Navigating the Dual Role of Clinician-Researcher in Qualitative Dental Research

In qualitative research, the researcher is the research instrument. Therefore, a qualitative researcher who is also a clinician must consider how their dual position informs participant consent, data collection, and analysis. This reflexivity is essential in research design to effectively respond to ethical questions around role, authenticity, trust, and transparency around disclosing their clinician status to participants.


Background
Qualitative research methods are widely used in dental health research to explore the sociocultural aspects of under-researched phenomena. These methods are valuable independently but can also complement quantitative approaches (Bower and Scambler 2007). In qualitative research, the researcher is the research instrument, directly impacting upon data collection and analysis. This is a common criticism but also an inherent feature and strength of qualitative methods (Malterud 2001). Inevitably, a researcher's personal and professional experiences will shape how data are generated and interpreted. Rather than seek to eliminate (or worse, ignore) this issue, which is logistically and theoretically impossible, the impact of the researcher should be acknowledged through "reflexivity." (Berger 2015). This process involves ongoing self-reflection where one questions the impact of his or her personal experiences and preconceptions on how he or she approaches the design, collection, analysis, and reporting of qualitative research (Finlay 2002). Reflexivity ensures the challenges related to being a clinician-researcher are acknowledged and discussed openly.

The Role of a Clinician-Researcher
Clinicians engaged in qualitative studies have a dual role as a professional and a researcher. Previous work in nursing and medicine has explored this phenomenon, suggesting that relevant clinical knowledge can benefit the conduct of health research (Holloway and Wheeler 1995;Arber 2006). In addition, clinicianresearchers may have easier access to recruit research participants through their direct clinical contacts, their familiarity with patient care pathways, and their proximity to relevant gatekeepers (Hiller and Vears 2016).
Despite these benefits, challenges arise when clinicians conduct qualitative research. Hunt et al. (2011) argue that while there can be a transfer of skills from clinical practice to qualitative interviewing, this transfer does not necessarily equate to good qualitative research conduct.
There may be a perceived (and often real) imbalance of power between the research participant and clinicianresearcher in qualitative interviews. Due to their professional status and clinical care provision, this power imbalance may be felt to be greater than for nonclinical researchers. While a patient would consult a clinician about a clinical need, based on the clinician's knowledge and expertise, the reverse is true in qualitative research. Here, the "patient" becomes the participant in qualitative research who is the expert on their lived experience and knowledge and the researcher's role is to seek to understand that knowledge and experience rather than provide clinical care. The balance of maintaining a professional duty of care while ensuring methodological integrity can be challenging (Hiller and Vears 2016). Understanding the dual role of clinician-researcher in qualitative research has yet to be explored in a dental context however, hence, the reflexive process is paramount to acknowledging and accounting for the challenges faced in this dual role.
The Unique Nature of the Dental Setting Sociocultural phenomena in dentistry are inherently different from other healthcare contexts. Dental care span the worlds of healthcare, cosmetics, and business ownership, and public perceptions of dental care are often less than ideal (Christensen 2001). Though viewpoints clearly vary, there is a hypothetical potential for a person's perspective to alter their willingness to contribute to qualitative dental research. This has not been explored in research, yet it would be a logical consequence of adverse experiences, dental phobia, and negative dental care attitudes. In contrast, patients with a positive viewpoint of the dental profession may potentially see a research invitation as an opportunity to support positive change by sharing their experiences. Dental clinician-researchers undertaking qualitative research are therefore faced with a dilemma: should they actively disclose their clinical background to research participants?
To Disclose or Not Disclose?
The dilemma of whether or not to intentionally disclose a professional role, and if so, at what point, is likely to have greater importance in qualitative than quantitative studies. Professional standards prohibit a clinician, if asked, from withholding their status from research participants (General Dental Council 2013). In situations where participants may not inherently know or ask about the researcher's background, a decision needs to be made about if, when, and how to disclose one's background as a clinician, and for what end. The impact of an intentional disclosure has the potential to affect studies differently, reflecting the breadth of phenomena that can be explored using qualitative methods. These potential impacts are yet to be explored in relation to dental care however, and warrant consideration for those designing qualitative or mixed-methods research.
Three approaches can be taken with disclosure of a professional role: open declaration before or at the start of an interview; disclosure mid-interview; or, only disclosing when directly questioned. Deciding which approach to take is considered a form of "reflexive accounting" (Finlay 2002). In addition to the declaration of role, the clinicianresearcher should also consider the practical elements of interviewing such as location, attire, and use of professional titles to avoid presenting "mixed messages" about their role to interview participants (Hunt et al. 2011).
Declaring a professional role at the outset may impact, positively or negatively, on recruitment and data collection. Therefore, engaging in a reflexive process earlier in the research process may help clarify decisions about disclosing one's professional status. Openly declaring one's role before an interview will make the role of the interviewer explicit and ensure transparency. This approach means that one can clearly stipulate the purpose of the interview and make clear that the discussion is not a clinical consultation. Alternatively, the professional role of the clinician-researcher may be disclosed intentionally during an interview. A topic guide could direct a clinician as to when this disclosure may be appropriate within a semi-structured interview. However, suddenly becoming aware of the interviewer's clinical status could negatively impact an otherwise positive interview. For example, it may be disconcerting for the participant particularly around topics such as dental phobia. This approach may, however, add value as it could change the direction of a discussion and lead to a deeper exploration of the topic of concern.
As dialogue progresses, an interview participant may directly question the researcher about their professional role. In the research design, a choice could be made not to disclose one's role unless specifically asked by the participant. As professional standard guidelines state, disclosing their clinical role when asked is both ethical and expected and it is hoped that participants would not construe the lack of intentional disclosure earlier as dishonest. Following disclosure, a participant could seek clinical advice in the interview (Hiller and Vears 2016). If any advice were either given, or more appropriately declined, due to the context of research, it could adversely affect the remainder of an interview. In addition, a mid-interview disclosure may instil a sense of mistrust in the clinician-researcher, contrasting the trust that can arise from knowing a professional's role (Hiller and Vears 2016). This may have a detrimental effect on a participant's perceptions of other research or of the dental profession. There is, therefore, an argument for making one's professional status clear to participants at an earlier stage, or intentionally planning to use nonclinician researchers where appropriate.

Conclusion
We suggest that while proactively withholding one's professional status, when asked, is not ethically justifiable, the approach taken to disclosure in qualitative research should be consciously chosen based on the specific nature of each study. As part of the reflexive process, this choice must be detailed and justified from the outset of study design. Various approaches may suit specific research topics, yet, in all topics, if a professional status is not disclosed it may be argued that the participant was inadequately informed about the study to consent to participation. Neglecting to adequately reflect on the impact of professional disclosure or a decision to withhold this can limit the data that may be collected. Reflexivity is a key element of good qualitative research (Malterud 2001;Berger 2015) and clinician researchers must proactively plan how to account for the difficulties arising from navigating these dual roles.

Author Contributions
A.R. Geddis-Regan, contributed to conception, design, data analysis, and interpretation, drafted and critically revised the manuscript; C. Exley, contributed to design and data interpretation, critically revised the manuscript; G.D. Taylor, contributed to conception, design, and data interpretation, drafted and critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work.

Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.