Can a white nurse get it? ‘Reflexive practice’ and the non-Indigenous clinician/researcher working with Aboriginal people

Context: Reflexivity is crucial for non-Aboriginal researchers working with Aboriginal people. This article describes a process of ’reflexive practice’ undertaken by a white clinician/researcher while working with Aboriginal people. The clinician/researcher elicited Aboriginal people’s experience of being haemodialysis recipients in rural Australia and their perceptions of their disease and treatment. The aim of this article is to report the methods used during this qualitative project to guide the researcher in conducting culturally appropriate health research with Aboriginal people. The goal of this work was to improve health services, informed and guided by the Aboriginal recipients themselves. The article describes the theory and methods used to develop reflexive skills. It also reports how the clinician/researcher managed her closeness to the topic and participants (some being patients under her care) and the processes used to ensure her subjectivity did not interfere with the quality of research. Issues: Three layers of reflexive practice are described: examining self within the research, examining interpersonal relationships with participants, and examining health systems. The alignment of the three ‘lenses’ used to describe the study is exposed. Complex insider/outsider roles are explored through multiple layers of reflexive practice. Regular journal writing was the primary tool used to undertake this reflexive practice. An Aboriginal advisory group and co-investigators collaborated and assisted the clinician/researcher to scrutinise and understand her positioning within the study. Researcher positioning, power and unequal relationships are discussed. Issues such as victim blaming and the disconnect between clinicians’ views about treatment compliance and Aboriginal peoples’ prioritisation of family obligations for before treatment are presented. Lessons learned: Aboriginal patients must negotiate a health services system where racism and victim blaming are institutionalised, but the effect of these on the research relationship can be mitigated through reflexive practice. Using a framework

for relational accountability that incorporates respect, responsibility and reciprocity can enable non-Aboriginal clinicians and/or researchers to work effectively with Aboriginal patients. These results may assist clinicians and policy makers develop strategies for improving quality of care.

Context
In 2007 I helped, as a renal nurse, to initiate an Aboriginal Elder onto haemodialysis. He was clearly distressed and confused and his feelings of disempowerment and dislocation were palpable. Once he became clinically stable, I talked with him and we agreed that someone should do some research aimed at finding ways to improve service delivery for the large number of Aboriginal people requiring dialysis. He encouraged me to talk with him further and to take on this research myself. I became increasingly aware of the struggles of many Aboriginal people with chronic diseases in negotiating a public health system where they were often viewed as non-compliant 'others' 1 who contributed to their own poor health outcomes. This was beyond my conventional nursing knowledge and not discussed within the clinical team except as problems of 'compliance' with treatment. As I wrote in my personal journal some years ago, a precursor to the research, I The writing of an Australian Indigenous nurse and scholar confirmed that I must be vigilant in exploring my motives and attitudes whilst engaging in a project aimed at improving the health and wellbeing of her people 2 . The seminal work of Maori woman L.T. Smith also provided valuable insight into the history of colonial research and the damaging effects of Western academic traditions in failing to view the world through the eyes of Indigenous people 3 .

Definitions
Guba and Lincoln view reflexivity as 'the process of reflecting critically on the self as researcher, the 'human instrument'' and define this as 'a conscious experiencing of the self as both inquirer and respondent, as teacher and learner, as the one coming to know the self within the process of research itself' 4 . According to Willig 5

Research methods/design
The research examined the experiences and perceptions of 18 Aboriginal people receiving haemodialysis in a regional centre of rural New South Wales (NSW), Australia. Ethical clearance for this project was gained from the local area health service, the Aboriginal Health and Medical Research Council of NSW and the University of Sydney. Participants provided an informed consent. The data drawn on in this article are predominantly from my own journals kept prior to and during the study rather from than data generated by the participants themselves, as I report the process of developing reflexive practice that underpinned my role within this research. These journals report my own responses, not participant data.
The project is embedded in an Indigenist research paradigm, with a decolonisation approach 3,12 . 'Indigenist research is research by [or for] Indigenous Australians whose primary informants are Indigenous Australians and whose goals are to serve and inform the Indigenous struggle for selfdetermination' 13 .
Principles of community-based participatory research (CBPR) 14

Relational accountability
According to Indigenous methodologies the rigour and validity of research are demonstrated through relational accountability 18 . Researchers have relational accountability to participants, co-investigators and the conduct of the study. For me, as a non-Aboriginal researcher, relational accountability is encapsulated by principles of respect, responsibility and reciprocity 19 . This is exemplified by this paper being written using my personal voice, despite being co-authored. In accordance with Indigenous methodologies where knowledge is developed through relationship and is shared and not owned by individuals, co-authors of this paper have been integral in the development of my reflexive practice. I cannot claim individual 'ownership' of this work and acknowledge this by sharing authorship with the coconstructors of this knowledge and the contributions of the Aboriginal advisory group within this paper. However, the use of my own voice has been retained as it better demonstrates my personal experience of the creation of this shared knowledge.

Issues
The process of developing reflexive practice My multiple relationships with participants created complex layers of subjectivity. As a nurse, a researcher and the partner of a man facing dialysis, reflexive practice was essential. By incorporating Indigenist methods with my reflexive practice I was able to acknowledge that the research was shaped by who I am and my experiences to this point, whilst attempting to view the topic through the worldview of the Aboriginal people with whom I was working.
Where do I begin to find a methodology that will give participants an authentic voice and result in real, ongoing improvements in their day to day lives as dialysis patients living in an alien biomedical world? (Journal entry, 2 Whilst I do try to explain to participants that I really need them to be honest to enable me to address real problems, I am wondering if they are partly blocked by my being a nurse, with participants not wishing to disclose to me. I do think I have a reasonable rapport with most, however I cannot know how much my insider role is impacting on how they disclose their issues with me around service delivery and communication with staff. (Journal entry, 10 July 2011)

Self reflexivity
The complexity of my relationship to this research initiated a lengthy period of journaling that helped unpack my worldviews, assumptions and attitudes. Tasmania  This reflexive practice became the catalyst for choosing an Indigenist methodology. I realised that to be an effective research 'instrument' and agent of change for the people with whom I was working, I needed to attempt to see the world through 'their' eyes, using ways of discovering new knowledge that were congruent with their world view.

Interpersonal reflexivity
In keeping with the Indigenous tradition of oral history for passing on knowledge and information, I sought the perspectives and experiences of Aboriginal participants using 'yarning' and storytelling to generate information 17,32 . This was my attempt to create a relational space between myself and participants that was comfortable for them. Yarning is a word often used by some Aboriginal people, meaning 'let's have a chat' 33 . Use of minimal questions and prompts and acute listening skills have been the key to allowing the stories of participants to unfold. Exploring interactions between researchers and participants can ensure that the emerging voices of participants are separated from the underlying social and cultural assumptions about those interactions brought by researchers' own values 6 . Although unpacking my privileged background and cultural assumptions helped to clarify my worldviews, there was still work to be done to address power issues within this research.
Power and unequal relationships: Issues of power and unequal relationships must be addressed by any researcher working with marginalised or vulnerable populations. Bishop describes how research with Maori people has perpetuated colonial power imbalances, belittling and undervaluing Maori knowledge 21 . Reflexivity can enable the voice of 'others' to be heard whilst tracking the 'reciprocal workings of power', including the 'changing position of the researcher within the research process' 11 . Educational researcher Heshusius has used the term 'participatory mode of consciousness' to describe a process of reordering the understanding of relationships between self and others in order to manage subjectivity within qualitative research. While it may not be possible to entirely overlook your 'self', this reordering takes focus away from self to an essential connectedness and relationship with others.
When one forgets self and becomes embedded in what one wants to understand, there is an affirmative quality of kinship that no longer allows for privileged status. It renders the act of knowing an ethical act 34 .
When attempting to understand or address power imbalances within researcher/participant relationships, I agree with Heshusius that absolute objectivity is impossible when exploring the experiences and perceptions of 'others'. However, researcher subjectivity can be managed by a genuine attempt to immerse oneself in the words and reality of research participants and use a reflexive and 'participatory lens' to view their experience and perceptions. When this occurs, the researcher and participant can share a form of 'participatory consciousness' within their relationship that can be viewed as a more ethical way of knowing and understanding. According to Heshusius 'A participatory mode of consciousness, then, results from the ability to temporarily let go of all preoccupation with self and move into a state of complete attention' 34 .
Through my journal I examined the potential for exploiting my position of power over participants, not only as a researcher, but also as a nurse, with the privilege of knowledge and experience of their disease and treatment 35 . Reciprocity proved a highly effective tool to assist with sharing of power.
Reciprocity: Reciprocity as a core principle of Indigenist research is essential in any project aimed at improving the health of Aboriginal people 19 . Reciprocity within the context of interviews with participants 36 and judgment used by researchers in the field can benefit greatly from reflexive practice. For example, during an interview a participant turned to me and asked, 'So, what's it like being a renal nurse?' As I attempted to answer this question honestly and clearly, a rich conversation ensued where we compared our perspectives. What I had intended to be an interview, where I listened to someone else's story, became a two-way dialogue and true 'yarning'. Journaling about this later, I realised that my concept of reciprocity was extended from reciprocal actions, for example providing transport and reimbursing costs, to a reciprocal exchange of ideas and experiences.
As my interactions with participants evolved from nursepatient encounters in a hospital environment to relating as people in a more neutral space or in their own environment, I became acutely aware of shifts in relational dynamics. Participants came to know me as a woman, the partner of a man with 'their' disease and a researcher. These new relationships clearly influenced their stories and enhanced disclosure 37 .
We had a really good yarn.

Lessons learned
This article has outlined three layers of reflexive practice that I have labelled as 'self', 'interpersonal' and 'health system'. These layers assisted me as a non-Indigenous clinician/researcher to engage more effectively in research aimed at improving services and health outcomes for Aboriginal people. I have detailed influences on my thinking and how reflexive practice has evolved in the context of my research. The tools of reflexive practice include regular personal and professional journaling, as well as ongoing collaboration and discussion with Aboriginal people as research colleagues, and co-investigators/supervisors. These tools as elements of reflexive practice relate to a conceptual framework that describes the method of research practice underpinning the study, and maps how my roles influenced it. I have described how self-reflexivity and the unpacking of my white privilege resulted in my embrace of an Indigenist paradigm to inform methods used to explore the research question through the eyes of participants. Interpersonal reflexive practice explores and clarifies how multiple roles and the self are managed in relationships with others. Critical examination of the health system that Aboriginal patients must negotiate to access treatment is the third layer of reflexive practice as I examined issues such as institutionalised racism, victim blaming, and hospitals as daunting and alien environments.
Insights and recommendations emerging from the stories of Aboriginal participants were based on analysis that was influenced by Aboriginal colleagues through the CRG. In this context, reflexive practice and Indigenist theory have helped me learn that I am merely the research 'instrument'. My role is to act rigorously and independently, but also as a conduit between the Aboriginal community and the health system to discover strategies that will return to Aboriginal patients some degree of self-determination and control that reliance on the health system has removed.
Through reflexive practice I discovered that positioning and separation of roles was of far less importance than how effective I am as a well-honed research 'instrument' that can contribute to improvements in treatment and health outcomes for the Aboriginal people with whom I am working. I realised that the key to being an effective 'instrument' was aligning the three lenses through which I viewed the study, incorporating respect, responsibility and reciprocity. Reflexive practice used in this manner can help manage complex relationships within Indigenous health research, aiming for clarity based on deep reflection and understanding that is validated by Aboriginal participants and colleagues.