CFIR)

A comprehensive implementation framework (CFIR) was adopted [ 15 ]. CFIR links existing theories to create ideas concerning what works, where, and why within services, aiding future service implementation and evaluation [ 15 ]. Specific components relating to service delivery including staffing structures, staff skills and competencies, and patient perceptions allow a detailed exploration of these areas through contextual discussions regarding service operations [ 15 , 16 ]. All five sections of CFIR were drawn upon throughout this study (see Table  1 ) and provide a framework for interview guide (additional file 1).

The AHCS registered CEP-led cardiac service

This NHS service was created over 30 years ago, initially as a nurse and physiotherapist-led cardiac rehabilitation programme, which shifted to being CEP-led for exercise provision ~ 25 years. The programme is delivered over two sites. The primary site being community-based, the other being within a hospital. An umbrella term for the service is cardiac rehabilitation, yet face-to-face exercise support for patients is offered for a variety of cardiac (e.g., post-myocardial infarction), vascular (e.g., peripheral vascular disease) and heart failure (e.g., left ventricular failure) conditions. Patients are contacted after diagnosis or treatment (either surgical or non-surgical) regarding the uptake of physical (e.g., exercise), nutritional and psychological support. Full details of the intervention are provided in Table  2 [ 17 ].

Participant recruitment

Participant recruitment was based on convenience sampling across both staff and patients, with all CEPs expressing a willingness to participate. An initial (virtual) scoping meeting was conducted with the service multidisciplinary team (MDT) [ 17 ]. In this service the MDT included AHCS-registered CEPs, dieticians, cardiac nurse specialists, and clinical service leads/managers, with occasional consultant interactions in the event of unforeseen complications. The meeting explained the study aims and objectives, after which written consent was obtained covering each aspect of the data collection, including semi-structured interviews and observation. The final sample included MDT staff ( n  = 10); a clinical service manager ( n  = 1), clinical service lead ( n  = 1) who oversaw the intervention, AHCS-registered CEPs ( n  = 5), cardiac nurse specialists ( n  = 2) and a dietician ( n  = 1). Staff members were white British, female ( n  = 7) and male ( n  = 2) and black male ( n  = 1), aged between 26 and 45 (mean age of 40). All participants were employed full-time by the NHS with a minimum of two years’ experience in the role.

Patient recruitment was conducted using a verbal announcement before weekly classes ( n  = 8) asking if attendees ( n  = 45) wanted to participate in the study with field notes used to record observational data, including conversations. All patients attending the sessions verbally consented to observational data collection by the lead researcher and were provided with a written study information sheet and consent form. No one formally declined or stated any reasons for not taking part, but often participants preferred to concentrate on the exercise components without fielding questions during conversations for data purposes. Patients ( n  = 7) were white British, female ( n  = 3), male ( n  = 2) and Asian, male ( n  = 2). Patients were retired/not working, had a mean age of 61 years, reported various long-term medical conditions, but were specifically referred due to having one of the umbrella terms of cardiac-related conditions accepted via the service inclusion criteria (e.g., post-myocardial infarction, heart failure, peripheral vascular disease). The research team’s involvement was limited to participant recruitment and data collection.

Data collection

Staff participants had individual caseloads, although patients came together during group exercise sessions. Patients were assigned to specific sessions (days/times) of their choosing, yet could be unpredictable in their attendance due to various factors (e.g., health, transport). Observational data in the form of field notes were used to capture a sufficient cross-section of patient experiences across different sessions within the intervention, encouraging peer interaction and the promotion of shared experience where possible [ 12 ].

Semi-structured interviews

The semi-structured interview guide (see additional file 1) was developed based on the CFIR framework. Pilot interviews were conducted by the first author with three independent researcher peers prior to study commencement to enhance credibility and refine interview questions where necessary [ 12 ]. Interviews ( n  = 10) were conducted on an individual basis by the first author via a secure virtual platform (Microsoft teams) lasting 28 min on average (ranging from 24 min to 36 min). Written consent was obtained and interviews were visually and audio recorded with prompts and probes used to elicit more detailed responses from participants [ 18 ]. A brief verbal summary was provided by the researcher at the end of the interview to clarify the main points and allow participants to add further information (where required) [ 19 ].

Observation and field notes

Ethnographic principles were adopted during the observation of the setting, including the daily practices of the staff and their patient interactions [ 13 ]. Notable moments were written down in a note pad in the form of keyword entries [ 14 ]. Memories and reminders in the field notes then allowed the observations and conversations to be developed into a research log, typically completed during lunch breaks or at the end of each day, and never more than 24 h after the original observation to prevent the risk of memory fading and details being lost [ 14 , 20 ]. Such accounts were accompanied by researcher insights and interpretations of events which contributed to the understanding of the setting and a narrowing of the research lens [ 14 , 20 ]. During this process, the research team acted as “critical friends” and theoretical sounding boards [ 21 ].

Data analysis

Data obtained through the semi-structured interviews and field notes via participant observations were audio and visually recorded using a portable Dictaphone and Microsoft Teams, then transcribed verbatim. Data were thematically analysed manually using reflexive thematic analysis recommendations such as data familiarisation, generating initial themes, coding and finalising patterns of shared meanings underpinned by a central concept, and writing up using data extracts interspersed with researcher insights and interpretations [ 22 ]. Although the data themes generated were (deductively) linked in relevance to the pre-determined categories formed by the CFIR-guided research questions, the patterns of shared meanings were generated from the data themselves allowing interpretation and researcher contextual awareness to be discussed [ 22 ]. Flexibility in analysis was driven by both the prevalence (number of speakers articulating the theme) and the importance placed on information [ 22 ]. It is important to note that “data saturation” or “data adequacy” could be assumed as no new themes were identified when analysing the final few transcripts [ 23 , 24 ]. Primary analysis was conducted by the first author with frequent debriefing sessions with the research team to discuss, challenge and reframe the thematic structure [ 21 , 25 ].

Creating the non-fiction composite characters

Large volumes of data were collected and analysed, therefore, alongside confidentiality issues, it was deemed unrealistic to present singular case studies for all staff and patients [ 26 ]. Subsequently, four ‘composite characters’ were created to tell the stories and journeys throughout the service. The narratives of the four participants were created based on participants who shared some similar, common experiences or backgrounds during their time within the clinical exercise service setting, but also have potentially different perspectives on the culture of clinical exercise services [ 26 ]. The theme and identity that holds these characters together are; Character 1 (Sam) was a CEP with more than six years’ experience in the role, undergraduate degree qualified in sport and exercise science with additional vocational qualifications in cardiac rehabilitation; Character 2 (Lauren) was a CEP with a minimum of three years’ experience in the role, has a master`s degree in a clinical exercise physiology-related field and additional vocational qualifications in cardiac rehabilitation; Character 3 (Tom) represented the wider MDT team of non-CEP clinical leads/managers, clinical nurse specialists and dieticians who had undergraduate degrees, Health and Care Professions Council (HCPC) or relevant nursing council registration and excess of five years’ experience working in cardiac rehabilitation; Character 4 (Mira) was a retired/non-working patient attending the 12-week programme due to cardiac-related condition. The stories and interactions are told using the CFIR themes as underpinning headings, through the critical moments that occurred within the journey through the programme, but not necessarily in chronological order [ 27 ]. The composite character interactions are told from the researchers first-person perspective as they had come to understand them [ 28 ].

Lead researcher positioning

Given this study was based upon ethnographic principles, lead researcher self-reflexivity was important due to researcher background and training within clinical exercise provision [ 29 ]. This experience could provide pre-conceived ideas regarding exercise provision and enable a broader interpretation of participant concerns or thoughts [ 29 ]. Such reflection means that this article will retain the use of “I,” “me,” or “my” on occasion and as such refers to the first author [ 29 ]. What follows is a researcher’s story of “self” experience, alongside the “other,” in this case, the collective thoughts of staff and patients concerning their experiences within a clinical exercise service [ 29 , 30 ]. The data extracts represent each individual’s experiences and opinions at a given time and, in combination with my observations, re-creates a holistic view of experience representative of what any individual may be exposed to in the service at a point in time [ 29 , 30 ].

As an AHCS registered CEP who had been employed in a similar role previously, I acknowledged that I needed to see past my own preconceptions or bias and use such constructs as a basis to probe further into specific actions and behaviours. An open and honest relationship developed during the early weeks of observation with any researcher vs. participant barriers seemingly lowered after the initial 2–3 weeks. At the outset I would have classified myself as an outsider in collaboration with insiders given that I approached the service to observe it [ 31 , 32 ]. Yet, after this initial period and given my cardiac rehabilitation background, the relationship felt like it had morphed into one of an insider, in collaboration with other insiders due to the flowing nature of the conversations and the mutual respect that appeared to develop through shared experiences [ 31 , 32 ]. The following findings and discussion include reflective extracts that are in italics, indented and single-spaced to ensure separation from the descriptive representation.

Results and discussion

Introduction.

The service was exiting COVID-19 restrictions when I was first introduced to Sam, Lauren and Tom, resulting in a pre-arranged virtual discussion over MS Teams. At this point they had little knowledge of me, my background, or how I might portray them and their service. After a brief introduction I verbally explained my purpose. Following this, I paused to allow time for questions/concerns (of which few were raised). I felt my research aims were understood and an acceptance of me (given my background) was initiated. Although the online meeting was challenging as it was hard to gain a true representation and sense of feeling displayed by staff, I had experienced this before (e.g [ 33 ]) and was prepared for some silences [ 34 ]. Moreover, because all staff were engaged (currently or previously) in research projects within their work, there was an understanding of what to expect and a recognition that research is vital in furthering the evidence base and maintaining currency in the field. Their acknowledgement of, and familiarity with, research alongside their level of comfort with observation was reassuring. I would be surprised if other services without research links would have been so at ease. I left the meeting feeling content that I had set the tone for my face-to-face encounter in a few days.

Face-to-face contact

I arrived on the primary community-based site early hoping to create a good impression, but also expecting to see how staff prepared for the day ahead. I received a warm welcome with open body language while being re-introduced to the team by Sam. A walk around the facility followed, accompanied by an explanation of the current staffing levels (two CEPs had recently left) and how that impacted exercise sessions. The building was two-floored, on the bottom was a café and seating area for patients to relax, prepare and recover from their exercise sessions. It had toilets, changing and showering facilities and included the main gym floor area where the cardiac-based sessions took place. The first-floor featured meeting rooms, offices, assessment rooms and exercise studio space which contained portable equipment for use within classes when applicable. The first hint of NHS involvement and clinical working was the separation of these spaces. There was a clear divide from a logistical perspective; keypad restrictions were in place throughout the second floor to negate public access, alongside telecom access through the front door into the building itself. The gym environment had a friendly, yet clinical feel, mainly due to uniforms displaying NHS logos, half of which were worn by clinical nurse specialists. Mask wearing by staff, although no longer mandatory by law, provided another example of how (inadvertently I`m sure) the service presented a clinical feel. Yet its size (roughly 20 m by 15 m) and the volume of apparatus (six rowers, two Ski Ergs, double digit treadmills/X-trainers, resistance machines, TRX suspension trainers, free weights and portable equipment) made the gym unique in its appearance compared to other clinical services I had observed.

This was a considered layout that maximises the available space. An area for walking around the equipment was ideal for a warm up and cool down and guidance resources were on the walls (information that could remind patients about how they should be feeling such as Rate of Perceived Exertion (RPE) and claudication charts, stretching and resistance-based exercise posters). Anecdotally this is not uncommon, but I`d be interested to see how staff use these – do they get patients to actively engage with the materials? Or, are they included because it`s best practice only?

Sam and I discussed current service operations, but swiftly digressed into how incorporating virtual exercise classes could improve their offering. There was a feeling from Sam that integration of online sessions could potentially lessen some of the access barriers regularly cited by patients (e.g., transport), in addition to advancing their `menu-based` delivery [ 35 ]. Rather unexpectedly, this discussion shifted into a Q&A led by Sam who wanted to understand my experiences of virtual exercise delivery (an area I had previously observed, e.g [ 33 ]).  Offsetting safety with expanding reach and exercise adherence were main discussion points, but from a personal perspective being a sounding board for virtual exercise delivery in practice felt fantastic and demonstrated a level of acceptance even at such an early stage of my stay.

One of my underlying concerns before I entered the service was the staff perceptions of me, as an unknown entity I expected doubts about my skillset and knowledge of the setting. It was refreshing to openly chat about patient screening and risk assessment, accessibility, exercise prescription and adherence – all of which I was familiar with and could offer insight into. My impression was that Sam gained confidence in my ability during our conversations (shared knowledge and findings) which demonstrated my own researcher and practitioner credibility. Over time I found these types of discussion became more prevalent and enabled me to be accepted as a peer rather than seen as an outsider collecting research. My opinions mattered and a more natural relationship with the staff began to form.

CFIR Sect. 1.1 – CEP-led service conception

I entered the service knowing that certain components were unique compared to the wider cardiac rehabilitation landscape through my previous research; primarily the sole use of registered CEPs for exercise delivery, compared to unregistered CEPs or exercise specialists with vocational qualifications [ 2 ]. I wanted to understand the reasons behind this; Did it change, why and how long has it been like this? Numerous conversations skirted around the subject over the weeks as both Sam and Lauren acknowledged that it was all they had known within this service. Interestingly, they talked about their initial assumptions regarding exercise delivery within clinical services, which centered on the belief that others (services) followed suit and utilized CEPs similar to themselves with training and education in exercise prescription and the ability to become registered once AHCS registration became available;

Sam: “I`ve never known anything different, it`s only when you start talking to other people (at other services) that you discover they are different…lots (of services) are nurse or physio-led…I don`t know why or when we changed…but to me it comes down to the knowledge and skillset…exercise prescription quality and knowledge…I feel the CEP background of exercise prescription is strongest due to CEP degree training (undergraduate and/or postgraduate)…physio`s and nurses look at things in a different way, more recovery focused”.

Without wanting to misrepresent the abilities of other health professionals, Sam made it clear that CEPs were his choice to lead the exercise component within clinical services. CEP inception within this service, however, came from somewhere and it was only during a conversation with Tom at the back end of my stay where I finally found some answers;

Tom: “We were working with physiotherapists some ~ 25 years ago, but they were coming to the end of their careers, so we looked at what was going on in America, how their private care providers worked. At the time BACPR was just taking off, we did some exercise-specific training for the nurses and we were approached to see if we wanted to take on a very young exercise specialist (officially titled a CEP) for 7 hours a week to complete our assessments and it grew from there…it was a new concept, nationally rehab was more about the nursing teams and physiotherapists… overall care could be very static and traditional for these patients…discharged at 10 days…rehab was 6–8 weeks post-MI but (exercise) with the physiotherapist felt quite static…a one size fits all approach…we felt that having a CEP that was solely exercise focused would be beneficial”.

This was one of many lightbulb moments for me. This service did not want to just follow tradition. Although they had no issue with the exercise provision that was being provided and valued the work of the current team (physiotherapists), they wanted to explore additional ways to improve the service and enhance the care they offered…they felt that a combination of healthcare professionals would do this and expanded the skillset across the team.

Tom identified that personalized patient care had to be at the forefront of service delivery. Exercise, although prominent in later stage care, was now even more vital in the rehabilitation process, therefore, the most specialist people (CEPs) were needed to deliver it.

CFIR Sect. 1.2 – referral pathways and health care professional interactions

It was clear from the outset that this service had a well-established referral pathway due to the levels of organization and clear protocols that were in place (e.g., referral forms sent via secure NHS email). Lauren explained that “Patients are picked up on the wards by the nurses, they’re referred straight into the service, from bedside risk factor education to consent for exercise participation”. From a patient perspective, the ease of the journey was vital. Mira acknowledged that the service was efficient; “I couldn`t believe how quick I got started and how thorough it was…they helped me understand my condition and that it was safe to exercise”. It became apparent when discussing referrals that the ability to educate and `recruit` patients efficiently was, in part, explained by their capacity to engage straight away, but also the knowledge and skills of how to communicate with patients. Conversations were engaging, open and friendly, with active listening taking precedence. I observed Sam discuss Mira`s procedure (angioplasty) and then listened as he provided a detailed brief of the steps she would go through during her time in the service, allowing questions along the way.

Active participation in research was also vital in the development and exploration of different referral pathways. One example being the Post-sternotomy Cardiac Rehabilitation Exercise Training Study (SCAR) which identified that (qualifying) patients could be exercising earlier than guidelines stated (2 weeks rather than 6 weeks post-sternotomy) [ 36 ]. This innovative research was translated into practice and shifted the referral process guidelines within this service into a new evidence-based format;

Sam: “I worked on the SCAR trial which monitored patients during exercise earlier than normal post-surgery…6 weeks was the guidance, but that had seemed to be plucked out of thin air with no real evidence…once the study had finished I went to the surgeons at the hospital, delivered the outcome evidence and developed new referral pathways…we have started bringing people in earlier, I had someone today who is at 4 1/2 weeks, rather than them sitting at home festering for 6 weeks”.

Generally, exercise services will rightly follow national guidelines (e.g., BACPR) for patient recruitment, this service (due to the knowledge and skills of the CEPs) looked to use their latest evidence to enhance patient outcomes in areas such as cardiovascular fitness in an earlier timeframe [ 36 ]. Moreover, this decisive integration into the rehabilitation system allowed a speedier onward referral into the CEP-led phase IV service that was available on site but delivered by a private partner. The concept of phase IV is nothing new, but having CEPs deliver it is quite unique [ 2 ] as Sam explained to me;

“It`s great being able to see patients move from us (to phase IV) and remain here…we can follow their journey from a distance…it`s great to know they`re remaining active…being looked after by similarly qualified CEPs in phase IV…I don`t think this continuity of care is common”.

Having that seamless onward referral process extremely positive for the service. There was a level of trust in Sam`s voice, happiness in the knowledge that patients were going to be looked after by equally qualified peers.

An on-site MDT was a positive factor in the whole referral process (more control and capacity to deal with the patient flow) [ 37 ]. From working in this setting, I know that creating a fluid, timely and consistent patient journey is not easy. Here, in part, it came from longevity of the service (pathway development over time), but primarily through the knowledge of how a clinical service should operate and a willingness to implement it by the team. The service had long-standing relationships with the hospital-based health care professionals (e.g., consultants) which enhanced their referral pathways. Even though patient suitability and uptake fell within the realms of Tom, frequent conversations by all team members could be had with consultants regarding surgical or non-surgical treatments, complications, or re-referrals if contraindications were identified at any point. Yet, even in this service, Sam made me realise that interactions with health care professionals can, on occasion, be difficult and sometimes a barrier to providing specialist care;

Sam: “…we speak to consultants, there was a time when they were not really sure who I was or what I did, for example, if I noticed someone hadn’t been started on a medication and queried it, they’d wonder why as I was not a nurse…I think it was a lack of understanding…it’s a fairly new role and not many trusts have CEPs”.

This lack of awareness, even in such an innovative service, was concerning, but not uncommon based on my own experiences. Sat in the office during admin time, I wanted to understand the cause of this issue so I questioned the team;

AC: “How could you improve your relationship with other health professionals?”

Sam: “…recognition of our role within a hospital setting in terms of registration is one way, but it`s challenging, we’re not recognised as a as an allied health professional, even though we`re now AHCS-CEPs”.

AC: “How`s that a problem?”

Sam: “It’s the understanding of our role, people (in the NHS) don’t feel that we have the skillset to deliver the intervention, sometimes it can be an issue, I`m sure it could impact referrals (in other services)” .

AC: “ But it doesn’t here ?”

Sam: “For us, not massively, but I would imagine it could do if we were not as well established as we are”.

On a wider scale, referral pathways could be impacted if a lack of confidence from referring practitioners were identified [ 4 ]. Moreover, perceptions about scope of practice may impact the patient journey, and ultimately the level of care they receive [ 4 ].

After two months of observation it is evident and acknowledged by the team that service links with health care professionals were in place. Having Tom on the wards with a nursing background made the whole process easier. Perceived or real scepticism from other health care professionals in NHS regarding the skillset and scope of CEPs was concerning. The questioning of their belonging and what they could offer, especially as they now hold healthcare registration, demonstrates that an awareness of CEPs is needed to improve interprofessional relationships which can only improve healthcare services in the long-term.

CFIR Sect. 2.1 – patient integration and support

A few weeks into my observations and keen to see the level of support Mira received, I sat in on an outpatient consultation (on site in the community exercise facility) led by Tom. This was the first time Mira met Tom outside of the hospital environment (4-weeks post-surgery). We sat in a small office upstairs which reminded me of a doctor’s surgery with its white walls and randomly placed NHS-based posters. There was a relaxed atmosphere yet the discussion, although polite, friendly and occasionally humorous, was clearly one of a patient/nurse due to its interview-based format. Tom and Mira exchanged high volumes of questions/answers/explanations, with the occasional probing for additional information by Tom. Mira described the build-up to the heart attack; “ …I had shortness of breath on various occasions when we were walking…it led to some chest pain…my husband called 999”.

Throughout the conversation Tom was friendly, clinically focused, yet compassionate during the enquiries, empathy was evident and matched by a clear understanding of the experience Mira had undergone. It was fascinating (and not uncommon I`m sure) to hear Mira describe the discomfort as “coming out of nowhere” , an interesting observation given the discomfort occurred at “multiple times” leading up to what was eventually diagnosed as a heart attack. Tom educated Mira that her symptoms were signs of a heart attack and not uncommon, frequently using lay terminology to explain the complexity of the condition and associated surgery via visual and verbal descriptors (e.g., pictures). This demonstrated a high level of knowledge, skill and experience as it factored in patient learning styles to the information delivery. In addition to re-enacting the sequence of events, this consultation was used as an extension of the behaviour change discussions from Mira`s bedside (e.g., risk factors for future events). The conversation shifted towards medications as Tom described (in great depth) each tablet Mira was taking, its purpose, side effects and why it was important.

I would have expected medications to have been discussed earlier, only to discover (via Tom after the consultation) that it had been, but to enable adherence there was a constant reiteration in the importance of compliance. This in itself formed a major part of Mira`s lifestyle change, one that had been thrust upon her quickly. I got the impression that without this discussion, medications could have been seen as short-term and not necessary, just from her body language and terminology used.

Mira could easily have fallen back into a curative mindset, no longer associating risk of future events with medication conformity. This again was a teachable moment created by Tom and relayed in a manner that Mira appreciated and hopefully accepted. A referral for CEP assessment was explained and consented, with Mira extremely receptive to attending. Overall, the appointment lasted ~ 45 min, not especially drawn out by either party, so I would take this as a standard timeframe. This consultation confirmed that support was individualised and tailored to Mira. Moreover, it continued the theme of a seamless patient journey created by a diverse MDT working efficiently in conjunction with their service protocols [ 37 ].

The behaviour change element was definitely initiated then followed through by Tom. Long-term observations (12 weeks) showed that it was Tom who began the goal setting process and CEPs only got involved during the exercise sessions when trying to encourage patients to work in a range of intensity or duration that facilitated progression. Behaviour change was not something the CEPs touched on in great detail, in fact, they themselves recognised it as an area they needed to improve and they had undergone a change recently to try an address the balance… .

I arrived on site (during week 8) to find no exercise sessions were planned. Sam explained that a behaviour change/education session was taking place;

“…we`ve tried the traditional exercise followed by education sessions that most services use…these were ok but some (patients) weren`t in favour…we now tell people there is no exercise this week and to turn up for some talks about how to manage their condition, but uptake hasn`t been great and the feedback is that they`d prefer to be exercising” .

The session I witnessed was led by Lauren via a Microsoft PowerPoint presentation. The group was small, I got the impression (closed body language through crossed arms) that they really wanted to be exercising rather than talking about cardiac risk factors, in fact, there was little engagement in the talk, and they finished early. Interestingly, Mira asked if they could use the gym before they left. After the talk Lauren gave her opinion on how it went; “It`s hard to find a balance, the turnout was disappointing (only 4 people rather than the 12–15 in sessions normally) and lack of interaction made it hard for me”. During the talk Mira frequently nodded, acknowledged information and appeared to understand the content, yet was not willing to step outside of the self-created comfort zone and answer questions that were posed or even challenge ideas that were presented, either positively or negatively. Was this due to the lack of numbers, or just the nature of the situation, i.e., discussing personal trauma in front of others, even those experiencing similar circumstances can be daunting and intrusive? Mira`s passion to exercise however was clear;

“…To be honest I`ve come because I feel that I should, the team are great and I don`t want to let anyone down, but really I`d prefer to be downstairs (exercising)…I can read this in a booklet I got off Tom anytime”.

There seemed to be a lack of value associated to the education (Mira`s perspective), suggesting that a format change may be needed for future cohorts.

That night I thought about behaviour change within services, especially what I had experienced and seen over the past few weeks. Was it ineffective or was it just wrong place/time in this service? Staff here were excellent at delivering impromptu support during conversations. Moreover, the patients identified the CEPs as exercise specialists, this is what they wanted from them, to get `fitter`. But, if the CEPs continued to subtly use their communication skills to integrate more behaviour change prompts into simple conversations, it may be sufficient. Sam and Lauren had the skills; the communication was good, specifically their empathy and active listening as they took note and responded to Mira when required. What this service lacked was a clear strategy, but not through a lack of trying or the ability to deliver the content successfully. A generic consideration may be how/when services present behaviour change information to a patient, who does it, and the depth of information needed.

CFIR Sect. 2.2 – patient safety mechanisms – `the huddle`

Patient safety underpinned everything I witnessed within this service. One of the most prevalent and enlightening examples of this was the `team huddle`, a daily activity that included the whole MDT. This event was equivalent to a pre-exercise session meeting taking place in a small conference room, whereby all patients were discussed re: progress and status (new starters and current attendees) including condition overviews and adherence. New starter referrals were explained in detail by either Sam or Lauren to ensure everyone who had contact with them were aware of any considerations such as medications or multi-morbidities. Sam/Lauren, in conjunction with Tom, completed the fitness assessment and retained primary responsibility and case management of specific patients during the exercise component, yet all staff were required to monitor the sessions and therefore needed these updates. On a Friday the discussions included a summary of the past week and information about the forthcoming week, including session fill rates, fitness testing waiting lists and any issues or potential problems (e.g., service capacity due to staffing levels or holidays). The shared responsibility and addition of Tom into these discussions highlighted the integrated nature of the service;

Tom: “There is nothing better than sitting and listening to the team discuss patients…there`s a real crossover of skills and learning via the shared experiences…everybody’s upskilling without even knowing it”.

This collective and unified working process is an unofficial and unaccredited knowledge exchange that enhances MDT skillsets [ 37 ]. The huddle facilitated this learning. Allowing different members of the team to lead the huddle each day fostered personal growth, developed workplace craft and enhanced the team ethic, demonstrating that each member held equal status concerning patient safety and were capable of adhering to NHS policy in this area [ 37 , 38 ].

Staff were vocal, no one hid, which demonstrated solidarity and respect – no fear of being chastised if they spoke. In the past hierarchal status might have overridden everything else, but this discussion was informal with room for social banter if the opportunity arose. Kudos regarding any achievements were given, but at the same time areas for improvement and development were highlighted. I watched an inclusive and engaging 15–20 min `chat` each day which created a learning environment in patient centered care, something I`d have liked to have been part of in the workplace.

CFIR Sect. 2.3 – patient safety mechanisms – fitness assessments

Patient facing activities that required a high level of risk management and in-depth safety protocols were often completed jointly between Sam/Lauren and Tom, an example being fitness assessments. Clinical services utilize a variety of fitness assessments, some highly clinical (e.g., cardiopulmonary exercise testing) and others more field-based (e.g., 6-minute walk test) [ 39 ]. The primary one in this service was a submaximal bike or treadmill assessment with a 12-lead electrocardiogram (ECG) and blood pressure monitor attached to the patient during the assessment. I observed Tom and Lauren work in combination to monitor Mira during a bike assessment. Lauren used lay terminology to explain the procedure, including the function and purpose of the ECG and focusing on what Mira would be asked as she pedaled (such as RPE levels). Mira seemed slightly anxious as Tom attached the leads, uncertain of what lay ahead, but Tom was empathetic whilst explaining how the results would help Mira`s exercise programme design. Mira was happy with this and continued though the assessment, pedaling at the required speeds against the increasing resistance and answering Lauren`s questions regarding RPE levels, while Tom monitored any ECG changes. The assessment itself went without issue. Mira looked comfortable throughout, even when faced with increasing resistance she challenged herself, clearly understanding the importance of providing an accurate representation of her capability as was explained by Lauren and Tom before she started. This itself displayed a high level of communication skill, specifically empathy as Mira was anxious about the unknown, yet this was managed by Lauren using active listening and questioning to dispel any undue fears. After Mira had left, I questioned Lauren and Tom about the importance of the assessment process in relation to patient safety;

Lauren: “Assessments are really important…it’s the first time we see that patient from an exercise viewpoint…understanding their fitness levels and their physiological responses is vital…observing the ECG, detecting issues…you need to be competent by conducting the assessment correctly, but also interpreting that information, then developing an exercise prescription that is fit for purpose”.

Lauren recognized that patient safety is multi-dimensional. Not only is there a theoretical knowledge requirement of how to carry out the assessment, there is the skill of completing it safely whilst screening/monitoring patients and then competently analyzing the results to formulate suitable exercise prescription. Tom outlined the nurse role;

“…I`m responsible for recognition analysis; having an understanding of ECG, chest pain management, the safety aspects for patients that have had a sternotomy during an assessment, aetiology of any particular condition and what adverse reactions we could see…we monitor that in conjunction with the CEP, it`s a shared responsibility, the CEP takes the lead but we collaborate throughout”.

It was interesting to hear that this service had adopted a policy of using both CEPs and clinical nurse specialists within the assessment process to further reduce risk. This `belts and braces` approach seemed to be valued in this service. It was good to see this level of collaboration between staff as I doubt a newly qualified, inexperienced CEP, with minimal exposure to a real-world setting would have been able to undertake that assessment safely and effectively without it. Personally, I think only being exposed to this type of situation would prepare you, therefore, having work placements during your training would greatly increase your understanding of the standards needed to provide safe, patient-centered care in a workplace, thus raising the standard of CEPs coming out of education settings.

CFIR Sect. 3.1 – MDT roles: training and development

Internal training and development have been recognised as good practice within MDTs [ 37 , 38 ] and it was pleasing to hear that this was evident in this service;

Sam: “I came here for work experience and basically stayed…the varying types of experience was great, you had people that had worked here for over 10 years…there were loads of opportunities to learn from others in the team, being able to sit and observe… discussing how and why they worked that way”.

As Sam moved quickly to assist Mira with the rower set up, I pondered about how this type of learning or craft within a real-world setting can only be achieved with the support of highly trained and skilled peers [ 38 ]. Moreover, a few weeks later the subject of planned supervision and observation was raised again by Tom;

“…CEPs come out of university with a masters or BACPR qualifications and that’s great, but it`s less clinical and includes less placement time (if any in non AHCS accredited masters courses) than a nursing degree… it’s that hands on experience that`s really important and where the learning occurs, and that`s missing”.

Tom identified that work placements are the cornerstone of a nursing degree, and this type of experience cannot be overlooked for CEPs. Here, internal staff training included observation of all MDT roles during the first few weeks of employment. This promoted growth for all staff, i.e., leadership opportunities for more senior members of the team through unofficial mentoring, and theoretical learning and practical application experience for the newer members of the team. Tom stressed that staff development was vital for preserving a consistent level of provision (and staff engagement/retainment) within the service. Moreover, the research generated by the team added further knowledge and skill development as described by Sam; “ …completing research with the university brings a whole new light on rehab as a service…our learning and how we think about exercise prescription”. I had never been exposed to a service that actively completed research within a cardiac rehabilitation setting, Lauren continued;

` …a couple of years ago the HIIT (high intensity interval training) or MISS (moderate intensity steady-state training) trial was done here…it heavily influenced our exercise prescription…recently we`ve completed the SCAR trial with similar changes being made in how we exercise patients .`

Interestingly, the research, although focused on exercise prescription in most cases also influenced MDT practice as a whole as Tom explained during our interview;

Tom: “SCAR was a really big learning curve for the nursing team who were set in their ways with regards to enrolling patients, but we embraced it and changed our referral policies… implementation into wider practice, regional or beyond is hard though as it requires a change in resources and working practice”.

Research was a driving force throughout this service epitomised by the working practice changes based on the scientific evidence and forward thinking. Whether it related to exercise prescription design or delivery, referral pathways, internal training programmes or progressive recognition of skills, this service pushed the boundaries in the field of cardiac rehabilitation through a determination to expand the evidence base and implement new findings into practice.

When I reflected on what I had been told, I concluded that real-world practitioner research completed by highly qualified and skilled practitioners with academic understanding was the ideal solution for advancing the field. This service is unique due to its long standing relationship with the local university developed by practitioner links and the academic development of staff. Such collaboration demonstrates the value in closing the gaps between research and practice yet I had not experienced this before. The evidence they unearthed was shared within the team and the service adapted, it didn`t conform to traditional guidelines, they took the proactive approach to develop their own safe and more effective practice based on scientific literature which I feel can only be commended.

CFIR 4.1 – theoretical knowledge levels

Exercise testing, assessment, interpretation, prescription, delivery and outcomes evaluation for individuals with chronic and complex conditions requires a specialist knowledge base and expertise [ 1 , 3 , 40 ]. Eight weeks into my visit and during an afternoon gym session I saw something that I had never seen in this setting before. Not unusually, patients were using their programme cards as guidance and referring to the charts on the walls on occasion for assistance in clarifying exercises or intensity, which answered one of my previous questions about Mira actively using resources rather than seeing them as decorations. But, more significantly as I walked past the rowing machines I noticed the speed and intensity of one particular patient. I know from speaking to Lauren that patient autonomy was encouraged, i.e., CEPs wanted patient`s to challenge themselves (safely) using the guidelines they have devised. Yet, this patient could have been in a regular `mainstream` gym. Rowing at a pace of ~ 2:00 min/500 meters for 1000 m is not something you generally see in a phase III cardiac setting in my experience, and would be challenging for most people. Technique was good; legs and arms in tandem, breathing maintained and visibly working hard. It was enlightening and I wanted to understand what gave the CEPs the confidence to safely prescribe and monitor this level of exercise and to have the confidence to let patients do it;

Sam: “…core knowledge is physiology of the body, cardiovascular response to exercise and the cardiovascular disease process including risk factors…you definitely need to have done a bachelors in sport and exercise science…also a masters specifically in exercise physiology would be ideal covering associated pathologies like obesity, diabetes…we get a wide range of patients presenting with multiple morbidities”.

Lauren reiterated the need for higher level academic qualifications and knowledge in exercise prescription and physiology, whilst stressing that experience in the role was vital. The stipulation of high-level qualifications (e.g., master`s degrees) is recommended in clinical exercise services [ 1 , 3 , 41 ] and in this service, it allowed for a more expansive patient inclusion/exclusion criteria as I discovered in one conversation with Tom;

“Some services are much more cautious in terms of high-risk patients or exercising patients to a level that`s effective…we’ve done a lot of research and have staff that are highly qualified, so we accept higher risk conditions and understand how to safely progress them”.

Academic knowledge of physiology and exercise prescription not only underpinned the way CEPs approached each patient but allowed a higher catchment of patients. Having AHCS-registered CEPs with exercise-specific knowledge and the application of it within research studies extended into challenging their own service effectiveness, alongside national guidelines which have been previously identified as ineffective [ 42 , 43 , 44 ].

Discussions concerning current practice were frequent. The topic of other services not aligning with newly updated literature and that national guidelines were outdated, or least needed more depth, demonstrated that a culture of learning and service evolvement was in place. This service went further and applied changes based on the evidence base (some of which they created) to support their rationale for innovative exercise design and delivery.

CFIR Sect. 4.2 – practical skill application and competency (effective task completion)

Clinical exercise skills relate to the practical application of theoretical learning (e.g., conducting physical assessments) and the ability to communicate the information effectively to patients [ 1 , 45 ]. Having previously discussed the importance of monitoring physiological responses in ECG or blood pressure during assessment, the implementation of the latest HIIT exercise design and acceptance of complex (higher risk) patients, it became clear that monitoring patients was a critical skill. One area of this was the ability to demonstrate and identify how to progress (or regress) exercise by coaching patients through sessions and leading group exercise activities (warm up/cool down) [ 46 ] as explained by Lauren after a group session warm up;

Lauren: “…putting exercise onto paper is the theory behind the practice….coaching patients, leading the class, making sure that everybody is safe and they understand what you`re asking them to do are the practical skills….ongoing monitoring using RPE, heart rate and pain scales is vital…adaptations could be range of movement, intensity, options for balance, avoiding exercises that could exacerbate risk such as quick turns or direction changes…we have to respond to the patient, how they feel…it cannot be generic and it might change daily”.   Working patients intermittently at heart rate percentages challenging 70% or above required clinical knowledge of physiology, patient history, accurate fitness assessments, precise exercise prescription and most importantly, excellent exercise delivery skills and monitoring throughout. For me, such replication across services requires an AHCS-CEP level of knowledge and skills as those individuals have demonstrated competence in adapting exercise to meet the needs of each individual and are capable of monitoring them at a level that minimises risk yet increase effectiveness.

The CEP role is diverse and complex, therefore, skills and competencies are wide ranging and not just associated with exercise per se [ 1 ]. Tom expanded and emphasised that potential employees (in this service) needed communication skills such as empathy, but also experience (and competency) in working with real patients;

Tom: “…we have some really challenging patients that don’t want to engage or haven’t got the literacy levels…CEPs need some of those softer skills that help to deliver personalized care to patients. I feel that at the moment that isn’t there nationally, when we’re interviewing CEPs with academic ability (master’s level) they don’t know what they don’t know… they’re hit with patients that come from all sorts of backgrounds, have all sorts of challenges and this is where soft skills come in”.

The combination of CEP and wider MDT interaction during daily/weekly huddles, the learning culture of shared practice and craft learning (teachable moments), alongside research exposure and proficiency in communication ensures that the knowledge and skills of this team were exceptional. I feel that this combination of theoretical and practical learning sees knowledge, skills and competency unify [ 22 , 40 ]. Similar research [ 40 ] identified that education alone would not be sufficient to create a well-rounded or complete CEP. The specialist nature of the role requires exposure to real world practice, with peer support and training (akin to Tom`s suggestions) essential [ 38 , 46 ]. This service provided that support network in abundance with staff able to reference it when applying for AHCS registration.

Hearing Tom, Lauren and Sam discuss the knowledge, skills and competencies required by a CEP made me think about how the AHCS registration could change the landscape of clinical exercise provision. Firstly, individuals could demonstrate they had undertaken the education and training akin to other health care professionals (e.g., physiotherapists), including rigorous assessments and exposure to the up-to-date scientific evidence base. Secondly, academic institutions would have to conform to Clinical Exercise Physiology UK standards to gain AHCS accreditation, updating their curriculum accordingly and ensuring it contained suitable work placements for students to observe those teachable moments (one of Tom`s concerns). Finally, I know from my own registration that behaviour change and communication skills feature prominently within the registration requirements, thus increasing student proficiency in these areas is essential for effective service provision. This service is unique, it has multiple AHCS-registered CEPs within it and a research arm that provides opportunities for staff to participate in innovative projects that undoubtably advance their knowledge within the field. Even so, a learning culture that supports staff and enhances their skills through shared practice has been created and exposure to it makes me feel that we (clinical exercise service providers) have to learn from it.

CFIR Sect. 5.1 - service effectiveness

My experience has shown me that service effectiveness can be subjective depending on who you are talking to and what level of interest (or bias) they have. Translating evidence into practice is not always easy, it requires a high level of understanding between team members who can communicate with each other to implement change as described by Lauren;

Lauren: “…we`ve all got different ways of prescribing exercise but we have a similar level of education, so if I talk about something and explain what I’m doing the other person understands…so qualifications are a big part of it (effectiveness) plus this culture of always trying to find the best ways of working … the passion of the staff that genuinely want to give their best and as a result of that our programme has got lots of options (for patients)”.

Moreover, the individualised case management approach, identified as effective in clinical MDT settings [ 37 ], was one of the real strengths of the service displaying a dedication to patient-centred care as recognised by Tom: “.from bedside to cardiac discharge post-exercise the patient receives personalised care…we help people get back to what they want to do in the long-term”. It would be remis of me not to highlight the strict NHS safety protocols in place which ensured streamlined referral pathways and the safeguarding of patients throughout their journey. Additionally, the facilities that were available to patients were, in my opinion, unrivalled in this field and duly recognised by the team while we were delivering exercise sessions;

“…w e are lucky with what we have in terms of our facilities…we’re able to use a fully equipped gym…we have consultation rooms, assessment rooms with dedicated equipment and clinical monitoring, other services only have circuit-based portable equipment” (Sam).

These processes all contributed to high levels of patient care highlighted by the 81% uptake from those eligible into the service, compared to the national average of 52% [ 7 ].

Strengths and limitations

The main strength of this study was the multi-method exploration of clinical exercise provision which allowed an in depth look at service operations and effectiveness, including staff knowledge, skills, competencies and challenges. The study was however conducted as a single service case study focusing on one long-term condition, therefore limited by a small, convenience sample. Some caution must be taken in generalising across the cardiac rehabilitation landscape as this service, although operating as an MDT, solely employed CEPs for exercise provision and had links to an academic institution for the research activities which is not widely available in the UK. It does, however, go some way in explaining the key considerations for effective clinical exercise provision for a long-term condition.

AHCS-registered CEPs within this cardiac-specific, hospital and community-based service were essential for the provision of innovative and individualised exercise prescription, underpinned by their high levels of academic education and participation in real-world clinical research trials. The localised (site specific) MDT structure enabled staff upskilling through shared peer experiences, observations and collaborative working between CEPs and healthcare professionals, ensuring effective working practices were maintained throughout the service. Clinical nurse specialists enabled a smooth transition of referrals from hospital into the exercise component of the service and delivered most of the behaviour change elements of the programme. Registered CEPs were able to take part in impromptu lifestyle conversations and `teachable moments` with patients, yet a clear strategy for delivering behaviour change information required development. It is important to consider that this cardiac-specific service was unique by solely employing registered CEPs for exercise provision and had links to an academic institution for the research activities which is not widely available in the UK. Future research should explore daily practices within CEP-led clinical exercise services across other long-term conditions (e.g., pulmonary rehabilitation) to assist in the generalisation of findings. These observations should focus on understanding how exercise specialists utilise their knowledge, skills and competencies within a service to create optimal exercise prescription.

Availability of data and materials

The datasets used and / or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

British Association for Cardiovascular Prevention and Rehabilitation

Clinical Exercise Physiologist

Electrocardiogram

Multi Disciplinary Team

National Audit of Cardiac Rehabilitation

National Health Service

Academy for Healthcare Science

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Acknowledgements

We would like to thank all the research participants without whom this study would not have been possible.

Patient involvement

Patient involvement was completed during the ethics application with a conclusion that the research methods were suitable with exploration required in this area.

This research was funded by Research England International Investment Initiative funding (i-CARDIO).

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AC contributed to the design of the study, collected and analyzed the data, and led the writing of the manuscript. HJ secured funding for the study. HJ, LG, KG and DR contributed to the study design and advised on data collection and analysis. All authors contributed to data interpretation and writing of the manuscript and approved the final version.

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Crozier, A., Graves, L.E., George, K.P. et al. A multi-method exploration of a cardiac rehabilitation service delivered by registered Clinical Exercise Physiologists in the UK: key learnings for current and new services. BMC Sports Sci Med Rehabil 16 , 127 (2024). https://doi.org/10.1186/s13102-024-00907-4

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DOI : https://doi.org/10.1186/s13102-024-00907-4

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