how to write reflexivity in qualitative research

Chapter 6. Reflexivity

Introduction.

Related to epistemological issues of how we know anything about the social world, qualitative researchers understand that we the researchers can never be truly neutral or outside the study we are conducting. As observers, we see things that make sense to us and may entirely miss what is either too obvious to note or too different to comprehend. As interviewers, as much as we would like to ask questions neutrally and remain in the background, interviews are a form of conversation, and the persons we interview are responding to us . Therefore, it is important to reflect upon our social positions and the knowledges and expectations we bring to our work and to work through any blind spots that we may have. This chapter discusses the concept of reflexivity and its importance for conducting reliable qualitative research.

Reflexivity: What It Is and Why It Is Important

Remember our discussion in epistemology ? Qualitative researchers tend to question assertions of absolute fact or reality, unmediated through subject positions and subject knowledge. There are limits to what we know because we are part of the social worlds we inhabit. To use the terminology of standpoint theorists, we have a standpoint from which we observe the world just as much as anyone else. In this, we too are the blind men, and the world is our elephant. None of us are omniscient or neutral observers. Because of this epistemological standpoint, qualitative researchers value the ability to reflect upon and think hard about our own effects on our research. We call this reflexivity. Reflexivity “generally involves the self-examination of how research findings were produced, and, particularly, the role of the researcher in their construction” ( Heaton 2004:104 ).

There are many aspects of being reflexive. First, there is the simple fact that we are human beings with the limitations that come with that condition. We have likes and dislikes, biases, blind spots, preferences, and so on. If we do not take these into account, they can prevent us from being the best researcher we can be. Being reflective means, first and foremost, trying as best as possible to bracket out elements of our own character and understanding that get in the way. It is important to note that bias (in this context, at least) is not inherently wrong. It just is. Unavoidable. But by noting it, we can minimize its impact or, in some cases, help explain more clearly what it is we see or why it is that we are asking the questions we are asking. For example, I might want to communicate to my audience that I grew up poor and that I have a lot of sympathy and concern for first-generation college students as a result. This “bias” of mine motivates me to do the work I do, even as I try to ensure that it does not blind me to things I find out in the course of my research. [1]

A second aspect of being reflexive is being aware that you yourself are part of the research when you are conducting qualitative research. This is particularly true when conducting interviews, observing interactions, or participating in activities. You have a body, and it will be “read” by those in the field. You will be perceived as an insider or an outsider, as a friend or foe, as empathetic or hostile. Some of this will be wrong. People will prejudge you based on the color of your skin, your presented gender, the accent of your language. People will classify you based on the clothes you wear, and they will be more open to you if you remind them of a friendly aunt or uncle and more reserved if you remind them of someone they don’t like. This is all natural and inevitable. Your research will suffer if you do not take this into account, if you do not reflect upon how you are being read and how this might be influencing what people tell you or what they are willing to do in front of you. The flip side of this problem is that your particular body and presence will open some doors barred to other researchers. Finding sites and contexts where your presented self is a benefit rather than a burden is an important part of your individual research career. Be honest with yourself about this, and you will be more successful as a qualitative researcher. Learn to leverage yourself in your research.

The third aspect of being reflexive is related to how we communicate our work to others. Being honest with our position, as I am about my own social background and its potential impact on what I study or about how I leveraged my own position to get people to open up to me, helps our audiences evaluate what we have found. Maybe I haven’t entirely eliminated my biases or weaknesses, but by telling my audience who I am and where I potentially stand, they can take account of those biases and weaknesses in their reading of my findings. Letting them know that I wore pink when talking with older men because that made them more likely to be kind to me (a strategy acknowledged by Posselt [ 2016 ]) helps them understand the interview context. In other words, my research becomes more reliable when my own social position and the strategies I used are communicated.

Some people think being reflective is just another form of narcissistic navel-gazing. “The study is not about you!” they might cry. True, to some degree—but that also misses the point. All studies on the social world are inevitably about us as well because we are part of that social world. It is actually more dangerous to pretend that we are neutral observers, outside what we are observing. Pierre Bourdieu makes this point several times, and I think it is worth quoting him here: “The idea of a neutral science is fiction, an interested fiction which enables its authors to present a version of the dominant representation of the social world, naturalized and euphemized into a particularly misrecognizable and symbolically, therefore, particularly effective form, and to call it scientific” (quoted in Lemert 1981:278 ).

Bourdieu ( 1984 ) argues that reflective analysis is “not an epistemological scruple” but rather “an indispensable pre-condition of scientific knowledge of the object” ( 92 ). It would be narcissistic to present findings without reflection, as that would give much more weight to any findings or insights that emerge than is due.

The critics are right about one thing, however. Putting oneself at the center of the research is also inappropriate. [2] The focus should be on what is being researched, and the reflexivity is there to advance the study, not to push it aside. This issue has emerged at times when researchers from dominant social positions reflect upon their social locations vis-à-vis study participants from marginalized locations. A researcher who studies how low-income women of color experience unemployment might need to address her White, upper-class, fully employed social location, but not at the cost of crowding out the stories, lived experiences, and understandings of the women she has interviewed. This can sometimes be a delicate balance, and not everyone will agree that a person has walked it correctly.

Examples of Reflexivity in Practice

Most qualitative researchers include a positionality statement in any “methods section” of their publications. This allows readers to understand the location of the researcher, which is often helpful for gauging reliability . Many journals now require brief positionality statements as well. Here are a few examples of such statements.

The first is from an ethnographic study of elite golfers. Ceron-Anaya ( 2017 ) writes about his class, race, and gender and how these aspects of his identity and social location affected his interactions with research participants:

My own class origins, situated near the intersection between the middle and the lower-middle class, hindered cooperation in some cases. For example, the amiable interaction with one club member changed toward the end of the interview when he realized that I commonly moved about in the city by public transportation (which is a strong class indicator). He was not rude but stopped elaborating on the answers as he had been doing up to that point.…Bodily confidence is a privilege of the privileged. My subordinate position, vis-à-vis golfers, was ameliorated by my possession of cultural capital, objectified in my status of researcher/student in a western university. However, my cultural capital dwindled in its value at the invisible but firm boundary between the upper-middle and the upper class. The few contacts I made with members of the upper class produced no connections with other members of the same group, illustrating how the research process is also inserted in the symbolic and material dynamics that shape the field. ( 288 )

What did you learn from Ceron-Anaya’s reflection? If he hadn’t told you about his background, would this have made a difference in reading about elite golfers? Would the findings be different had Ceron-Anaya driven up to the club in a limousine? Is it helpful to know he came by bus?

The second example is from a study on first-generation college students. Hinz ( 2016 ) discusses both differences and similarities between herself and those she interviewed and how both could have affected the study:

I endeavored to avoid researcher bias by allowing the data to speak for itself, but my own habitus as a White, female, middle-class second-generation college student with a few years of association with Selective State [elite university] may have influenced my interpretation. Being a Selective State student at the time of the interviews provided a familiarity with the environment in which the participants were living, and an ease of communication facilitated by a shared institutional culture. And yet, not being a first-gen myself, it seemed as if I were standing on the periphery of their experience, looking in. ( 289–290 )

Note that Hinz cannot change who she is, nor should she. Being aware (reflective) that she may “stand on the periphery” of the experience of those she interviews has probably helped her listen more closely rather than assume she understands what is really going on. Do you find her more reliable given this?

These statements can be quite long, especially when found in methodological appendixes in books rather than short statements in articles. This last lengthy example comes from my own work. I try to place myself, explaining the motivations for the research I conducted at small liberal arts colleges:

I began this project out of a deep curiosity about how college graduates today were faring in an increasingly debt-ridden and unequal labor market. I was working at a small liberal arts college when I began thinking about this project and was poised to take a job at another one. During my interview for the new job, I was told that I was a good fit, because I had attended Barnard College, so I knew what the point of a liberal arts college was. I did. A small liberal arts college was a magical place. You could study anything you wanted, for no reason at all, simply for the love of it. And people would like you for it. You were surrounded by readers, by people who liked to dress up in costume and recite Shakespeare, by people who would talk deep into the night about the meaning of life or whether “beauty” existed out there, in nature, or was simply a projection of our own circumstances. My own experience at Barnard had been somewhat like that. I studied Ancient Greek and Latin, wrote an undergraduate thesis on the legal standing of Vestal Virgins in Ancient Rome, and took frequent subway rides to the Cloisters, the medieval annex of the Metropolitan Museum of Art, where I sketched the courtyard and stared at unicorn tapestries. But I also worked full-time, as a waitress at a series of hectic and demanding restaurants around the city, as a security guard for the dorm, as a babysitter for some pretty privileged professors who lived in doorman buildings along Riverside Park, and at the library (the best job by far). I also constantly worried I would not be able to finish my degree, as every year I was unsure how I would come up with the money to pay for costs of college above and beyond the tuition (which, happily, was covered by the college given my family’s low income). Indeed, the primary reason I studied the Classics was because all the books were freely available in the library. There are no modern textbooks—you just find a copy of the Iliad. There are a lot of those in a city like New York. Due to my fears, I pushed to graduate one year early, taking a degree in “Ancient Studies” instead of “Classics,” which could have led on to graduate training. From there, I went to law school, which seemed like a safe choice. I do not remember ever having a conversation with anyone about how to find a job or what kinds of job one could do with a degree in Ancient Studies. I had little to no social networks, as I had spent my time studying and working. And I was very lucky, because I graduated with almost zero debt. For years, until that job interview, I hadn’t really thought my Barnard experience had been that great or unusual. But now it was directly helping me get a job, about fifteen years after graduation. And it probably had made me a better person, whatever that means. Had I graduated with debt, however, I am not so sure that it would have been worth it. Was it, on balance, a real opportunity and benefit for poor students like me? Even now? I had a hunch of what I might find if I looked: small liberal arts colleges were unique places of opportunity for low-income first-generation working-class students who somehow managed to find and get in to one of them (no easy task). I thought that, because of their ethos, their smallness, the fact that one could not hide from professors, these colleges would do a fair job equalizing opportunities and experiences for all their students. I wanted to tell this story. But that is not the story that I found, or not entirely. While everyone benefits from the kind of education a small liberal arts college can offer, because students begin and continue so differently burdened and privileged, the advantages of the already-advantaged are amplified, potentially increasing rather than decreasing initial inequalities. That is not really a surprising story, but it is an important one to tell and to remember. Education doesn’t reduce inequality. Going to a good college doesn’t level the playing field for low-income, first-generation, working-class students. But perhaps it can help them write a book about that. ( Hurst 2019:259–261 )

What do you think? Did you learn something about the author that would help you, as a reader, understand the reasons and context for the study? Would you trust the researcher? If you said yes, why?

How to Do It

How does one become a reflective researcher? Practice! Nearly every great qualitative researcher maintains a reflexive journal (there are exceptions that prove the rule), a type of diary where they record their thinking on the research process itself. This might include writing about the research design (chapter 2), plotting out strategies for sample selection (chapter 6), or talking through what one believes can be known (chapter 3). During analysis, this journal is a place to record ideas and insights and pose questions for further reflection or follow-up studies. This journal should be highly personal. It is a place to record fears, concerns, and hopes as well. Why are you studying what you are studying? What is really motivating you? Being clear with yourself and being able to put it down in words are invaluable to the research process.

Today, there are many blogs out there on writing reflective journals, with helpful suggestions and examples. Although you may want to take a look at some of these, the form of your own journal will probably be unique. This is you, the researcher, on the page. Each of us looks different. Use the journal to interrogate your decisions and clarify your intent. If you find something during the study of note, you might want to ask yourself what led you to note that. Why do you think this “thing” is a “thing”? What about your own position, background, or researcher status that makes you take note? And asking yourself this question might lead you to think about what you did not notice. Other questions to ask yourself include the following: How do I know “that thing” I noted? So what? What does it mean? What are the implications? Who cares about this and why? Remember that doing qualitative research well is recursive , meaning that we may begin with a research design, but the steps of doing the research often loop back to the beginning. By keeping a reflective journal, you allow yourself to circle back to the beginning, to make changes to the study to keep it in line with what you are really interested in knowing.

One might also consider designing research that includes multiple investigators, particularly those who may not share your preconceptions about the study. For example, if you are studying conservative students on campus, and you yourself thoroughly identify as liberal, you might want to pair up with a researcher interested in the topic who grew up in a conservative household. If you are studying racial regimes, consider creating a racially diverse team of researchers. Or you might include in your research design a component of participatory research wherein members of the community of interest become coresearchers. Even if you can’t form a research team, you can reach out to others for feedback as you move along. Doing research can be a lonely enterprise, so finding people who will listen to you and nudge you to clarify your thinking where necessary or move you to consider an aspect you have missed is invaluable.

Finally, make it a regular part of your practice to write a paragraph reporting your perspectives, positions, values, and beliefs and how these may have influenced the research. This paragraph may be included in publications upon request.

Internal Validity

Being reflexive can help ensure that our studies are internally valid. All research must be valid to be helpful. We say a study’s findings are externally valid when they are equally true of other times, places, people. Quantitative researchers often spend a lot of time grappling with external validity , as they are often trying to demonstrate that their sample is representative of a larger population. Although we do not do that in qualitative research, we do sometimes make claims that the processes and mechanisms we uncover here, in this particular setting, are likely to be equally active in that setting over there, although there may be (will be!) contextual differences as well. Internal validity is more peculiar to qualitative research. Is your finding an accurate representation of what you are studying? Are you describing the people you are observing or interviewing as they really are? This is internal validity , and you should be able to see how this connects with the requirement of reflexivity. To the extent that you leave unexamined your own biases or preconceptions, you will fail at accurately representing those people and processes you study. Remember that “bias” here is not a moral failing in the way we commonly use bias in the nonresearch world but an inevitable product of our being social beings who inhabit social worlds, with all the various complexities surrounding that. Because of things that have happened to you, certain things (concepts, quotes, activities) might jump out at you as being particularly important. Being reflexive allows you to take a step back and grapple with the larger picture, reflecting on why you might be seeing X (which is present) but also missing Y (which is also present). It also allows you to consider what effect/impact your presence has on what you are observing or being told and to make any adjustments necessary to minimize your impact or, at the very least, to be aware of these effects and talk about them in any descriptions or presentations you make. There are other ways of ensuring internal validity (e.g., member checking , triangulation ), but being reflective is an essential component.

Advanced: Bourdieu on Reflexivity

One researcher who really tackled the issue of reflexivity was Pierre Bourdieu. [3] Known in the US primarily as a theorist, Bourdieu was a very capable and thorough researcher, who employed a variety of methods in his wide-ranging studies. Originally trained as an anthropologist, he became uncomfortable with the unreflective “outsider perspective” he was taught to follow. How was he supposed to observe and write about the various customs and rules of the people he was studying if he did not take into account his own supposedly neutral position in the observations? And even more interestingly, how could he write about customs and rules as if they were lifted from but outside of the understandings and practice of the people following them? When you say “God bless you” to someone who sneezes, are you really following a social custom that requires the prevention of illness through some performative verbal ritual of protection, or are you saying words out of reflex and habit? Bourdieu wondered what it meant that anthropologists were so ready to attribute meaning to actions that, to those performing them, were probably unconsidered. This caused him to ponder those deep epistemological questions about the possibilities of knowledge, particularly what we can know and truly understand about others. Throughout the following decades, as he developed his theories about the social world out of the deep and various studies he engaged in, he thought about the relationship between the researcher and the researched. He came to several conclusions about this relationship.

First, he argued that researchers needed to be reflective about their position vis-à-vis the object of study. The very fact that there is a subject and an object needs to be accounted for. Too often, he argued, the researcher forgets that part of the relationship, bracketing out the researcher entirely, as if what is being observed or studied exists entirely independently of the study. This can lead to false reports, as in the case where a blind man grasps the trunk of the elephant and claims the elephant is cylindrical, not having recognized how his own limitations of sight reduced the elephant to only one of its parts.

As mentioned previously, Bourdieu ( 1984 ) argued that “reflective analysis of the tools of analysis is not an epistemological scruple but an indispensable precondition of scientific knowledge of the object” ( 92 ). It is not that researchers are inherently biased—they are—but rather that the relationship between researcher and researched is an unnatural one that needs to be accounted for in the analysis. True and total objectivity is impossible, as researchers are human subjects themselves, called to research what interests them (or what interests their supervisors) and also inhabiting the social world. The solution to this problem is to be reflective and to account for these aspects in the analysis itself. Here is how Bourdieu explains this charge:

To adopt the viewpoint of REFLEXIVITY is not to renounce objectivity but to question the privilege of the knowing subject, which the antigenetic vision arbitrarily frees, as purely noetic, from the labor of objectification. To adopt this viewpoint is to strive to account for the empirical “subject” in the very terms of the objectivity constructed by the scientific subject (notably by situating it in a determined place in social space-time) and thereby to give oneself awareness and (possible) mastery of the constraints which may be exercised on the scientific subject via all the ties which attach it to the empirical “subject,” to its interests, motives, assumptions, beliefs, its doxa, and which it must break in order to constitute itself . ( 1996:207 ; emphases added)

Reflexivity, for Bourdieu, was a trained state of mind for the researcher, essential for proper knowledge production. Let’s use a story from Hans Christian Andersen to illustrate this point. If you remember this story from your childhood, it goes something like this: Two con artists show up in a town in which its chief monarch spends a lot of money on expensive clothes and splashy displays. They sense an opportunity to make some money out of this situation and pretend they are talented weavers from afar. They tell the vain emperor that they can make the most magnificent clothes anyone has ever seen (or not seen, as the case may be!). Because what they really do is “pretend” to weave and sew and hand the emperor thin air, which they then help him to put on in an elaborate joke. They tell him that only the very stupid and lowborn will be unable to see the magnificent clothes. Embarrassed that he can’t see them either, he pretends he can. Everyone pretends they can see clothes, when really the emperor walks around in his bare nakedness. As he parades through town, people redden and bow their heads, but no one says a thing. That is, until one child looks at the naked emperor and starts to laugh. His laughter breaks the spell, and everyone realizes the “naked truth.”

Now let us add a new thread to this story. The boy did not laugh. Years go by, and the emperor continues to wear his new clothes. At the start of every day, his aides carefully drape the “new clothes” around his naked body. Decades go by, and this is all “normal.” People don’t even see a naked emperor but a fully robed leader of the free world. A researcher, raised in this milieu, visits the palace to observe court habits. She observes the aides draping the emperor. She describes the care they take in doing so. She nowhere reports that the clothes are nonexistent because she herself has been trained to see them . She thus misses a very important fact—that there are no clothes at all! Note that it is not her individual “biases” that are getting in the way but her unreflective acceptance of the reality she inhabits that binds her to report things less accurately than she might.

In his later years, Bourdieu turned his attention to science itself and argued that the promise of modern science required reflectivity among scientists. We need to develop our reflexivity as we develop other muscles, through constant practice. Bourdieu ( 2004 ) urged researchers “to convert reflexivity into a disposition, constitutive of their scientific habitus, a reflexivity reflex , capable of acting not ex poste , on the opus operatum , but a priori , on the modus operandi ” ( 89 ). In other words, we need to build into our research design an appreciation of the relationship between researcher and researched.

To do science properly is to be reflective, to be aware of the social waters in which one swims and to turn one’s researching gaze on oneself and one’s researcher position as well as on the object of the research. Above all, doing science properly requires one to acknowledge science as a social process. We are not omniscient gods, lurking above the humans we observe and talk to. We are human too.

Further Readings

Barry, Christine A., Nicky Britten, Nick Barbar, Colin Bradley, and Fiona Stevenson. 1999. “Using Reflexivity to Optimize Teamwork in Qualitative Research.”  Qualitative Health Research  9(1):26–44. The coauthors explore what it means to be reflexive in a collaborative research project and use their own project investigating doctor-patient communication about prescribing as an example.

Hsiung, Ping-Chun. 2008. “Teaching Reflexivity in Qualitative Interviewing.” Teaching Sociology 36(3):211–226. As the title suggests, this article is about teaching reflexivity to those conducting interviews.

Kenway, Jane, and Julie McLeod. 2004. “Bourdieu’s Reflexive Sociology and ‘Spaces of Points of View’: Whose Reflexivity, Which Perspective?” British Journal of Sociology of Education 25(4):525–544. For a more nuanced understanding of Bourdieu’s meaning of reflexivity and how this contrasts with other understandings of the term in sociology.

Kleinsasser, Audrey M. 2000. “Researchers, Reflexivity, and Good Data: Writing to Unlearn.” Theory into Practice 39(3):155–162. Argues for the necessity of reflexivity for the production of “good data” in qualitative research.

Linabary, Jasmine R., and Stephanie A. Hamel. 2017. “Feminist Online Interviewing: Engaging Issues of Power, Resistance and Reflexivity in Practice.” Feminist Review 115:97–113. Proposes “reflexive email interviewing” as a promising method for feminist research.

Rabbidge, Michael. 2017. “Embracing Reflexivity: The Importance of Not Hiding the Mess.” TESOL Quarterly 51(4):961–971. The title here says it all.

Wacquant, Loïc J. D. 1989. “Towards a Reflexive Sociology: A Workshop with Pierre Bourdieu.” Sociological Theory 7(1):26–63. A careful examination of Bourdieu’s notion of reflexivity by one of his most earnest disciples.

• Someone might ask me if I have truly been able to “stand” in the shoes of more privileged students and if I might be overlooking similarities among college students because of my “biased” standpoint. These are questions I ask myself all the time. They have even motivated me to conduct my latest research on college students in general so that I might check my observations that working-class college students are uniquely burdened ( Hurst 2019 ). One of the things I did find was that middle-class students, relative to upper-class students, are also relatively disadvantaged and sometimes experience (feel) that disadvantage. ↵
• Unless, of course, one is engaged in autoethnography! Even in that case, however, the point of the study should probably be about a larger phenomenon or experience that can be understood more deeply through insights that emerge in the study of the particular self, not really a study about that self. ↵
• I mentioned Pierre Bourdieu earlier in the chapter. For those who want to know more about his work, I’ve included this advanced section. Undergraduates should feel free to skip over. ↵

The practice of being conscious of and reflective upon one’s own social location and presence when conducting research.  Because qualitative research often requires interaction with live humans, failing to take into account how one’s presence and prior expectations and social location affect the data collected and how analyzed may limit the reliability of the findings.  This remains true even when dealing with historical archives and other content.  Who we are matters when asking questions about how people experience the world because we, too, are a part of that world.

The branch of philosophy concerned with knowledge.  For researchers, it is important to recognize and adopt one of the many distinguishing epistemological perspectives as part of our understanding of what questions research can address or fully answer.  See, e.g., constructivism , subjectivism, and  objectivism .

A statement created by the researcher declaring their own social position (often in terms of race, class, gender) and social location (e.g., junior scholar or tenured professor) vis-à-vis the research subjects or focus of study, with the goal of explaining and thereby limiting any potential biases or impacts of such position on data analyses, findings, or other research results.  See also reflexivity .

Reliability is most often explained as consistency and stability in a research instrument, as in a weight scale, deemed reliable if predictable and accurate (e.g., when you put a five-pound bag of rice on the scale on Tuesday, it shows the same weight as when you put the same unopened bag on the scale Wednesday).  Qualitative researchers don’t measure things in the same way, but we still must ensure that our research is reliable, meaning that if others were to conduct the same interview using our interview guide, they would get similar answers.  This is one reason that reflexivity is so important to the reliability of qualitative research – we have to take steps to ensure that our own presence does not “tip the scales” in one direction or another or that, when it does, we can recognize that and make corrections.  Qualitative researchers use a variety of tools to help ensure reliability, from intercoder reliability to triangulation to reflexivity.

In mostly quantitative research, validity refers to “the extent to which an empirical measure adequately reflects the real meaning of the concept under consideration” ( Babbie 1990 ). For qualitative research purposes, practically speaking, a study or finding is valid when we are measuring or addressing what we think we are measuring or addressing.  We want our representations to be accurate, as they really are, and not an artifact of our imaginations or a result of unreflected bias in our thinking.

A method of ensuring trustworthiness where the researcher shares aspects of written analysis (codes, summaries, drafts) with participants before the final write-up of the study to elicit reactions and/or corrections.   Note that the researcher has the final authority on the interpretation of the data collected; this is not a way of substituting the researcher’s analytical responsibilities.  See also peer debriefing . 

The process of strengthening a study by employing multiple methods (most often, used in combining various qualitative methods of data collection and analysis).  This is sometimes referred to as data triangulation or methodological triangulation (in contrast to investigator triangulation or theory triangulation).  Contrast mixed methods .

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

A practical guide to reflexivity in qualitative research: AMEE Guide No. 149

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A practical guide to reflexivity in qualitative research: AMEE Guide No. 149

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Qualitative research relies on nuanced judgements that require researcher reflexivity, yet reflexivity is often addressed superficially or overlooked completely during the research process. In this AMEE Guide, we define reflexivity as a set of continuous, collaborative, and multifaceted practices through which researchers self-consciously critique, appraise, and evaluate how their subjectivity and context influence the research processes. We frame reflexivity as a way to embrace and value researchers’ subjectivity. We also describe the purposes that reflexivity can have depending on different paradigmatic choices. We then address how researchers can account for the significance of the intertwined personal, interpersonal, methodological, and contextual factors that bring research into being and offer specific strategies for communicating reflexivity in research dissemination. With the growth of qualitative research in health professions education, it is essential that qualitative researchers carefully consider their paradigmatic stance and use reflexive practices to align their decisions at all stages of their research. We hope this Guide will illuminate such a path, demonstrating how reflexivity can be used to develop and communicate rigorous qualitative research.

• Reflexivity
• qualitative methods
• qualitative research

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T1 - A practical guide to reflexivity in qualitative research

T2 - AMEE Guide No. 149

AU - Olmos-Vega, Francisco M.

AU - Stalmeijer, Renée E.

AU - Varpio, Lara

AU - Kahlke, Renate

N1 - Publisher Copyright: © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

N2 - Qualitative research relies on nuanced judgements that require researcher reflexivity, yet reflexivity is often addressed superficially or overlooked completely during the research process. In this AMEE Guide, we define reflexivity as a set of continuous, collaborative, and multifaceted practices through which researchers self-consciously critique, appraise, and evaluate how their subjectivity and context influence the research processes. We frame reflexivity as a way to embrace and value researchers’ subjectivity. We also describe the purposes that reflexivity can have depending on different paradigmatic choices. We then address how researchers can account for the significance of the intertwined personal, interpersonal, methodological, and contextual factors that bring research into being and offer specific strategies for communicating reflexivity in research dissemination. With the growth of qualitative research in health professions education, it is essential that qualitative researchers carefully consider their paradigmatic stance and use reflexive practices to align their decisions at all stages of their research. We hope this Guide will illuminate such a path, demonstrating how reflexivity can be used to develop and communicate rigorous qualitative research.

AB - Qualitative research relies on nuanced judgements that require researcher reflexivity, yet reflexivity is often addressed superficially or overlooked completely during the research process. In this AMEE Guide, we define reflexivity as a set of continuous, collaborative, and multifaceted practices through which researchers self-consciously critique, appraise, and evaluate how their subjectivity and context influence the research processes. We frame reflexivity as a way to embrace and value researchers’ subjectivity. We also describe the purposes that reflexivity can have depending on different paradigmatic choices. We then address how researchers can account for the significance of the intertwined personal, interpersonal, methodological, and contextual factors that bring research into being and offer specific strategies for communicating reflexivity in research dissemination. With the growth of qualitative research in health professions education, it is essential that qualitative researchers carefully consider their paradigmatic stance and use reflexive practices to align their decisions at all stages of their research. We hope this Guide will illuminate such a path, demonstrating how reflexivity can be used to develop and communicate rigorous qualitative research.

KW - Reflexivity

KW - qualitative methods

KW - qualitative research

UR - http://www.scopus.com/inward/record.url?scp=85129218492&partnerID=8YFLogxK

U2 - 10.1080/0142159X.2022.2057287

DO - 10.1080/0142159X.2022.2057287

M3 - Article

AN - SCOPUS:85129218492

SN - 0142-159X

JO - Medical Teacher

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The Eye Regards Itself: Benefits and Challenges of Reflexivity in Qualitative Social Work Research

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Barbara Probst, The Eye Regards Itself: Benefits and Challenges of Reflexivity in Qualitative Social Work Research, Social Work Research , Volume 39, Issue 1, March 2015, Pages 37–48, https://doi.org/10.1093/swr/svu028

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Much has been written about the central role of reflexivity in qualitative research, yet there has been no empirical study of how researchers actually practice reflexivity and what it is like for them to do so. To address this question, a project was developed to gather information directly from qualitative social work researchers about the perceived benefits, challenges, and limitations of reflexivity. Participants, representing eight countries with the majority (65%) from the United States, included researchers using diverse methods with varying degrees of experience. In their interviews, these 34 scholars discussed the benefits of reflexive activities for both themselves and their research projects; obstacles that were personal, project-related, professional, and systemic; a discrepancy between valuation and actual use of reflexive practices; and the need to balance flexibility and rigor. The article concludes with directions for further inquiry and suggestions for assessing the adequacy of reflexivity in published studies.

“Reflexivity” is generally understood as awareness of the influence the researcher has on the people or topic being studied, while simultaneously recognizing how the research experience is affecting the researcher ( Gilgun, 2008 ). Reflexive engagement while planning, conducting, and writing about research promotes an ongoing, recursive relationship between the researcher's subjective responses and the intersubjective dynamics of the research process itself.

Although much has been written about the importance of reflexivity in qualitative research, there has been no empirical study of how researchers actually practice reflexivity and integrate it into their work. The literature has focused largely on definition (for example, Finlay, 2002a ; Pillow, 2003 ), utility (for example, Ben-Ari & Enosh, 2011 ), and typology (for example, Barusch, Gringeri, & George, 2011 ; D'Cruz, Gillingham, & Melendez, 2007 ; Longhoefer & Floersch, 2012 ), yet there has been no study of qualitative researchers themselves to find out how and why they engage in actions they consider “reflexive.” The purpose of this study was thus to examine the role of reflexivity in qualitative social work research through the eyes of those who practice it, with particular interest in perceptions of reflexivity's benefits, challenges, and limitations. Although the study is primarily descriptive, it also includes prescriptive elements and concludes with suggestions for scholars, editors, and consumers of qualitative research.

Reflexivity and Knowledge

The term “reflexive” is used to denote actions that direct attention back to the self and foster a circular relationship between subject and object. Nonreflexive actions , in contrast, are those that distinguish subject from object, cause from effect, in a linear or temporal relationship. Each approach rests on a different epistemology and leads to a different way of searching for knowledge. Epistemology, not methodology, determines the place of reflexivity in a particular study. A researcher may use qualitative or quantitative methods—for example, conduct a participatory or community-based project using surveys, observations, and focus groups—and, within that study, be more or less reflexive.

In research based on a positivist worldview, the “experimenter effect”—the impact of the researcher's presence—is generally considered to be a methodological problem, a form of reactivity in which a researcher's biases cause him or her to unconsciously influence participants, contaminating both process and outcome; the more rigorously this influence is minimized or isolated, the better the study. Within the constructivist paradigm, on the other hand, reactivity is not seen as a problem to be reduced or overcome but as an essential element in the cocreation of knowledge ( Ben-Ari & Enosh, 2011 ). The subject is always present in the object ( Finlay, 2002b ), and the researcher is always “written into the text” ( Lynch, 2000 ); thus, both research er and research ed shape the encounter, and “research” becomes the collaborative construction of knowledge rather than the discovery of knowledge assumed to already exist. The measure of rigor is the clarity with which both personal and relational subjectivity have been identified and revealed, not how thoroughly they have been “controlled for” ( Jootun, McGhee, & Marland, 2009 ). At the same time, as Lynch (2000) pointed out, the function of reflexivity in this process is not quite clear. Sometimes it is seen as a way to enhance objectivity by “bracketing” the researcher's subjectivity and thereby eliminating or reducing bias, while at other times it is seen as a means for exposing false claims of objectivity ( Lynch, 2000 ).

Awareness of one's subjectivity develops through an internal process that is supported by external activities ( Probst & Berenson, 2014 ). Both are aspects of reflexivity, which can be understood as a process of self-examination (exploring one's assumptions, emotional reactions, cultural positioning) through specific actions (keeping a journal, debriefing with others, and so on) within a field of inquiry that is also an object of awareness. Reflexive researchers are, in essence, gazing in two directions at the same time. As they attend to what is taking place in the field of study, they become aware of their own projections, attachments, assumptions, agendas, and biases—like an eye that sees itself while simultaneously seeing the world. Ideally, this double perspective is present throughout the research endeavor, from the selection of topics and populations to be studied to the presentation and dissemination of findings ( Probst & Berenson, 2014 ), affecting the way a project is conceptualized and the way it is experienced.

“Muddy” Nature of Reflexive Research

Reflexive analysis is challenging, fraught with danger. As Finlay warned, “The researcher treads a cliff edge where it is all too easy to fall into an infinite regress of excessive self-analysis at the expense of focusing on the research participants” ( Finlay, 2002b , p. 532). She likened reflexivity to a “swamp,” a murky and confusing terrain of self-analysis and self-disclosure rife with “endless narcissistic personal emoting or interminable deconstructions of deconstructions” ( Finlay, 2002a , p. 226) where the researcher can become hopelessly lost. Others agreed, describing reflexivity as “muddy,” “messy,” a teeming mass of endlessly layered subjectivity that requires the researcher to “come clean” ( Brown, 2006 ; Pillow, 2003 ; Valandra, 2012 ).

Pillow (2003) cautioned against excessive reflexivity, “wading in the morass of our own positionings” (p. 175), and argued that reflexivity is not a way to solve the “problem” of subjectivity. “We do not escape from the consequences of our positions by talking about them endlessly,” she wrote ( Pillow, 2003 ); reflexivity can be misused to imply that issues of inequity, bias, and misunderstanding have been adequately addressed just because the researcher is aware of them. At the same time, she stated, “I do not believe that the solution is then to stop talking about our positions” ( Pillow, 2003 , p. 177). She raised a concern, as others also have (for example, Finlay, 2002a ), about whether reflexivity is a distraction, focusing on the researcher's internal processes and shifting attention away from the people or phenomenon being studied.

Access to one's motivations, biases, and reactions—the “stuff” of reflexivity—may not be as simple as it sounds, however. The very things that most need to be seen are often the most deeply hidden ( Gemignani, 2011 ). The intellectual conviction that self-awareness is important may not be sufficient to expose masks and blind spots to self-scrutiny. A particular kind of skill and stamina may be needed, because confronting one's limitations, vulnerabilities, and mistakes is not an easy task, even for the most sincere researcher. Both novice and seasoned researchers may feel uncomfortable, threatened, and even resistant, though perhaps for different reasons, to the idea of critically interrogating their own positions and emotional experiences ( Hsiung, 2008 ); researching sensitive topics can also trigger unexpected and powerful reactions ( Gilgun, 2008 ) that are not so easily “managed away” by writing a memo. Because the process is so idiosyncratic, the researcher cannot know in advance what will require reflexivity or what tool will serve best, so it may be difficult to build reflexivity into a study design. Here again, reflexivity asserts its “messy” nature.

Evaluating Reflexivity

Perhaps the “muddiest” issue is whether reflexivity produces better research. Gilgun (2008) argued that reflexivity opens the researcher to a fuller, more “connected knowing,” and Ben-Ari and Enosh (2011) described how reflexivity between interviewer and interviewee can be used for the construction of new knowledge. Others, however, have cautioned against assuming that just because we are reflexive our work is truer, better, or more valuable. Reflexivity is not, as Pillow (2003) warned, a cure for the problem of representing someone else's reality. Finlay (2002a) made a similar point: A researcher's apparent openness does not guarantee that the voices of participants have been faithfully represented.

Lynch (2000) also questioned the notion that reflexivity contrasts with or transforms an “unreflexive” condition into something with greater “critical potency and emancipatory potential” (p. 36), and thus more valuable or true. There is no inherent advantage to being reflexive, he noted, unless something useful comes from it, nor does a reflexive approach necessarily bring the researcher closer to the meaning of a phenomenon ( Lynch, 2000 ). He especially challenged the sense of virtuousness and “epistemological hubris that often seems to accompany self-consciously reflexive claims” ( Lynch, 2000 , p. 47).

The relation of reflexivity to rigor is part of the broader question of how qualitative researchers can “produce credible work when objectivity is no longer assumed or even pursued” ( Barusch et al., 2011 , p. 11). Criteria for qualitative rigor tend to emphasize the relational aspects of knowledge construction, including transparency, reciprocity, and critical self-reflection. And yet, in their review of qualitative social work articles, Barusch and colleagues found a surprising absence of reflexive practice, with only 14% of authors they surveyed disclosing information about background or positioning. This does not mean, of course, that the other 86% of researchers were not reflexive. They may very well have been reflexive in their data collection and analysis but did not include that information in published reports.

Gringeri, Barusch, and Cambron (2013) reported a similar discrepancy in their review of social work publications. Although they cited theory and reflexivity as the “twin pillars of rigorous qualitative research” ( Gringeri et al., 2013 , p. 61), they found that only 16% of the articles in their sample incorporated reflexive accounts. Perplexed by social workers' reluctance to situate themselves in their research and by an apparent discrepancy between what researchers claim to value and what they claim to do, Gringeri et al. (2013) concluded that “the low rate of reflexivity in social work articles requires our attention” (p. 61).

Clearly, there is a paradox worth examining. On the one hand, reflexivity is cited as an important tool for enhancing the rigor and trustworthiness of a qualitative study ( Gilgun, 2010 ; Gringeri et al., 2013 ; Longhofer & Floersch, 2012 ). It is often invoked, in fact, as the qualitative equivalent of tests of validity, something qualitative researchers can point to as an evidentiary trail in their justification of claims to knowledge. On the other hand, there is a persistent uncertainty about reflexivity's contribution to rigor or knowledge. It seems difficult to study the topic in a systematic way. As Lynch (2000) and others noted, there are different kinds of reflexivity—awareness of social positioning and power relations, documentation of choices, cybernetic feedback loops, stepping back to “break the frame,” methodological self-consciousness or self-criticism—corresponding to different philosophical perspectives, research aims, and types of analysis. Varying from researcher to researcher, and from situation to situation even for the same researcher, reflexivity appears to be inherently emergent and personal, eluding manualization.

Still, the question remains whether or how one can determine that a researcher has been “reflexive enough.” Is it possible to evaluate the reflexivity of a study without mechanizing something that is inherently idiosyncratic and co-constructed—that is, without imposing criteria from a dissonant epistemology? If so, how can that be done? And if not, how can both reader and researcher feel comfortable that sufficient reflexivity has been used?

By asking qualitative researchers to be reflexive about their own reflexivity, this study opens the door to investigation of these important questions. Providing insight into barriers and benefits of reflexive research, this article offers suggestions for enhancing, supporting, and evaluating the use of reflexivity in social work research.

The study was undertaken to gather information about how qualitative social work researchers experience and incorporate reflexivity into their work. It sought to identify specific actions researchers take to support or enact reflexivity ( Probst & Berenson, 2014 ) and to explore how they view the benefits, challenges, and limitations of reflexivity. Research questions included the following:

Benefits : What do qualitative social work researchers perceive to be the benefits of reflexivity? Beneficial for what or for whom?

Supports : Are there personal factors or external conditions that foster the use of reflexivity?

Challenges : What are the obstacles or drawbacks? When reflexivity is not used, why not?

Potential dissonance : Are there any differences between how qualitative social work researchers think about reflexivity and how they actually use it? If so, what might be the source of that dissonance?

A realist epistemology served as the framework for the research, because participants' responses were taken as offered (that is, literally) and analyzed thematically across the data set. Because qualitative research was itself the topic of study, a qualitative approach to data collection, analysis, and interpretation seemed appropriate. Within the qualitative paradigm, thematic analysis ( Boyatzis, 1998 ; Braun & Clarke, 2006 ) was chosen for its flexible yet grounded approach. Thematic analysis is an inductive method for identifying, analyzing, and reporting patterns within the data, allowing the researcher to use a bounded theoretical question as a starting point for identifying themes that can shed light on an identified area of interest; themes can thus be theory driven or data driven.

Participation in the project was offered through flyers, sign-up sheets, and e-mail to members of the Listserv for the Qualitative Special Interest Group (SIG) of the Society for Social Work and Research (SSWR), individuals on the e-mail list for Social Work Day of the International Congress on Qualitative Inquiry, and other researchers who had expressed interest during workshops and conversations at SSWR's annual conference in January 2012. The only inclusion criterion was experience conducting qualitative social work research, and all who volunteered were interviewed. Because there is no information about the total number of people on either Listserv, the response rate is not known.

A total of 34 people took part. Of these, 65% ( n = 22) were from the United States, with the remaining 35% ( n = 12) from the United Kingdom (England, Ireland, and Scotland), Australia, New Zealand, Canada, and Israel. Based on self-reported descriptions of their research experience, half were rated as highly experienced ( n = 17), and approximately one-fourth each of medium ( n = 9) and limited ( n = 8) experience. Most of those in the third group were doctoral students nearing completion of their dissertations. Among the participants, 30% ( n = 10) were male and 70% ( n = 24) were female. When asked about the specific qualitative approaches they used (for example, ethnography, grounded theory), all described projects that spanned various approaches, with the most common kinds of research experience being focus groups, thematic analysis, narrative studies, content analysis, and grounded theory. Because no one self-identified as adhering to a single methodology, categories were nonexclusive and it was not possible to link responses to particular qualitative methods.

Data Collection

Individual interviews lasting 45 to 60 minutes were conducted in person, via Skype, or by telephone. Informed consent was obtained before each interview; interviews were audio-recorded and transcribed. After providing background information, participants were asked what reflexivity meant to them and why they were interested in the study. To guard against premature closure based on assumptions about what reflexivity “ought” to look like, an inclusive approach was selected to capture data that might otherwise slip through the semantic net; thus, a range of experiences and practices were explored, as was the use of these practices in both individual and group projects. Finally, participants were asked what they felt were the benefits, obstacles, and potential drawbacks to reflexivity.

Author Positioning

I have an ongoing interest in reflexivity stemming from my professional work and personal mindfulness practice, and have conducted a number of sessions on reflexivity in qualitative research at professional conferences. I knew approximately one-third of the people interviewed, although only in broad professional contexts and, with one exception, not well. This shared community was useful for recruitment. A number of people said they wanted to help a colleague or, as several joked, store up “good research karma.” Engagement was not a problem. Participants were interested in talking about their work, and many stated at the end of the interview that they had found the experience extremely useful.

Studying members of a group to which one belongs has both advantages and perils, of course. As Chew-Graham, May, and Perry (2002) noted, when interviewing someone who is a member of the same profession or known to the interviewer in a professional context, access may be easier, yet prior knowledge can affect the way that the researcher is perceived, the kind of material that is offered, and the way that material may be interpreted. Because of their common profession, interviewees may assume that the researcher sees things the same way they do. Perception of the researcher as a peer with a common language and shared understanding can make participants less cautious and guarded, resulting in more genuine data or, in contrast, cause them to compete, seek to impress, or collude with the researcher in “a case of shared conceptual blindness” ( Chew-Graham et al., 2002 , p. 288).

As researchers, our study participants understand what participating in a study will entail because they know the “tricks of the trade”; they know the data may be interpreted in ways that they did not intend, and they understand what “confidentiality” and “anonymity” mean in practice. This meant, for many of them, that they were cautious in how they presented themselves. ( Wiles et al., 2006 , p. 293)

Concerns expressed by participants in Wiles et al.'s study (2006) , such as fear that the researcher would “steal” their ideas or reveal their criticism of fellow researchers, did not arise in this study; at least, these concerns were not voiced. It is certainly possible, of course, that some of the other issues raised by both Chew-Graham et al. (2002) and Wiles et al. (2006) were taking place below the surface. Assumptions of a shared understanding may have masked important nuances, and some participants may have presented themselves as more reflexive than they really were. The topic itself (described on the informed consent form) may have conveyed the assumption that reflexivity is a hallmark of “good” qualitative research and evoked the desire to seem like “good” researchers in the interviewer's eyes. Although it is never possible to entirely rule out social desirability bias, numerous comments about not being sure what reflexivity “really was” or wishing they had time to “do it more” seemed to indicate an overall candor in interviewees' responses.

From time to time I also offered examples of my own reflexivity. For instance, I shared with several people the mortification I felt in discovering that I was competing with my own study participants, feeling jealous when they seemed “more reflexive” than I was and then wanting to impress them by performing the identity of “expert researcher.” In this way, a parallel process took place between collecting data about reflexivity in qualitative research while also experiencing reflexivity in qualitative research.

Data Analysis

Following data collection, iterative thematic coding was carried out in stages. The data set was divided into three segments, each including a heterogeneous group of participants irrespective of when the interviews took place; one set of interviews was used for developing a theme book and other two for successive testing and refining of the themes. In the first stage, one-third of the interviews were independently coded by the researcher and a doctoral intern, who then compared and collapsed themes into a collaborative preliminary code book. This tentative list of codes was checked against a second group of interviews to confirm, refine, and elaborate on the codes and to highlight fresh ideas that were not yet represented. Themes endorsed or articulated by this second group were noted, along with additional nuances or alternative viewpoints. A revised code book was developed and organized into a chart.

The chart was shown to the third group of qualitative researchers so participants and individuals similar to participants could review the preliminary findings. Volunteers for these follow-up interviews were solicited at SSWR and through the SIG Listserv. Of the eight people who took part in this third set of interviews, three had been interviewed previously and five had not. Four were experienced, three were mid-level, and one was relatively new. All but one were from the United States; 75% were female.

During this process, which served as both peer review and member check, participants were asked to comment on anything they felt was omitted, unclear, or did not “ring true,” as well as any thoughts about their own experience of reflexivity. A number of additional points emerged from these conversations, and the outline was expanded accordingly. With this outline as a template, the interviews were reviewed again for further refinement. Finally, findings were organized into a conceptual diagram (see Figure 1 ) to illustrate relationships among key elements.

Reflexivity in Qualitative Research

Respondents spoke candidly about the benefits and the difficulties of reflexivity. Although benefits are described below in a somewhat dichotomous manner as either “for oneself” or “for the project” and challenges are noted as either personal or systemic, these distinctions are for ease of exposition only, because most participants saw these processes as fluid and overlapping.

Benefits of Reflexivity

Benefits of reflexivity included accountability, trustworthiness, richness, clarity, ethics, support, and personal growth—beneficial for the integrity of the research process, the quality of the knowledge generated, the ethical treatment of those being studied, and the researcher's own well-being and personal growth.

For the Research Project

Participants considered reflexivity essential for rigor because it made positionality, subjectivity, and reactivity more transparent. “Being aware of your positioning in relation to the research” and “knowing that there's no neutrality, however much people might claim they can remain neutral in their research” provided a baseline of honesty and served as a check against naïve claims of purity or objectivity. Being reflexive “helps me remember what my voice is because, while my voice is important, I need to see past it or hear past it.” Reflexivity also provided a way to document choices, keep track of an evolving process, and leave a trail that could be retraced later if choices needed to be revisited. Memos and journals helped to guard against forgetting or distorting what took place in earlier stages of a project and served as a reminder to keep an open mind.

In particular, reflexivity was seen as important for epistemological rigor. “To be aware of how you conceptualize, why you conceptualize in that way,” to think about “how do I know this, or why am I saying this,” and to examine “the kind of questions you ask and what things may have happened in the actual interviewing” were essential for participants “because you're making a case all the time for your version of knowledge, and are you cutting off other people all the time from their version?” Without recursive self-inquiry, assumptions masked as professional expertise might infiltrate one's work, undermining its authenticity or value. “It's like, is the unexamined life worth living, is the unexamined study worth doing?”

Closely related were the benefits of reflexivity for ethics. Ethics included the honesty of the investigator about his or her agenda, hopes, and potential for personal gain, and extended to openness about power relations, often covert, between researcher and those being studied. Participants saw reflexivity as a way to promote trust, equity, integrity, and respect for those being studied, as well as a way to guard against the self-deception and further inequity that can result when power imbalance is not acknowledged.

“You can't look at other people's lives without looking at what else is going on in you” because “reflexivity means testing the knowledge–power relationship that's going on in that process all the time.” Participants were keenly aware of power issues in the research process, the question of whose knowledge or authority was being upheld, and the distaste of benefiting from someone else's story. Reflexivity could help to bring these issues into the light and to work through specific ethical dilemmas that might arise. “It's a way of trying to be as honest as we can about what we're doing, a way of testing ourselves that we're being honest about what we're bringing and what we're drawing from the research.”

Many also considered reflexivity helpful for the development of professional knowledge. “Using reflexivity allows me to think through, test, wonder, and use it as a base to explore, all of those things, reflecting on what I heard in an interview, and then looking at it from multiple places in myself.” Both self-reflection and feedback from others offered new layers of meaning, depth, and nuance.

For the Researcher

Self-awareness was also seen as beneficial for the researcher. It provided a framework for processing, sustaining, renewing, and gaining insight both into the research and oneself. As a tool for managing the research experience, it could serve as a way to discharge and work through intense, surprising, or upsetting issues and thus avoid becoming sidetracked or emotionally depleted. Some participants saw reflexivity as a way to normalize one's reactions, put them into context, and create appropriate distance; others noted that it could also help to un normalize experience and support the effort to “lean into the discomfort” and open new perspectives. “Stepping back from the data, thinking about what's in there and how I'm reacting to it” was seen as a helpful counterweight to the tendency to become overimmersed or overidentified. “You have to know who you are, how you're interacting, and what you're feeling and what role you're playing in the data collection and your analysis.” A qualitative researcher without self-awareness cannot, participants agreed, be a good researcher.

By Type of Reflexive Activity

Speaking with others provided an opportunity to “bounce ideas off people who are less directly immersed” and can “call me on things about my understanding that I may have missed or taken for granted.” Other people can bring awareness of blind spots and “sticky moments,” opening up multiple or alternative viewpoints. Debriefing and working through problems with others was seen as a “way to hold myself accountable and to manage my own bias and reactivity, to see what you're unable to see in your own work,” thus adding to transparency and trustworthiness.

Research unfolds over time and I find that it is easy to forget initial ideas and thoughts as I become more familiar with something. There are things that are potentially relevant to the project but not immediately pertinent at the moment, so it provides a record of experiences to refresh my memory.

Thinking about the context acts as an orienting tool that allows me to be mindful of my own role throughout the research process. Being aware of all I take into the research process and how my history, perspectives, etc., influence what I ask, how I hear the answers, and what I choose to report in the findings.

Returning reflexively to the literature “can affirm or challenge your material and make you examine it more critically.” Pondering what has already been written helped to position the researcher, identify limits to his or her understanding, and situate findings in existing knowledge. “We must know what we already know, what we need to know, how our work conflicts with or agrees with that knowledge. Research is about building knowledge, which means knowing what is already there and how our work fits in.”

Reflexivity could be especially important when working as part of an interdisciplinary research team where members approach knowledge differently ( Malacrida, 2007 ; Paulus, Woodside, & Zeigler, 2010 ). Shared awareness of the criteria each uses to formulate categories—the assumptions, filters, and professional stance inherent in each discipline—contributes to the trustworthiness of study findings. The aim of collaborative reflexivity between team members was not seen as reaching consensus, but as articulating the differing assumptions and agendas that contribute to multifaceted understanding. As one respondent noted, “Team reflexivity is something different, it's not just a collection of each person's individual reflexivity.”

Challenges to Reflexivity

Obstacles and drawbacks to reflexivity were personal, project-related, and systemic.

Personal Challenges

When you first start, it is scarier or feels riskier than after you have been doing it for a while because of our nature to judge ourselves, and if you are really going to be reflexive, you need to find a way to be okay with our own foibles, mistakes, things you didn't do quite so well.

The line between openness and intolerable rawness could be difficult to navigate. “Sometimes asking others for comments opens up more than I had anticipated. Being open to unexpected or critical feedback is sometimes quite painful.”

Many respondents reported using additional supports such as mindfulness, contemplation, psychotherapy, creative writing, or “venting” with friends. They differed, however, in whether they felt reflexivity aggravated or mitigated the sense of being overwhelmed and flooded. Some felt that this would happen anyway and that self-awareness helped to manage the feelings, making them less traumatic; others felt that focusing on areas of personal sensitivity made the researcher more vulnerable and traumatized.

Project-related Challenges

Time constraints were the most frequently cited obstacle. Reflexivity took time and self-discipline, participants agreed, especially after long days of field observation, and was not always feasible because of pressure to move at a rapid pace or attend to other commitments. “The first challenge is time. The second challenge for me probably would be not being patient enough to let it unfold because I think being reflexive and taking time to do it well can be a slow and painful process.”

I've seen some material where self-reflexivity almost goes into what I would call self-indulgence, and I don't like it. Some of the stuff that people write about is really just biographical. I don't need to know that. I don't need to hear the person in the publication—I don't need to hear all of their doubts and all of their going back and forth, and all of that; it just doesn't work, to me.

Objections to reflexivity as self-indulgence had to do with published reports, however, not necessarily with its use during the research process, which might or might not find its way into the written presentation. Here again, there was a difference of opinion, with some feeling that the more rigorously one engaged in reflexivity, the less the likelihood of inappropriate “navel gazing” and narcissistic distortion.

External or Systemic Challenges

A lack of valuation by colleagues, administrators, funders, and journals was a major concern. Many participants felt that explicit endorsement of reflexivity could threaten their credibility with tenure committees operating from a quantitative model; one person even said that he had been advised to remove a highly reflexive published article from his portfolio. This kind of vigilance could make people feel defensive, torn, devaluing the sense of themselves as professionals. In addition, the pressure to publish made it tempting to move projects forward quickly or to jettison reflexive activities that were unlikely to be included in the final report.

Isolation from supportive peers engaged in similar reflexive research was a related concern. “You need colleagues who believe in and practice reflexivity to be able to maintain your own resilience.” This was not always possible, however, because “coresearchers and peers aren't always as keen to participate in reflexivity as I am … if you're working on a group project and members of your group are not naturally reflexive or the need for process isn't shared.” The biggest challenge was “believing in reflexivity enough to be able to put up with accusations of taking too long, not meeting deadlines, or being self-indulgent.”

Other participants cited a lack of training, preparation, or the availability of clear or consistent guidelines for assessing whether one has been adequately reflexive. Knowing when to disclose personal reflections was a related concern. Sharing one's biases or doubts was not always useful, especially if those being studied were hostile or might be influenced by what they learned about the researcher. For many participants, there was a discrepancy between valuation of reflexivity—what they believed they ought to do—and their actual use of reflexive practices. Reasons for this discrepancy were linked to the obstacles and limitations they encountered in their attempt to put into practice the self- and collaborative reflection they believed was so important for their work.

Clearly, interest in qualitative research and respect for the qualitative paradigm continue to grow. More social work graduate students are attracted to qualitative research; more professional journals accept qualitative studies; and more time is devoted to qualitative research at professional conferences. Thus, it is vital for qualitative scholars to be able to articulate what they have learned and to transmit that knowledge to the next generation of researchers who will need to become skilled users and skilled producers of qualitative scholarship.

As many participants in this study noted, however, the quantitative paradigm with its equation of measurement with evidence continues to dominate academia. Subjectivity, ambivalence, partial and multiple meanings, and the constructed nature of knowledge carry little currency within this paradigm. Time constraints and pressure to produce research with “hard” findings, especially in tenure-track positions, may inhibit the incorporation of reflexivity into both the research process and the written report. It is difficult to know, of course, whether the scarcity of reflexive accounts in published studies ( Barusch et al., 2011 ; Gringeri et al., 2013 ) means that reflexivity was absent from the research process itself. It is possible, as Gringeri et al. (2013) suggested, that researchers have indeed been reflexive but do not include those reflexive accounts in their manuscripts because they believe journal editors and reviewers do not expect it, or because they believe it would decrease their chances of publication and professional advancement. Barusch et al. (2011) offered a similar suggestion that social work authors may fear that self-disclosure would be “unprofessional” or inconsistent with journal editors' expectations and preferences, a finding supported by this study.

Lack of training also appears to be an issue. Several participants commented that they would like to “do more reflexivity” but had not been formally or adequately trained, pointing to a need to examine, and perhaps modify, how qualitative research is taught. It is not enough to espouse reflexivity as a value; students must be given models, tools, opportunities to learn by doing, and a place for including reflexive accounts in dissertations.

The skillful use of reflexivity can pose a number of additional challenges. One difficulty, noted by several respondents, is that we can only reflect on what strikes us as requiring reflection, what we become aware of with our conscious minds, although other forces may be operating and affecting the research. One can only be reflexive up to a point on one's own, and the very things one most needs to examine may be those that are most deeply hidden. Supervision and peer debriefing can help, as several respondents noted.

Another question has to do with the relationship between reflexivity, the disclosure of oneself to oneself , and disclosure to others . To what extent should the fruits of self-awareness and self-interrogation be shared with those one is studying? From one perspective, transparency with participants can help to build trust, repair power imbalance, and foster the co-creation of knowledge. At the same time, self-disclosure moves the researcher more forcefully “into the room,” perhaps too much so, just as self-disclosure by the therapist in psychotherapy can move the work forward or divert it ( Gemignani, 2011 ). Put another way, what should researchers do with the products of their self-reflections? Is there a way to put reflexivity's output to use that can effectively balance its benefits and limitations?

Other themes that invite further exploration include the following:

Professional expectations and issues of status : What is the impact of professional pressures and expectations on using and revealing reflexivity in one's research? Are there tacit messages and unspoken barriers? If so, how might this be addressed at the institutional or professional level? For instance, how explicit or flexible should policies be about the way research is taught and the way it is evaluated by tenure committees?

Electronic reporting in journals : What are the possibilities for including description of reflexive practices in published work, given the expansion of journals into electronic formats? While keeping to page limits for the main document, are there ways to offer electronic links to supplementary material about the reflexive “back story”? Should this become standard practice for qualitative manuscripts?

Supporting reflexivity outside the research project : Are there informal actions or personal qualities, extrinsic to the research process itself, that foster reflexivity? Without intruding on students' or scholars' privacy (for example, without making psychotherapy, collaboration, or mindfulness a requirement), how might these beneficial practices be supported? What are the ethical and practical challenges of doing so?

Reflexivity is an important tool that enables the researcher to stay engaged in critical self-awareness throughout the research process. It is the embodiment of an epistemology in which the knower is always present, a way of looking that gazes outward at what is taking place while sustaining an inward gaze at the looker. More than just a vehicle for honesty or management of the research experience, reflexivity offers a means for using self-knowledge to inform and enhance the research endeavor. As such, it has broad applicability for social work research regardless of methodology. That is, it is equally relevant and valuable for qualitative, quantitative, and mixed methods projects (see, for instance, Ryan & Golden, 2006 ).

Assessing the adequacy of a study's reflexivity remains problematic, however. As noted earlier, the absence of explicit mention of an author's reflexivity does not mean there was none. What, then, to look for? The notion of establishing benchmarks applicable across a range of designs risks objectification of what is inherently idiosyncratic, yet editors and readers need guidelines for determining if reflexivity is present. The following questions are far from a blueprint but represent a sample of what might be asked:

Agenda : Is there note of the author's background, previous scholarship, or the genesis of the project, other than the usual “gap in the literature”? Why was the study undertaken? Why does it matter, and to whom?

Process : Was there more than one step in the analysis? Were there any opportunities to reassess or revise?

Intersubjectivity : Who else was included in interpretation of the data? Was anyone invited to co-construct or review the findings? How convincing are the author's claims of trustworthiness, beyond his or her own perspective?

Self-interrogation : Are any contradictory or disconfirming data presented, or does everything fit (too) neatly into tidy categories?

Audit trail : Is there mention of how the author kept track of choices, hunches, and interpretations?

Although few manuscripts will offer explicit evidence on all these points, the absence of any evidence does raise a question about whether reflexivity was incorporated into the research.

Despite its “messiness,” reflexivity remains a fundamental way, particularly in qualitative studies, to bolster credibility by parsing the research endeavor into its mutually affecting parts and documenting the pathways through which knowledge was generated. This is particularly critical in social work research, because decisions about policies and practices affecting the nation's most vulnerable populations rely heavily on the strength of research findings. Consumers of social work research, as well as those whom their work ultimately serves, should be able to trust the authenticity of the knowledge offered to them. The practice of reflexivity can support this aim.

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Birks Y, Harrison R, Bosanquet K, et al. An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration. Southampton (UK): NIHR Journals Library; 2014 Jul. (Health Services and Delivery Research, No. 2.20.)

An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration.

Appendix 8 detailed statement for reflexivity.

• Team data analysis

At significant points during the process of data analysis, the researchers most closely involved in data collection and the early stages of analysis (YB, RH, KB) met with members of the wider research team with extensive qualitative (VE) and clinical (IW) experience, to discuss emerging codes and categories, the interpretation of key texts and potential new lines of enquiry, thereby drawing on the combined insights of those ‘handling’ the data closely and members of the team with a wider perspective of methodological and open disclosure issues.

• Reliability of coding

Towards the end of the analysis of the qualitative data, a member of the wider research team (VE) examined five transcripts which had been coded by the members of the team most closely involved in data collection and analysis (YB, RH, KB), as an independent check on the assignment of codes to data.

• Comparison of data within and across cases in the data set

This was facilitated by the use of the analytic matrix which forms the basis of the framework approach. Comparing data within cases allowed for the exploration of contextual meaning, while comparing cases across the data set facilitated the search for regularities (key themes) and exceptions (negative cases).

• Use of memos

The careful use of memos (by the prime analysts) during initial stages of analysis provided a visible ‘audit trail’ as the analysis moved from ‘raw’ data, through interpretation, to the production of findings.

Attention to ‘negative’ cases

Analysis included a search across the data set for ‘negative’ cases (evidence that contradicts, or appears to contradict, the explanations being developed) and alternative ways of explaining the data were considered. Systematic searching for negative cases or ‘outliers’ can help illuminate the connections that link the other cases together.

• Reflexivity

Reflexivity relates to sensitivity to the ways in which the researcher and the research process may shape the data collected, including the role of prior assumptions and experience.

Prior assumptions and experience

Within the context of the current study, the members of the research team involved in face-to-face contact with study participants needed to consider the ways in which their interactions with participants might be influenced by their own professional background, experiences and prior assumptions. The two interviewers (RH and KB) were both academic research fellows from non-clinical backgrounds. An important question we needed to address in drawing conclusions from the data concerned whether or not knowing about our professional background could have impacted on participants’ willingness to talk openly about experiences, or how this knowledge might have shaped what was said.

Awareness of social setting and the social ‘distance’ between the researcher and the researched

The majority of interviews were conducted in participants’ workplaces or homes (for patients), either face to face or over the telephone, as this was usually more convenient for them. Although we were invited in as researchers, we were also mindful that we were guests in the participants’ work or living spaces; respondents were therefore given the lead in ‘setting the pace’ of the interview. By deliberately adopting a ‘back seat’ approach in setting the scene for the interview to take place, the researchers hoped that participants would feel they were exercising a measure of control over the interview process.

Fair dealing

Dingwall 247 has suggested that one way of reducing bias in qualitative research is to ensure that the research design explicitly incorporates a wide range of different perspectives, so that the viewpoint of one group is never presented as if representing the sole truth about any situation, an analytic technique he has referred to as ‘fair dealing’.

Our study was designed to elicit contributions from a broad range of stakeholders in open disclosure. During the analytic process no particular group’s views were ‘privileged’ over those of others; that is to say, data analysis included a process of constant comparison between accounts of each group of participants, to uncover similarities and differences, which were subsequently highlighted (for example, health professionals identified a lack of certainty around what should be disclosed to a patient or carer, more so than other participants).

A main goal of data analysis was the identification of common themes that emerged from comparison across cases (individual interviews). However, equal importance was attached to focusing on the minutiae of individuals’ accounts relating to specific incidents of disclosure; in the analysis, we sought to identify the views and experiences of individuals, as well as the majority, where these were divulged.

Awareness of wider social and political context

As a research team, we discussed the fact that participants recruited from a policy level, professional organisation or national ‘consumer’ group might show a strong commitment to a particular personal or political agenda, or wish to raise particular issues during group discussions which may relate only tangentially, or not at all, to the main purpose of the discussion. We discussed how we might handle this situation if it arose and decided to emphasise the purpose of the research prior to interview and through the questions and probes used. This strategy appeared to be successful in keeping participants engaged in the research process.

The role of the research team as collaborators in knowledge production

Collaborative research is highly valued for its ability to bring together multiple researchers with distinctive and specialist perspectives to tackle large or complex research problems, though frequently the ‘putting together’ of multiple perspectives in the construction of knowledge is not described. 248

Within the Being Open research team, there was a strong commitment from the outset to work collaboratively in the collection, analysis, interpretation and reporting of the qualitative data, though individual involvement with the various stages of the research process necessarily varied. The three team members most closely involved in fieldwork (YB, RH, KB) met frequently (on average at least once per week) to discuss the progress of fieldwork and reflect on data collection; meetings intensified during the early stages of analysis, when themes and codes were beginning to be identified. At this crucial stage, input was sought from other members of the research team with extensive experience of qualitative research and a broad knowledge of patient safety research (VE, IW) to assist with ‘firming up’ the coding framework. During the early stages of analysis, an all-day meeting was convened in a location away from the interruptions of the office environment, which served as a kind of ‘interpretative retreat’. Throughout the day, we explored a sample of transcripts to gain a sense of the data that were emerging, the effectiveness of the topic guides and whether or not there may be additional participants who we wanted to invite to take part. A more intense focus on a subset of transcripts (which had been sent to VE in advance) in a further half-day analysis session was used to draw up the coding framework that would serve to underpin the analysis (and interpretation) of all the interview data. This endeavour resulted in an analytic strategy that was informed by insights from team members with a broad understanding of the research field and methodological issues, and those with field-based contextual and experiential understanding.

Potential for psychological harm

Members of the research team involved in fieldwork (RH, KB) were acutely sensitive to the possibility that focusing on the research topic could potentially provoke anxiety in the research participants concerning the disclosure of adverse events. At the end of each interview, researchers took time to ensure that participants were not feeling distressed by their participation; in these interviews, none of the participants expressed such concerns or appeared to be distressed or uneasy.

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• Cite this Page Birks Y, Harrison R, Bosanquet K, et al. An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration. Southampton (UK): NIHR Journals Library; 2014 Jul. (Health Services and Delivery Research, No. 2.20.) Appendix 8, Detailed statement for reflexivity.
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• Published: 31 July 2024

Shaping understandings through reflexive practice: Learnings from participatory research on aging with multiple sclerosis

• Sofie Olsgaard Bergien 1 , 2 ,
• Lasse Skovgaard 1 ,
• Josephine Lyngh Steenberg 1 &
• Maria Kristiansen 2  

Research Involvement and Engagement volume  10 , Article number:  78 ( 2024 ) Cite this article

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Participatory research has gained traction as an approach to unlock perspectives when creating scientific knowledge and to facilitate societal changes. By conducting research with people, participatory research strives to engage individuals’ perspectives in designing, conducting, and disseminating the research. Nevertheless, few studies have unpacked how understandings of the studied phenomenon are shaped among diverse research partners and, concurrently, how different perspectives are combined. Nested within an overall participatory mixed methods study on aging with multiple sclerosis (MS), this qualitative study explores how understandings of aging with MS are shaped in encounters between university researchers, older adults with MS, and employees in a patient association.

The study was collaboratively conducted in Denmark by three research partners: a group of older adults with MS, employees in a patient association, and university researchers. Data on how different understandings of aging with MS were represented and shaped during the three-year research process was generated through field notes, meeting minutes, focus group interviews, and individual interviews. The collected data was analyzed through a thematic network analysis.

The study demonstrates how different understandings of aging with MS were represented among the research partners when the research was initiated. These understandings were shaped prior to —and, therefore, outside—the research setting, drawing from the research participants’ lived experiences, professional backgrounds, and organizational cultures or situated in larger societal narratives. Through a process centered on reflexivity among the engaged research partners, the understandings of what it means to age with MS was shaped and re-shaped and eventually merged into a more dynamic understanding of later life with MS where different perspectives could co-exist.

The findings demonstrate that research partners, including older adults with MS and employees from a patient association, brought diverse understandings to the study. Reflexive practices enabled these perspectives to co-exist, enhancing engagement and transparency, and fostering a dynamic understanding of later life with MS. This highlights the value of reflexivity in evolving complex understandings within participatory research.

Plain English summary

In recent years, participatory research has been increasingly utilized in various research fields (e.g., aging research) with the ambition of engaging a diverse group of research partners to leverage their perspectives and contributions. This approach aims to form a more nuanced understanding of the studied phenomenon and to identify insights useful for practice However, working in diverse research teams have also been found to be complex, and it is poorly understood how the perceptions of the different research partners shape the final research product. Based on a study conducted in collaboration with employees in a patient association, older adults with multiple sclerosis (MS), and university researchers, the present study aims to unfold how perspectives of aging with MS are represented and shaped doing a participatory research period. It occurred over a three-year period where data was collected through field notes, meeting minutes, focus group interviews, and individual interviews. The findings highlight how research partners represent different understandings of the studied phenomenon, which is embedded in their social, cultural, and professional background and which potentially influence their expectations of and contributions to the research process. Furthermore, the study demonstrates how engaging in a critical dialogue about expectations and understanding of the studied phenomenon can provide insight into which perceptions are represented, making the participatory research process more transparent. Lastly, the study conveys how such critical dialogue facilitates understandings and perspectives evolving during the research process into a potentially more dynamic understanding of the studied phenomenon.

Peer Review reports

In recent decades, participatory research has been increasingly used in various research fields with the ambition of engaging a diverse group of research partners (e.g., community members, patients, and private or public organizations) to leverage their perspectives, form a more nuanced understanding of the studied phenomenon, and identify insights useful for practice [ 1 , 2 ]. According to Andrea Cornwall and Rachel Jewkes, participatory research can be understood and applied as a research methodology, not referring to a particular theory, method, or toolset but rather a broader concept defined in terms of: “…who defines research problems, and who generates, analyses, represents, owns and acts on the information which is sought.” [ 2 ] (p. 1668). Following this definition, participatory research can be viewed as a flexible and iterative process [ 3 , 4 ]. Consequently, the engagement of research partners in a particular research process cannot be predetermined, as the context and characteristics of the partnership influence how collaboration unfolds [ 4 , 5 ]. Instead, researchers working in a participatory research setting should take into account the specific context they are working in and strive to empower those who are normally the “objects’ of research to become ‘agents’ with the ability to analyze their own situation and co-design future initiatives [ 2 ].

Within aging research, scholars have argued that applying participatory approaches may be particularly important because it can challenge widely held assumptions about later life [ 4 , 6 , 7 ]. Where research within the field of aging historically has focused on the “vulnerability” of aging, participatory research holds the potential to challenge this perspective [ 6 , 7 ]. By engaging older adults as active research partners and enabling their contribution with their own understanding of later life, participatory research can provide a more in-depth and nuanced understanding of what it means to age—including both the agency and strengths of a population [ 4 , 6 , 8 , 9 , 10 ].

Working in participatory research setting often means that lived experiences should work together with professional insights or expertise – coming from e.g. researchers or medical or social care professionals [ 11 , 12 , 13 ]. While this combination enriches both the research and the process of implementing findings in care settings or institutional practices [ 6 , 14 , 15 ], conducting research within a diverse partnership consisting of university researchers, citizens, and public or private institutions (e.g., patient associations) also entails potential challenges [ 9 , 10 , 16 ]. Studies in the field of participatory aging research, for instance, stress that a diverse partnership means that many understandings and positions are brought into the research setting, potentially creating a complex environment that is difficult to monitor and understand [ 10 , 17 , 18 ], with the risks of imbalanced power relations affecting which perspectives dominate the final research outcome and of neglecting the lived experiences over professional or academic insights or preferences [ 3 , 18 , 19 , 20 ].

While the overall reasons for conducting participatory research are to let different perspectives and understandings shape the study [ 10 , 21 ], the social dimensions of how research partners’ perspectives are shaped by the context they are coming from or their encounters within the collaboration are often neglected [ 19 , 22 ]. Today, few studies unfold how research findings are shaped by the research partners engaged in the research process, as well as how their different perspectives are combined during the research process to prevent one perspective from overshadowing another. To contribute to this field, this study aims to determine how understandings of the studied phenomenon are shaped among research partners engaging in a participatory research setting by drawing on data collected during the mixed-method participatory research study, “Aging with MS” [ 23 , 24 ].

Context of the paper

The research presented in this paper builds on data generated during the participatory mixed methods “Aging with MS” study conducted between October 2020 and October 2023 in Denmark. The aim of the overall study was to contribute to the field of research concerning later life with multiple sclerosis (MS) by exploring how aging with MS unfolds in people’s everyday lives. As the scientific literature on aging with MS, especially in the context of people’s everyday lives, is limited the “Aging with MS” study was conducted based on a participatory methodology [ 2 ], aiming to involve patients and the public as research partners to define the focus of the research. Further this methodology were applied in order to not only inform new scientific knowledge but also provoke societal innovations by empowering the engaged research partners to seek for solutions or future initiatives target later life with MS [ 2 , 13 ]. The “Aging with MS” study were designed as an exploratory sequential mixed methods design [ 25 ], with a qualitative study (sub-study 1) followed by a quantitative study (sub-study 2) (Fig.  1 ). For a more detailed description of sub-study 1 and 2 please see the following references [ 23 , 24 ]. In order to support that the findings from sub-studies 1 and 2 were combined into joint recommendations for future research and support offerings targeting older adults with MS, a two-day workshop was held for all engaged research partners. During this workshop findings were discussed and specific recommendations for how the patient associations in the future should focus on later life with MS were crafted. Concurrently with the two sub-studies and the final workshop, the study presented within the present paper were conducted, aiming to unfold the participatory process and to understand how different perceptions of the later life with MS were shaped among the research partners and formed into what ended up being the final research outcome (Fig.  1 ).

“Aging with MS” study design

The engaged research partners

Three research partners were engaged in the “Aging with MS” study: university researchers, employees in a patient association, and a group of older adults with MS (aged 65 years or older). The older adults living with MS were represented by a nine-member advisory board. Advisory board members were recruited through the patient association’s social media, newsletters, social workers, and psychologists, as well as its magazine. One hundred and twenty older adults with MS registered to be part of the advisory board. Nine people were purposefully sampled [ 26 ] to ensure diversity in terms of gender, age, residence, educational level, and physical function. All selected members had MS and were aged between 65 and 78 years; four members were male and five were female. One advisory board member had previous experience with participatory research and eight participants did not. During the three-year research period, four members withdrew from the advisory board. Of these, two members withdrew due to MS-related symptoms (primary cognitive challenges), one withdrew due to not having their expectations fulfilled, and one left due to an illness in their family. Among the four dropouts, two were replaced with new members with matching background characteristics. The two remaining members were not replaced as they withdrew close to the end of the research period.

The patient association employees were engaged in the study through the participation of 55 employees with professional backgrounds in psychology, social work, communication, event planning, research, administration, and marketing. Employees were continuously recruited via email or face-to-face invitations during the research period. The employees were recruited on an ongoing basis when their expertise was needed. None of the employees invited to participate in the research refused, and employees only withdrew from the study if they ended their employment at the patient association. Lastly, the first author of the study was affiliated with both the university and the patient association, thus bridging the practical and academic worlds.

How the research partners worked together

Throughout the study period, the three research partners worked in collaboration to design, conduct, analyze, and disseminate the results from sub-studies 1 and 2. This collaboration were embedded in a participatory research methodology and by guided recommendations from the field, including how to foster trustworthy relationships, use inclusive language, ensure participants do not feel disempowered, and encourage a flexible approach through shared dialogue and reflexivity [ 10 , 15 , 16 , 27 ]. As participatory research within the present study, are defined and applied as a flexible iterative process, that should by shaped by its context and determined in collaboration with all engaged research partners, the activities and approaches used for engagement and collaboration differed depending on the preferences of the participating research partners. For instance, a two-day workshop including accommodation was arranged when the advisory group engaged in data analysis in sub-study 1, while the online platform Miro was used to create the desired flexible work environment for the employees. Finally, phone calls, email correspondence, and personal visits were used to involve those participants who could not participate in the more formal activities due to personal or professional reasons. For instance, when an advisory board member fell ill during the research period, phone calls, a home visit, and email correspondence kept that member engaged. In total, one workshop and five meetings with the patient association employees and one workshop and three meetings with the advisory board prior to the joined dissemination workshop.

In the first two stages of the study (Fig.  1 ), separate meetings were held between the first author and the advisory board and the first author and the employees. This arrangement was made under the assumption that the patient association employees were in a position of power that could overshadow the older adults’ perspectives and consequently skew the research toward a professional viewpoint [ 1 , 28 ]. However, both groups were presented with each other’s input and given the opportunity to comment and discuss ideas and suggestions. In the third phase of the research process, all three research partners participated in a joint workshop to discuss the findings of sub-studies 1 and 2 (Fig.  1 ).

Finally, to ensure that the advisory board members and employees could share their thoughts and critically reflect upon their own and others’ perspectives on an ongoing basis, the first author strived to facilitate shared and individual reflection sessions inspired by reflexive practices [ 29 , 30 , 31 ]. Reflexivity can be defined as a process which invites people to critically questioning their “… own way of thinking, assumptions and underlying patterns of values and world views” [ 32 ] (p. 420), which can potentially yield insights into how pre-existing beliefs and contexts affect data generation and interpretation [ 33 , 34 ]. In the realm of qualitative research, reflexivity is often deemed essential for researchers as it allows them to examine how their assumptions and values might have impacted the creation and interpretation of research data [ 34 , 35 ]. Furthermore, in participatory research, reflexivity has been highlighted as an approach that may facilitate the sharing of different perspectives represented in a research setting, giving the involved research partners the opportunity to learn from each other [ 32 ]. Consequently, the present study aimed to facilitate critical dialogue in which research partners’ assumptions, values, prejudices, and attitudes were not only questioned by the researchers, but also by themselves. The engaged research partners were invited on several occasions to share their thoughts about later life with MS, working in a participatory research setting, and their expectations for the study. These reflections either took the form of shared group discussions or were individual exercises where the research partners wrote their reflections and shared them in the group afterward if they wished. In every instance, data was collected from the exercises to gain insights into the research partners’ thoughts about the research process as well as their contributions to the study.

To report on the engagement of research partners in the participatory study ‘Aging with MS’, we employed the Guidance for Reporting Involvement of Patients and the Public (GRIPP2, short form) (see Additional file 1 ).

Data generation

To collect data on how an understanding of later life with MS was shaped within the participatory mixed methods study ‘Aging with MS,’ multiple methods (e.g., field notes, meeting minutes, focus groups, and individual interviews) were applied across the entire research process (see Fig.  1 ). Combining field notes, meeting minutes, focus groups, and individual interviews allowed us to triangulate methods, generating data from different perspectives and gaining insights into the context, the research partners’ understandings of aging with MS, and how these understandings were formed during the research process [ 36 ].

From fall 2020 to fall 2023, field notes were collected during individual visits or conversations at the office, phone conversations, email correspondence, workshops, and meetings with the advisory board or employees. Furthermore, formal meeting minutes were taken when meetings or workshops were facilitated, and written contributions by the research partners were likewise collected.

In addition, two focus group discussions were conducted among advisory board members a year into the study period. The focus groups were moderated by JLS, who had not previously been attached to the study. This decision was made to create a ‘safe space’ where members of the advisory board felt they could freely discuss their thoughts while remaining anonymous to the first author. The group discussion was structured using a guide constructed in collaboration between all authors that was inspired by existing literature, with the primary aim of understanding how advisory board members experienced engagement as research partners and how the dynamic between them unfolded [ 37 ]. The group discussions were audiotaped, transcribed, and anonymized before the first authors received them. Shortly after the two focus group discussions, a semi-structured individual interview with the first author was facilitated by JLS. The interview aimed to gain insight into the first author’s considerations about conducting participatory research, as well as how she perceived the collaboration between research partners unfolding. Instead of solely gathering the first author’s thoughts about the research process through field notes and reflections, the semi-structured interview allowed her thoughts to be questioned and further elaborated upon. The interview was structured by an interview guide inspired by existing literature on potential dilemmas, barriers, and methodological and ethical reflections relevant to researchers working with participatory research [ 10 , 12 , 29 ]. The interview was audiotaped and verbally transcribed.

During the research period the collected data were at an ongoing basis read through and informing the following focus in terms of question to ask or specific situations to be aware of during the partnership.

Data analysis

The data analysis was initiated by typing field notes and transcribing audio recordings using NVivo 12. This process was performed parallel to the data generation, as preliminary findings were important for the continuous reflection on how perspectives and understandings of later life with MS were shaped over time. After the data generation, all data was reread to gain an understanding of the empirical data collected and for the first author to become familiar with the material. An analysis was then performed, guided by the steps of an thematic network analysis [ 38 ]. First, data was reduced into smaller meaningful units by applying a coding framework focusing on the three research partners and their understandings of later life with MS. Second, themes were extracted from the coded text segments and organized into coherent groupings [ 38 ]. To understand if and how the perceptions of each research partner evolved over the three-year research period, particular attention was given to the timing of data collection and which research partner it related to. After all themes were identified, they were placed in relation to how they emerged across a timeline and grouped into organizing themes, namely the research partners’ understanding of later life with MS and the circumstances shaping their perceptions. In order to cross-validate and enrich findings, data generated at approximately the same point in the research process were compared to look for differences or similarities in, for instance, the meeting minutes, field notes, or interview data. During the analysis, all authors of the paper discussed the emerging themes to enhance reflexivity [ 39 ]. The findings will be presented by drawing on empirical examples from the data material, through the following headings: [ 1 ] older adults’ representations of aging with MS, [ 2 ] employees’ representations of aging with MS, and [ 3 ] mediating diverse understandings of aging with MS as a university researcher.

The analysis unfolded how the research partners engaged in the participatory study “Aging with MS” represented varied perspectives of what later life with MS may entail. These different perspectives – situated in existing social narratives of aging, lived experiences, organizational cultures, and professional backgrounds or expertise – were particularly noticeable in how the research partners perceived later life with MS, often characterized within one of the two dichotomies “vulnerability” or “agency”. Where the older adults with MS quickly found a way where stories about both vulnerability and agency could co-exist in their representation of later life with MS, many of the patient association employees stuck more strongly to their perception of later life being predominantly described in terms of vulnerability and decline. Thus, while the understandings of later life with MS varied among the research partners and at times seemed contradictory, the analysis outlines how the practice of reflexivity enabled them to evolve their perceptions as the research progressed. This allowed for a more dynamic understanding where different perspectives and understandings could co-exist.

Knowledge about later life with MS situated in lived experiences and professional insights

During the initial conversations between the first author and members of the advisory board, most of the members expressed a two-fold understanding of what it means to age with MS. On the one hand, many participants considered aging with MS to entail a life of opportunities and agency despite their possible physical or cognitive challenges. The representation of what later life with MS entails, was typically embedded within the members’ individual lived experiences but often also referred to as an “atypical” way of aging with MS. Referring to themselves as atypical, the older adults often emphasized their physical state (e.g., “(…) not that disabled” [Field Notes, Fall 2021]), or they considered themselves to be better at managing challenges compared to other older adults with MS. This perception of later life situated in personal lived experience was also reflected in how they perceived their role within the research setting as well as their perception on what should be the main aim of the study. As one advisory board member explained to the first author, he did not only want to focus on the terrible parts of his life “…but that he wanted to tell the story of the people who are having good experiences” (Field Notes, Spring 2021). Furthermore, this representation of themselves as being “atypical,” in opposition to a more typical older adult with MS, unveiled a general understanding of old age with MS as being characterized by physical decline, cognitive challenges, and dependency on others. When asked to reflect on the typical older adult with MS, the majority of the members within the advisory board referred to “decreased mobility,” facing a “lack of network,” “not being social,” or “needing help” (Field Notes, Fall 2021). These descriptions were in contrast to the members’ views of their own lives with MS, which, for instance, one participant described as “us sitting here and not being that heavily affected by our MS” (Field Notes, Fall 2021).

Having faced this apparent dichotomy in the description of later life with MS between “oneself” and “others” on an ongoing basis, the first author was prompted to ask the advisory board why they thought that these two opposing views on aging with MS were prevalent. One participant reflected that one’s “positive” view on their own circumstances could partly be a “coping mechanism—to underestimate your handicap” to help manage the difficult circumstances of aging with MS by telling themself that despite an everyday life with challenging situations, others were doing worse than them. Another participant suggested that healthcare professionals were projecting such perspective and that their neurologist often informed them that they were not among the individuals who were the most affected by MS.

The doctors tell you, that you are not one of the worst affected—because you do not have assistive devices. It is the doctors who decide whether you are considered heavily affected by the disease or not, as they will tell you so. The system tells you whether you are lucky or unlucky. You become defined by your appearance. And we believe what the doctor says (Field Notes, Fall 2021).

This dichotomy in understanding later life with MS – being either heavily affected by the disease or not - was likewise present among the patient associations employees, although the employees’ perceptions were predominantly focused on describing later life with MS in terms of “vulnerability” and “decline”. When asked to articulate their understanding of aging with MS in a workshop at the beginning of the research process, the employees’ descriptions of later life with MS were dominated by statements such as “extremely challenged cognitively,” “isolated,” “heavily affected by their MS,” and “dependent on others” (Field Notes Workshop, Spring 2021). Although some employees across professions described the group as being “very engaged and active” and “reflective and reconciled about their situation,” these perceptions were not the prevailing view of later life with MS among the employees. Furthermore, some employees phrased aging with MS in opposition to “normal aging.” As one employee elaborated,

The disease has made its marks on the body and the mind. [It is] a picture, which shows marks of inefficiency and inactivity. Compared to people of 65 + years of age without sclerosis, who play golf and run around (…) people with MS being 65 + years of age do not have the same opportunities, as the disease has consumed the body (Meeting Minutes, Spring 2021).

This understanding of later life with MS as being in opposition to “normal” aging was found to be important for the employees’ expectations for what kind of knowledge the research should produce as well as how new insight should be applied. For example, when preliminary results from sub-study 1 were presented, some employees emphasized that “they would like more focus on how older adults with MS are different from ‘healthy peers,’” as “it [the research findings] sounds a lot like ‘normal’ aging” (Field Notes, Spring 2022). Furthermore, some employees emphasized that for the research findings to be valuable for them and their work, they required insights into those who “need[ed] their help the most.” As articulated by one employee working in social or psychological counseling for people with MS, “… the picture must not be too rosy” when the research results were disseminated, as they had experienced a “less rosy story” when working with aging individuals with MS (Field Notes, Spring, 2022). Another employee working within marketing and fundraising similar explained that a substantial part of their work was to communicate “the severity of MS, as this is an important message for the [name of patient association]—as people prefer to give money to a severe disease” (Field Notes, November 2021).

Although the employees’ understanding of aging with MS reflected their individual roles within the association and the prevalent mandate of their profession and culture, it was common across professions, that the employees positioned themselves as those who should provide support for people living with MS, creating a need for clearly defined problems that they could address, which reflected their expectations of what the study research should achieve, namely specific knowledge on the difficulties of later life with MS.

Forming a more dynamic understanding of later life with MS

As the research progressed and the research partners were engaged in working with, discussing and interpreting research data, it became apparent that especially the members of the advisory board started to form a more dynamic understanding of later life with MS. This was particularly clear at a workshop with the aim of discussing and interpretating qualitative data generated in sub-study 1 (Fig.  1 ). Grounded within common reflections on older adults with MS and their reflections on the empirical data, the advisory board’s perspectives on aging with MS started to evolve to represent a more dynamic description of later life with MS, where both vulnerability and agency could co-exist and where the story about “us” and the “others” became less prevalent. One participant summarized the essence of the workshop: “ As you age you gain experiences (…) but there is also a sorrow in getting older, you no longer can run, hike on Kilimanjaro or play with your grandkids. (…) Aging with MS is a paradox” (Meeting Minutes, Fall 2021). One woman who subsequently evaluated the workshop, had positioned herself as “atypical” and “not that disabled” a month earlier, yet she concluded that working with interview data about other older adults’ experiences had made her realize that her situation was not as unique as she had thought:

Our eyes are opened to this [aging with MS] not just being one dimensional but having, really, a lot of dimensions. But it is also confirmed that one fits into one of these narratives [interview data from sub-study one]. At least I did (Focus Group Discussion, Fall 2021).

As the research process progressed, advisory board members often represented this new understanding of later life with MS as being a paradox or having manifolded stories. For instance, it was important for the advisory board that the dissemination of the research findings reflected the complexity and the many nuances of later life with MS. As one woman concluded, “It is important that the narrative on aging with MS does not become overly negative, such that it becomes excessively sad to reflect oneself in. But it cannot become overly happy either” (Meeting minutes April 2022). Although the participants developed a somewhat shared understanding that aging with MS is a paradox, they still conveyed different understandings of the nuances of later life with MS that reflected their individual situations. Some participants believed that aging with MS was dominated by loneliness, others highlighted their cognitive challenges and other comorbidities, and yet others focused on the importance of staying invested in society or planning their future. While each understanding of aging with MS was individual and unique, they embraced a more dynamic perception, where both agency and vulnerabilities could co-exist in later life with MS.

In opposition to the members of the advisory board, the majority of employees from the patient association held a more consistent understanding of aging with MS. Where the members of the advisory board highlighted that stories on agency and the opportunities could co-exist in describing later life with MS, the employees saw stories about agency in later life with MS to mainly have a role in providing younger people living with MS with “…hope – that life becomes more than MS” (Meeting Minutes, Spring 2022), and kept requested more insight into the ‘vulnerable’ sides of later life to better support the specific group of older adults living with MS. employees’ their professional backgrounds, their roles within the organization, and expectations for how they should apply the final research results at times, became a barrier to accepting and engaging with research findings or inputs unaligned with their understandings of aging with MS. For example, an employee questioned the first author regarding data on well-being “… as [they] had heard from the psychologists that they [the members] had struggled greatly” (Field Notes, May 2021). Or as a fundraising employee explained the first author, “vulnerable” groups were more attentive if the patient association were to receive money from outside grant holders (Field Notes, November 2021).

However, although some of the employees were asking for insight about the vulnerable sides of later life with MS or the differences between “normal” aging and aging with MS, the reflexivity that emerged during workshops or meetings also sparked reflections among other employees regarding whether their workflow, professional insights, and day-to-day contact with specific groups of members could hinder them from developing a more nuanced understanding of what aging with MS may entail. As noted during a workshop centered on the employees’ perception of aging with MS, “(…) a participant says that they probably do not involve [people with MS] as much as they should, because they [the employees] have become ‘too’ professionally knowledgeable” (Meeting Minutes, Spring, 2021). At the same workshop, another participant wondered if the work within the organization might only give them insights into a small group of people living with MS:

In the best of worlds, we want to be an association relevant for everyone with [multiple] sclerosis [being more than 18,000 in Denmark], but perhaps we are only that for 4,000 people [those using the patient association and the offerings available for members]. Quite a few members do not use us and, thus, we do not learn much about them (Meeting Minutes, Spring 2021).

Despite some employees reflected that their professional background and focus as a patient association might hindered them in getting insight about some people living with MS, it was still difficult to others when research data were contradicting their understanding of later life. This especially became clear when the research findings from sub study 1 were to inform the aim of sub study 2. Where the findings of sub study 1 represented the many nuances of later life with MS – being both agency and vulnerability, these findings were not accepted by all patient association employees because they did not align with their professional experiences. While the first author decided “to trust her research findings” and the older adults’ representations of later life with MS, she acknowledged that it was necessary to address the employees’ expectations in the research process to better maintain their active collaboration.

The questionnaire [planned for sub-study 2] should map who is susceptible to having challenges [in participating in the selected activities], as this would imply that the [patient association’s name] can fulfill its role as a patient association by designing support offerings to those in need (…). It is, however, not certain that this is faithful to the participants’ narratives [from sub-study 1], which to a large extent center on how they have learned to handle and navigate everyday life with MS (…). On the other hand, there are factors that challenge this group. And despite the survey exploring in depth these challenges, it does not imply that this should dominate the overarching story (Field Notes, Spring 2022).

Hence, to accommodate the employees’ request for more insights on the “vulnerable” aspects of aging with MS, sub-study 2 was – in collaboration with both the advisory board and the employees - designed to provide insights on areas in which the group required the support of the patient association, making the findings directly useful for potential service providers. Furthermore, to address the employees’ request for knowledge that resembled “normal” aging less, the first author consulted advisory board members to determine how their representation of later life and the findings of sub-study 1 could be combined with the employees’ request. One advisory board member advised the first author to accept that aging with MS is similar to normal aging and “that growing older is like for peers, but having MS just adds an extra dimension to it” (Field Notes, Summer 2022). Based on this dialogue with the advisory board, the first author acknowledges the employees desire to use “normal aging” as a point of references. Upon receiving comments from employees related to the findings and results overly resembling “normal” aging, the first author for instance highlighted that older adults with MS may find meaning and joy in the same things as their peers. However, these older adults may require support due to their MS to engage more fully in a life they find meaningful. After the final workshop in the third stage of the research process (Fig.  1 ), it became evident that the employees had, to some degree, embraced a perception of later life encompassing both agency and vulnerability. This were for instance became apparent when a group of employees approached the first author with the idea of dedicating a members’ magazine to aging with MS centered around cases from the research and through their stories “…unfold the many nuances which exist in later life with MS” (Fall, 2023). The magazine would thus not only provide hope to younger people living with MS, but also allow older members to see their own circumstances reflected, providing them with inspiration for daily activities and management strategies.

In participatory research involving both private and public research partners, it is inherent—or even a methodological premise—that the research process is influenced by the partners’ understandings of the study phenomenon situated in their lived experiences or professional insights [ 1 , 28 ]. This study found that involving older adults with MS and patient association employees led to different, and sometimes conflicting, perspectives on later life with MS, often framed as either vulnerability or agency. Such differences have earlier been described as a potential barrier as some perspectives risk overshadowing others [ 18 , 40 , 41 , 42 ]. Previous research has for instance described that service providers’ understandings of what constitutes useful knowledge can be a barrier to the representation of lived experiences and contributions by non-professional research partners [ 12 , 17 , 18 ]. As individuals in a participatory setting, tend to align their actions and contributions with those in power [ 43 ], disputes within research partnership can potential lead to hindering people with lived experience from redefining their situation, thus perpetuating narratives of later life already dominated by stories of decline, dependency, and vulnerability [ 6 , 7 ]. Similar findings were also present in the present study, in terms of how some employees’ professional backgrounds and organizational contexts shaped a particular understanding of later life with MS, entailing vulnerability and specific needs, which then made it difficult for them to adapt to and implement findings that did not align with their prior perceptions.

To navigate differences between research partners and prevent some perspectives from suppressing others, several suggestions and calls for action have been made [ 18 , 40 , 41 , 42 , 44 ]. For instance, researchers have stressed the need for shared dialogue, where research partners can equally share perspectives to shape a joint understanding [ 18 , 40 , 41 , 42 ]. Conversely, researchers have argued that if consensus and agreement are too easily achieved, it may indicate that the partnership has lacked room for truly sharing different perspectives and contributions that may entail contradictions, tensions and developments over time [ 44 ]. Instead of aiming to create a frictionless atmosphere where agreement and consensus are seen as the main success criteria or end points, researchers should make room for dissensus and disagreements among research partners [ 43 , 44 ]. In this study, reflexivity was found to facilitate the co-existence of disagreement and differences among the research partners, including university researchers, older adults, and employees. This practice allowed them to gain insights into and critically examine the origins and implications of their varied understandings of later life with MS. Over time, reflexivity helped the research partners develop a more dynamic understanding of later life with MS, where both stories of agency and vulnerability could co-exist. These findings align with Christopher Kelty’s description of how perplexity and dissensus within a participatory research setting can indicate a truly collaborative process, where diverse perspectives and understandings of the world contribute to a new and more nuanced comprehension of the study’s phenomenon [ 44 ]. While it is crucial to acknowledge that, in order to create an environment where research partners can embrace each other’s differences, they must also feel that their own perspectives are recognized and respected. In some instances, power imbalances may cause individuals with lived experiences to perceive peaceful and respectful dissent as insufficient, leading them to advocate for more radical, possibly confrontational forms of dissent to effect change. While our study demonstrates how the practice of reflexivity can support mutual curiosity and space for differing perspectives, it is equally important to recognize that there can be situations where engaged research partners may not desire peaceful co-existence of perspectives, as they feel it may overshadow their unique viewpoints and contributions. Therefore, while promoting reflexivity and the co-existence of differences, it is essential to remain open to stronger or less peaceful forms of dissent when necessary to ensure all voices are genuinely heard and valued.

In addition to supporting the co-existence of differences between the patient association’s employees and the older adults with MS, reflexivity also facilitated the co-existence of different perspectives and nuances within the two groups. For instance, aligned with existing research [ 19 , 28 , 45 ], the present study demonstrates how the older adults with MS represented different understandings of later life with MS. These findings highlight, as also stressed in the existing literature, the importance of researchers being aware that individuals engaged in research projects, despite sharing characteristics like age, illness, or geographical location, do not necessarily hold a homogeneous understanding or perception of the studied phenomenon. Therefore, it is crucial to engage a diverse sample of older adults [ 19 , 46 , 47 ]. However, the findings of this study further emphasize the importance of ensuring that potential differences within a diverse sample can co-exist during collaboration without some perspectives potentially overshadowing others. While existing studies in participatory research have argued that reflexivity can help researchers navigate the complexity of working with partners from different backgrounds [ 12 , 40 , 41 , 48 , 49 ], this study demonstrates how other research partners—including older adults—can also benefit from reflexive practices by learning about each other’s differences and finding ways for their diverse perspectives to co-exist.

Methodological considerations

The data presented within the present study was generated through a triangulation between qualitative methods, which potentially increased the trustworthiness of the findings by allowing the phenomenon to be studied from different angles [ 50 ]. Furthermore, a strength of the study is that the data was generated across a three-year period, allowing the study to unfold how understandings are shaped and evolved over time. However, the study also entails potential limitations. As mentioned, four advisory board members withdrew due to MS-related symptoms or family illness. This suggests that older adults with severe MS or caregiving responsibilities for sick family members may have been underrepresented on the advisory board. On the other hand, it may also be perceived as unavoidable that some participants withdrew during the lengthy three-year research period and the older adults who did not withdrew from the advisory group did represent a broad group of older adults with MS (e.g. some with comorbidities, some with a severely ill spouse, some living alone, some with a low income, some with cognitive difficulties, and some with advanced MS). Furthermore, it may be argued that the partnership between the patient association employees, the older adults with MS, and the researcher was challenged by the employees and the advisory board not meeting until the third stage of the research process (Fig.  1 ), which prevented these two research partners from communication during the conduction of sub-studies 1 and 2. However, due to the differences in power between the engaged research partners, we do believe it has been a strength to the study as it has a created a space where both the older adults and the employees could contribute with their insights and understanding without overshadowing one another. Moreover, this design allowed the study to unfold how complex and nuanced understandings of a phenomenon are not only shaped through ongoing communication, but also by separated practices of reflexivity Hence, this design means that the academic researchers hold a great responsibility in facilitating the partnership ensuring that understandings and contributions are merged. Although this study addresses a partnership between three research partners, only the academic research team contributed to the analysis and writing of this paper due to a limited time schedule and lack of financial resources to engage the employees and the older adults in the writing process. However, three of the four authors are affiliated with the patient association, and the advisory board was presented with the final analysis and offered the opportunity to comment and suggest adjustments to the paragraphs. None of the nine board members accepted this invitation, with the argument that the level of the English language was not accessible for them. The study’s timeline and our financial resources did not allow us to translate the text into Danish or use other co-creating tools to engage the advisory board in drafting the manuscript. As this factor created a power imbalance in the dissemination of the present paper, we encourage future studies to engage all research partners in terms of data generation and when interpretation of the findings. Lastly, although the present study was conducted in a Danish context, the findings may be relevant to researchers working in partnership with older adults and their potential service providers in other settings. However, it is essential to acknowledge that different settings and cultures involve unique circumstances that always must be considered.

The findings of the present study illustrate how each research partner, including older adults with MS and employees from a patient association, brought different understandings of later life with MS to the research, influenced by their professional roles and lived experiences with MS. These perspectives were often represented by perceiving later life with MS in terms of either agency or vulnerability. Although the research partners did not form a joint perspective of what it means to grow older with MS, they created a common research contribution that represented their different interpretations and perspectives. Through reflexive practices, their diverse perspectives on later life with MS were able to co-exist, allowing the research partners’ differences to form a more dynamic understanding of later life with MS. Based on these findings, the study highlights that reflexivity may support a complex and dynamic understanding of the studied phenomenon, where differences can co-exist within a participatory research partnership.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available to avoid compromising the anonymity of the people engaged as research participants. However, the data is available from the corresponding author by request.

Abbreviations

• Multiple sclerosis

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Acknowledgements

The authors thank the members of the study’s advisory whose lived experiences about aging with MS increased the quality of not only the study presented in this article, but the entire research project Aging with MS. The new insight this research project has added to the field of later life with MS, has not been possible without your contribution.

This work was funded by Innovation Fond Denmark.

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Bergien, S.O., Skovgaard, L., Steenberg, J.L. et al. Shaping understandings through reflexive practice: Learnings from participatory research on aging with multiple sclerosis. Res Involv Engagem 10 , 78 (2024). https://doi.org/10.1186/s40900-024-00614-x

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Reflexivity: promoting rigour in qualitative research

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• 1 University of the West of Scotland, Hamilton campus, Lanarkshire. [email protected]
• PMID: 19263905
• DOI: 10.7748/ns2009.02.23.23.42.c6800

This article illustrates how the concept of reflexivity has matured in conjunction with developments in qualitative research, and makes the case for inclusion of a reflexive account to increase the rigour of the research process. A qualitative study (Jootun and McGhee 2006) is used to show how the reflexive process improved data reliability. Reflexivity is an invaluable tool to promote understanding of the phenomenon under study and the researcher's role. The relationship between, and influence of, the researcher and participants should be made explicit.

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To teach is to learn twice, revisited: a qualitative study of how residents learn through teaching in clinical environments

• Takeshi Kondo   ORCID: orcid.org/0000-0002-3307-671X 1 , 2 ,
• Noriyuki Takahashi   ORCID: orcid.org/0000-0003-1982-7019 3 ,
• Muneyoshi Aomatsu   ORCID: orcid.org/0000-0002-1871-7232 4 &
• Hiroshi Nishigori   ORCID: orcid.org/0000-0002-0715-7073 5  

BMC Medical Education volume  24 , Article number:  829 ( 2024 ) Cite this article

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Teaching helps the teacher’s own learning as a professional—as the saying goes, ‘to teach is to learn twice’. Near-peer teaching in clinical practice has been shown to contribute to the development of both teaching skills and necessary competencies for doctors. Research on how near-peer teachers learn through their teaching roles has mainly focused on classroom learning. However, understanding how the phenomenon of ‘teaching is learning twice’ occurs in clinical settings and its influencing factors is important for the development of a quality workplace learning environment. Therefore, this study investigated how residents learn through teaching in clinical practice and the factors influencing this process.

This study’s methodology is based on the constructivist grounded theory from a social constructivist perspective. Several teaching hospitals in Japan were included, and the study participants were post-graduate year 2 residents (PGY2s) from these hospitals. The interviews were recorded, transcribed into text, and analysed by the first author.

From January 2016 to July 2022, 13 interviews were conducted with 11 PGY2s from nine educational hospitals. The PGY2s played diverse educational roles in clinical settings and learned competencies as physicians in almost all areas through such roles. We found that knowledge transfer and serving as role models stimulated PGY2s’ intrinsic motivation, encouraged reflection on their own experiences, and promoted self-regulated learning. Further, educating about procedural skills and clinical reasoning prompted reflection on their own procedural skills and thought processes. Supporting post-graduate year 1 residents’ reflections led to the refinement of PGY2s’ knowledge and thought processes through the verbal expression of their learning experiences. Such processes required the formation of a community of practice. Thus, education promoted learning through reflection and clarified the expert images of themselves that PGY2s envisaged.

Conclusions

The study found that residents acquire various physician competencies through multiple processes by teaching as near-peer teachers in clinical settings, that a community of practice must be formed for near-peer teaching to occur in a clinical setting, and that teaching brings learning to those who teach by promoting reflection and helping them envision the professionals they aim to be.

Peer Review reports

The adage ‘To teach is to learn twice’ implies that acting in the role of a teacher contributes to one’s growth as a learner [ 1 ]. This means that in a near-peer teaching situation where learners teach other learners of the same or slightly lower grade, near-peer teachers can also learn through teaching [ 1 ]. Several studies have reported on the knowledge and competencies that near-peer teachers acquire through teaching. Medical students who are involved in teaching are better at acquiring and retaining knowledge than those who are not involved in teaching [ 2 , 3 ]. Near-peer teachers also learn skills in self-reflection, leadership, and communication through teaching [ 4 ]. Here, an understanding of the contents and methods of their learning is required to enhance the learning environment [ 5 ]. Thus, further research on how near-peer teachers learn through teaching is required.

In this regard, Dandavino et al. [ 6 ] examined how learning by teaching occurs and developed the Dandavino model to explain how medical students learn by teaching. They outline that near-peer teacher learning through teaching is facilitated by the interaction of three processes: (1) metacognitive awareness, which is the reflection on one’s own attitude, skills, and knowledge; (2) deliberating practice, which is shown by near-peer teachers’ thoughtful instruction to support learners and when they receive feedback about the process from more senior instructors; and (3) self-explanation, which occurs in the mind of near-peer teachers when they explain learning contents to learners and which supports the detection and repair of defective mental models. The model was validated by Srivastava et al. [ 7 ] for peer-teaching in physics classrooms, where the interaction between improved practice and metacognition described in the Dandavino model was also found in the classroom. Prior research in clinical environments suggests that near-peer teachers gain confidence from the realisation that they can teach, and they reflect on their own thinking when trying to teach a particular learner [ 4 ]. However, such statements in previous research in clinical settings are only fragmentary in describing what near-peer teachers learn from teaching and are insufficient for an in-depth understanding of how near-peer teachers learn from teaching.

Clinical environments are increasingly recognized as important learning places for medical professionals [ 5 , 8 ]. However, clinical settings are often understaffed, and this is more so the case with staff for education. Therefore, there are high expectations for the enhancement of near-peer teaching in clinical settings [ 1 ]. Exploring near-peer teachers’ learning that occurs through their teaching practices in medical environments will contribute to facilitating mutual learning in this setting. Therefore, the following research questions were proposed: What and how do near-peer teachers learn through teaching in the medical field, and what factors influence this learning?

Ethical considerations

The study was conducted with approval from the Ethical Committee of Nagoya University School of Medicine (approval number: 2015-04516983) and in accordance with the Declaration of Helsinki. All participants received prior written explanations regarding the study and provided written consent to participate. The names of the research participants in the obtained data were replaced with letters, such as A, B, and C, and any identifiable information, such as facility names, was replaced with symbols before being treated as data for the analysis. The table linking these names and symbols is stored in encrypted electronic storage to ensure that personal information is adequately protected.

Quality assurance

As a quality assurance standard for this study, the Standards for Reporting Qualitative Research (SRQR) were used [ 9 ]. The SRQR is a set of evaluation criteria for qualitative research consisting of 21 items, created by identifying and reviewing guidelines, reporting standards, and critical evaluation criteria for qualitative research published up to July 2013. Throughout the design, implementation, and writing of this study, the researchers referred to the SRQR and ensured that all items were adequately met in the final work.

The study was conducted in residencies in multiple teaching hospitals in Japan. In Japan, medical graduates who have completed 6 years of undergraduate medical education are required to undergo 2 years of initial postgraduate residency training. During the 2-year residency, residents rotate through major departments for 4−12 weeks each [ 10 ]. They also work night shifts in emergency departments approximately 4−6 days a month throughout the residency, and their clinical responsibility tends to be higher in the emergency department than in day shift rotation [ 11 ]. Near-peer teaching commonly occurs in the workplace learning environment consisting of post-graduate year 1 residents (PGY1s), post-graduate year 2 residents (PGY2s), and supervising doctors [ 11 , 12 ]. PGY2s teach PGY1s, young supervising doctors teach PGY2s, and senior supervising doctors teach young supervising doctors.

Methodology

Based on the constructivist grounded theory, researchers have adapted the theory of how to learn through teaching that was developed in non-clinical settings into a theory for clinical settings [ 13 , 14 ]. In contrast to the traditional grounded theory, which assumes that the researcher begins the study with no preconceptions, constructivist grounded theory aims to ensure that the researcher is aware of the framework they already have and to develop this framework [ 15 ]. In this study, the researchers deemed constructivist grounded theory to be appropriate because prior literature has already provided a general framework for understanding how learning occurs through teaching, and the researchers have a strong involvement in educational settings within clinical environments, possessing internal frameworks.

Study participants

The study participants were PGY2s working in multiple teaching hospitals in Japan. Since PGY2s are both learners and educators who teach PGY1s in clinical settings, the researchers considered PGY2s to be a suitable target population for the study investigating how people learn through teaching in clinical settings. Interviewees were recruited through the clinical educator community and direct acquaintances. The recruitment of study participants was done iteratively. Initial interviewees were recruited to ensure as much diversity as possible in terms of enthusiasm for teaching, size of the institution, and geography, to gain broader insights. After several rounds of interviews, the next set of potential interviewees was considered and selected.

Data collection

One-on-one interviews were conducted to explore the experience of participants in detail. All interviews were conducted by the first author (TK). The topics of the interview questions included participants’ clinical responsibilities, their relation to PGY1s and other medical staff, their teaching role, and what and how they learned through their teaching (see Table  1 ). The interviews were audio-recorded and transcribed to text. Additional participants continued to be added until all researchers agreed that sufficient data had been obtained to construct a theory.

Data analysis

Data analysis was performed by three authors in an iterative process with an audit review. After completing a few interviews, the text data were split into chunks and tabulated into columns. As a tool for the coding process according to grounded theory, the researchers utilised the ‘Steps for Coding and Theorization’ (SCAT) method, which is a four-step coding process [ 16 ]. In this method, the process is explicitly shown in a table and a storyline, providing text consisting of codes developed to contribute to theory formation; thus, this explicit process improves confirmability [ 16 ]. TK developed codes using the SCAT method and then prepared a preliminary figure of the concept. Images used in the figure were developed with licensed authoring software or purchased from creators. Co-authors (NT and MA) examined the text, codes, storyline, and figure independently before discussing them for further refinement. They also discussed the requirements for the next participants, who were recruited based on the results of the discussion, and the same process was conducted to refine the codes and the figure. The process was repeated until the three authors agreed on data saturation. The last author (HN) examined the entire data and analysis process again with TK to complete the data analysis.

Reflexivity

This study was conducted by multiple researchers who are also medical education researchers and supervisors: TK is a supervisor at a university hospital and supervises residents in emergency medicine at Nagoya University; TK is also involved in teaching residents as an educational consultant at several teaching hospitals. TK is a medical education researcher and conducts research on resident assessments; although some of TK’s interviewees were residents whom he directly supervised, the study included interviewees with whom he was not directly involved in teaching. NT is a supervisor of residents in an outpatient general medicine department at a university hospital and is currently researching empathy in medical education. MA is a supervisor at a city hospital and is conducting research on empathy as a medical educator. HN is a supervisor at a university hospital and is conducting research on empathy as a medical educator. HN supervises residents in the general medicine outpatient department of a university hospital. He is a medical education researcher specialising in professionalism. The researchers all participated in the analysis by engaging with the residents, understanding their situations, and bringing the perspectives of multiple specialisms in medical education research. The process of analysis was articulated using the SCAT method and the discussion process was recorded during the audit trail.

Patient and public involvement

Patients or the public were not involved in designing or conducting this research. The researchers plan to disseminate this paper publicly by introducing it to members of the Japanese Society for Medical Education.

A total of 13 interviews were conducted with 11 PGY2s (seven men and four women) from nine teaching hospitals between January 2016 and July 2022. Each interview lasted 1–2 h. What and how PGY2s learned through teaching, followed by what influenced them in this process, is described below. Regarding the citations in the following descriptions, each ID is based on the interview number and the order of data extraction (e.g., 10–87). The English translations of the interview data and the list of IDs can be downloaded from Additional File 1 .

What and how PGY2s learn through teaching

The analysis of the interviews reveals that PGY2s played diverse roles as educators in the medical field. In addition to imparting knowledge and skills, they observed and evaluated PGY1s, assisted them in reflecting on their practice, coordinated learning environments to consider PGY1s’ abilities, and served as role models. Through their role as educators, PGY2s acquired competencies in almost all the domains described in the Guideline for Medical Residency 2020 [ 10 ], including medical knowledge, procedural skills and patient care, patient safety and quality improvement, lifelong learning, medical practice in the context of society, communication, practice in interprofessional teams, and professionalism. The learning that PGY2s gained through teaching, and how each aspect of learning occurred through particular educational activities, is described below.

Medical knowledge

As mentors, when PGY2s were transferring knowledge and helping PGY1s reflect, PGY2s were re-exposed to knowledge that they had learned in the past, which helped to strengthen their current knowledge. Additionally, in doing so, their awareness of the incompleteness of their knowledge and their desire to impart more accurate knowledge led them to explore diverse sources of information, including related literature, which contributed to structuring and concretizing their knowledge. A PGY2 explains rereading previous lecture transcripts and texts to reconfirm his knowledge to prepare lectures for PGY1s:

…So, first of all, I have to know what kind of presentations my seniors gave last year and what kind of knowledge is the minimum for a PGY1 to be able to treat patients. I studied by rereading and brushing up on reference books on how to read ECGs… (Dr. I, 10−87).

Procedural skills and patient care

PGY2s learned about procedural skills and patient care themselves as they taught clinical procedures and clinical reasoning. The teaching of clinical procedures motivated PGY2s to perform the procedures on their own and contributed to their awareness of standard procedures and verbalisation of implicitly learned experiences. Teaching clinical reasoning contributed to its verbalisation and reflection and observing this among PGY1s provided an opportunity for PGY2s to learn about others’ clinical reasoning.

Well, I think I had accumulated something beforehand. I showed the PGY1s the procedures, and after I finished, I taught the PGY1s the points to keep in mind I had noticed during the procedures. And then let them do the next one on their own. When they failed, I told them, ‘Well, that’s what I did, too’. When things don’t go well, you could make it work this way. (Dr. H, 9−48)

In addition, a PGY2 realised that as he observed PGY1s to teach them clinical reasoning, it led him to learn about others’ reasoning processes and was a learning experience for him as well:

… and it’s important for me to know how the first-years (PGY1s) diagnose. It is also useful for me to know how other doctors (PGY1s) think. (Dr. A, 2−43)

Patient safety and quality of medical care

PGY2s were prepared to review their own clinical processes to ensure more accurate and faster care so that they could adjust the learning environment for PGY1s in the clinical setting. In addition, by working as interpreters between PGY1s and their clinical supervisors, PGY2s gained a better understanding of work processes and were able to recognize problems in the system.

The following two PGY2s were treating other patients quickly to ensure that the less experienced PGY1 residents had adequate time to thoroughly examine and learn from their patients. The PGY2s also reviewed and prepared their own practice processes so that they could do so.

In the first year at our hospital, we have to treat each case with care and evidence; our hospital has a tradition of treating each case cautiously with evidence to acquire basic skills for medical care. In the meantime, the PGY2s and the senior doctors take care of the other cases quickly. (Dr. I, 10−10) …So, for example, I prepared my own medical record system so that I could operate my own medical records without stress to some extent. I have also started to collect various medical content such as through apps and websites. (Dr. G, 8−77)

In the following example, a PGY2 describes becoming aware of certain problems with communication. This PGY2 communicates via chat tools with a senior doctor who leaves the ward on various errands and connects the senior doctor with PGY1s and other ward staff:

…It’s the same with chat tools, the information flows one after another. When you have dozens of messages, I think everyone can honestly say that there are times when you don’t see all of them, or you miss something. If we ask three questions and the senior doctor answers two of them but doesn’t reply to one of them, then there is inevitably a misunderstanding… (Dr. G, 8−67).

Lifelong learning

PGY2s served as role models and engaged in knowledge transfer to PGY1s, which motivated PGY1s’ learning. Furthermore, PGY2s’ observations of PGY1s’ medical treatment helped PGY2s consider their own current achievements and future goals. The following PGY2 explains how, when faced with previously unexamined questions that arose in clinical practice, they began to research and summarise clinical questions in an attempt to answer PGY1s’ questions:

… there were many things I wondered about in my first year, but I realised at that time that there were many things I had wondered about but had neglected. I thought that maybe next year’s first-year residents would think the same thing, and maybe they would ask me questions, so I thought I should be able to explain things to them properly. (Dr. A, 2−149)

The following PGY2s were previously unable to grasp how they had developed as doctors over a year when they were only observing senior doctors. However, by observing PGY1s and comparing themselves with them, they were able to understand how they had developed, and based on this, they were able to clearly envision how they should progress to become the senior doctors they aspired to be in the future.

So, until the new PGY1s arrive, I didn’t really have anything to compare myself to, but I think that when the first years arrive, every PGY2 can feel that they have grown a little. (Dr. H, 9−86) The difference between the first year and the second year is huge, and of course, the speed of decision-making and the breadth and depth of what is possible is completely different in the third and fourth years. I really felt it. (Dr. H, 9−68)

Medical practice in the context of society

Through observing PGY1s’ practices and comparing them to their own practices and those of their senior doctors, PGY2s became more aware not only of the symptoms and diseases occurring in the patients they saw at that moment but also of the patients’ families and their long-term progress.

The first-year juniors are only able to see what is happening to the patient in front of them. In the second year, I am able to see a little bit more than what is happening in front of me, such as the patient’s family. I think it is amazing that senior doctors in their third or fourth year are able to see beyond the patient’s family, what to do for transfer at the time of admission, what level of care is needed, and so on. (Dr. H, 9−69)

Communication

PGY2s taught PGY1s how to communicate with patients and provided feedback to PGY1s as they observed PGY1s communicating with patients. Through this process, PGY2s became aware of the need to reflect on and improve their own communication as well. The following PGY2 began to reflect on their own communication through observing PGY1s’ medical treatment:

While watching PGY1s talk to patients, I began to notice that their language and attitude seemed arrogant, or that their words were too difficult for patients to understand. (Dr. A, 1−36)

Practice in interprofessional teams

PGY2s supported PGY1s with problems that arose when PGY1s performed their medical duties. Through such support, they were able to become aware of the roles of multiple professions. The following PGY2 was communicating with medical clerks, prompted by questions from PGY1s.

.They (PGY1s) said, ‘I received a notice like this’. I had never seen such a notice before, so I decided to ask the medical office staff and they told me what I should do… (Dr. E, 6−93).

Professionalism

PGY2s reflected on their knowledge and experience to share their knowledge with PGY1s. This suggests that the ability to be a reflective practitioner [ 17 ], which is important for physicians’ professionalism, was cultivated. In addition, PGY2s reflected on and improved their own attitudes through observing PGY1s’ practices and by serving as role models to PGY1s. Through observing PGY1s’ medical practice, a PGY2 was inspired by PGY1s’ sincere attitude towards patients and made efforts to change their own behaviour. The following PGY2 observed a PGY1 accompanying his assigned patient to rehabilitation, which reaffirmed the importance of such gestures in establishing a good doctor-patient relationship.

When I saw a PGY1 following a patient around while the patient was doing rehabilitation, I thought, ‘Oh, I need to do that too. That’s important, come to think of it. I forgot about that’. (Dr. E, 6−228)

Factors influencing learning through teaching

During the interviews, it became clear that multiple factors influenced PGY2s’ learning through teaching in clinical settings. The factors were divided into two categories: those related to the system and those related to the PGY2s themselves. Factors related to the system were identified as the place where residents can be involved in the practice together, a practice system based on near-peer teaching, discretion in practice, respect as an educator, and the place to teach. Further, factors related to the system were identified as shared tasks, communication, and responsibility for medical practice, while factors related to the PGY2s themselves included reflection, aspirations as supervising physicians, and adequate competence in the relevant area. Further details on each of these aspects are given below.

System factors

Shared tasks.

Education from PGY2s to PGY1s was more likely to occur when PGY2s and PGY1s were not just in the same place but had a shared task, such as working on the same case. For example, the following PGY2 worked with PGY1s in the same emergency room shift and gave advice before the PGY1s treated patients:

If I am available when the PGY1 makes the first contact, I will be involved with the PGY1, looking at the information from the triage that the nurse has already done, and giving advice such as ‘this is the main complaint, so let’s perform these examinations’. (Dr. C, 4−6)

Education from PGY2s to PGY1s was less likely to occur when they were in the same place but working on completely different cases. The following explanation from an interviewee suggests that residents taught each other about cases when PGY2s and PGY1s worked on cases together in the department in which they rotated:

When he (PGY1) told me about things I didn’t notice in the physical findings, I told him that I would look at it with him the next time. (Dr. J, 13−14)

However, education from PGY2s to PGY1s did not occur when they were on rotation in the same department but working on different cases:

I don’t go and teach them. They have a senior doctor who they can consult, so I don’t really go and teach them about it. (Dr. J, 13−17)

PGY2s functioned as educators when there was a mechanism for PGY2s and PGY1s to communicate about their practice. For example, in Japan, PGY2s sometimes teach PGY1s, and then a senior advisor teaches PGY2s; this is called the yanegawara (translates to ‘roof tile’ in Japanese) system. Under such a system, PGY1s always consult PGY2s first about their practice; thus, much communication occurs between PGY2s and PGY1s. In the emergency department rotations to which the following PGY2s belonged, PGY1s consulted PGY2s on all cases under the yanegawara system, so PGY2s were always involved in educating PGY1s by giving advice and evaluating PGY1s’ assessments.

Well, when I was on rotation last month, the first-year residents were consulting with us, the second-year residents. If I thought a first-year resident was having difficulty communicating directly with the senior doctor, I would sometimes communicate with the senior doctor myself. If I thought the first-year residents were well organised, I would ask them to tell the senior doctor about the situation after doing an assessment and so on. (Dr. H, 9−20)

At the facility where the following PGY2 belonged, the practice structure differed according to the time of day, with no communication between PGY2s and PGY1s occurring when PGY1s were supposed to consult directly with senior doctors. However, communication occurred between PGY2s and PGY1s during the times when PGY1s were supposed to consult with PGY2s, with instructions and knowledge shared from PGY2s to PGY1s.

.On weekdays, until 8:00 p.m., the supervising doctors are in close contact with the first-year students, so the second-year and first-year students are not closely involved. However, after 8:00 p.m., the second-year and first-year students are working together with the medical advisors, so I have the impression that there is a lot of involvement during that time. (Dr. I, 10−8)

In particular settings, PGY2s and PGY1s were encouraged to interact with each other in different years because of the mosaic arrangement of desks to avoid clumping PGY2s and PGY1s in the same year group:

Yes. The desks are arranged in such a way that we can interact with each other without clumping together, so if there are any problems with medical treatment, they can ask for advice, and that is often the case. (Dr. I, 10−36)

Responsibility for medical practice

In clinical settings, PGY2s were actively consulting with and advising PGY1s and creating a learning environment for PGY1s where they had some discretion and responsibility for medical care, for example, deciding what tests and treatments to perform and whether to send patients home. PGY2s, certified by a committee of supervisors at the institutions where they belonged, had greater discretion in their practice in the emergency department, and PGY1s actively consulted with such PGY2s in making decisions.

The first-year residents often see patients first, so they ask us for advice about things they don’t understand, or when we go to look in on them. I would like to consult with them so that I can guide them in the right direction and provide them with good medical care advice. (Dr. A, 2−4)

Meanwhile, when PGY2s only had the same discretionary authority as PGY1s regarding their practice, PGY2s avoided making adjustments to facilitate PGY1s’ learning in the clinic or giving advice that was directly related to the content of their practice. In the emergency department where PGY2s were working in a different hospital, PGY2s were encouraged to teach PGY1s, but senior doctors determined the course of treatment and PGY2s were rarely entrusted with clinical decisions. Under these circumstances, PGY2s were withheld from teaching PGY1s.

.in the end, the senior doctors would make the final decisions, including whether patients should be sent home or hospitalised, and what examinations should be performed. So, I was kind of wondering if PGY2s shouldn’t meddle with them (PGY1s) too much. (Dr. E, 6−10)

PGY2s’ own factors

PGY2s’ teaching of PGY1s encouraged the former to reflect, which contributed to their learning, but whether this led to successful reflection varied from person to person. As described previously, when PGY2s prepared to teach PGY1s, they reflected on their own previous experiences and learning to explore new knowledge and structure their knowledge. They also reflected on their own knowledge and skills during the teaching sessions, recognizing their own imperfections and verbalizing what they had learned tacitly. In addition, PGY2s’ reflection on what happens as a result of their teaching led to their own learning. The following PGY2 was reflected on his own behaviour, as he was aware that he was a role model, that his behaviour was mirrored by PGY1s, and that the knowledge he taught affected PGY1s’ practice.

Let’s see…, I’ve changed…, I’ve changed. Because PGY1s see what I do and PGY1s do the same thing. I think I check more often to see if what I am doing is really correct, if I am doing it for the right reasons, if the knowledge I am teaching and if the techniques I am doing are also correct. (Dr. A, 1−2)

However, some residents were unable to reflect on the impact of their teaching on themselves or their teaching and attitude on others, and could not successfully link teaching to their personal development, as seen in the following quote from a PGY2:

Hmmm… Well, first of all, the main premise is whether the junior staff are motivated, or have the qualities, or are willing to work hard, otherwise it’s already over at that point, and even if they are, I don’t know if I can do anything. What was the question, again? (Dr. B 3−34)

Supervising physicians’ future vision of themselves

PGY2s’ desire to move closer toward the image of the supervising physician they envisioned to be in the future motivated their learning. This vision of the supervising doctor influenced the way PGY2s interacted with PGY1s in terms of knowledge transfer, acting as a role model for PGY1s, and creating a learning environment for PGY1s. One PGY2, who was not in the practice of searching for articles in English at first, followed the example of his senior doctors and began to search for English-language articles and share them with PGY1s.

When I asked senior doctors questions before, in many cases, they sent me English articles and references, or gave me copies of them. I think that had an influence on me. I think that is why, when I was asked by a first-year doctor, I was more likely to look for articles on my own. (Dr. G, 8−63)

This image of the supervising doctor was shaped by the influence of past experiences of being supervised. The image of the supervising doctor was sometimes formed based on the good role models mentioned above; at other times, it was formed by recalling and refraining from the behaviours of bad role models. For example, a PGY2 aimed to be gentle with the PGY1s, trying not to be like the senior doctors who were always irritable.

Yeah, but I’ve thought about it because there was a senior doctor one grade above me who was a little bit of an irritating senior doctor. It was kind of anti-teaching, and I thought that was a bad move. (Dr. D, 5−84)

In addition, the image of the supervising doctor sometimes changed during the reflections with the senior doctors. One PGY2 thought that, as supervisors, PGY2s should avoid taking control of PGY1s’ medical care in the teaching process, but during his reflections on senior doctors, he came to believe that the supervisor should lead and show the junior doctors how to treat patients.

During the discussion, we came to the conclusion that it is important for PGY2s to learn what we are lacking, such as how to speak, and to show PGY1s what we have learned through practice, rather than just giving them a lecture in words… (Dr. I, 10−92).

This image of the supervisor they aspired to become was also made clearer by the presence of PGY1s, the target group to teach. The following PGY2 had a clear desire to become a knowledgeable supervisor due to the presence of PGY1s.

When there is a first-year resident, I don’t know what I don’t know, but I still feel a certain amount of tension as a second-year resident, I want to have more knowledge than the first-year student. That’s a bit different. (Dr. J, 13−48)

Sufficient competency in the relevant area

For PGY2s to teach PGY1s, they needed to be competent in the area they were teaching and trusted by others. The following PGY2 was fully proficient in arterial punctures for blood gas sampling during their previous year’s residency and actively taught the technique when requested by PGY1s.

At first, for example, in April or May, when I was writing medical records in the ward, they (PGY1s) would ask me for help because they couldn’t collect blood gas. (Dr. F, 7−64)

If PGY2s did not have sufficient competency in the relevant area, they would consider themselves unfit to teach and refrain from teaching PGY1s, as in the case of a PGY2 who was enthusiastic about teaching but lacked confidence in suturing procedures: ‘…I don’t teach suturing procedures very much. I don’t think I’m really good at those procedures …’ (Dr. A, 2−129).

An integrative model of learning through teaching

The processes through which learning occurs through teaching in a clinical environment and the factors influencing it have been described so far as they can be integrated using several conceptual frameworks, such as legitimate peripheral participation, communities of practice, and reflection. The structure of a community of practice including PGY2s and PGY1s constitutes common tasks, communication, and position as practitioners. In this context, the image of the senior doctor to aspire to as an expert within the community of practice directs learning and teaching, and promotes reflection; this process is summarised in Fig.  1 .

Integrated model of learning through teaching

Legend: PGY1s and PGY2s form a community of practice when they have a shared task, ensure adequate communication, and have roles as practitioners. Teaching promotes the learning of those doing the teaching through a clear awareness of the expert they wish to become and through reflecting their actions back to them

Prior studies have established a theory of legitimate peripheral participation that sees learning as a process of participation in a community of practice, rather than merely the acquisition of knowledge by an individual [ 18 , 19 ]. From the perspective of legitimate peripheral participation, PGY2s are both learners aiming to become experts and educators guiding new PGY1s. The interviews revealed that the image of the senior doctor to aspire to influences PGY2s’ learning. Here, the PGY2s envisage themselves as the experts they aspire to be within the community of practice. This can theoretically influence both the direction in which PGY2s themselves learn and the direction in which they educate PGY1s. Theoretical aspects can also explain how this influences both the PGY2s’ own direction of learning and the direction of teaching PGY1s. In addition, the presence of PGY1s, the target of teaching, makes this image of the desired expert clearer for the PGY2s, and teaching may be helpful in forming the image of the desired expert.

Reflection is said to play an important role in learning in such communities of practice [ 20 , 21 ]. The interviews revealed that the PGY2s were inspired by teaching PGY1s, were able to reflect in preparation for teaching, and connected teaching to their own growth by gaining awareness of their teaching practice and reflecting on the impact that teaching had. However, PGY2s did not connect teaching to their own learning if they were unable to reflect well throughout. Thus, teaching in communities of practice may need to support reflection in some cases while facilitating learning through reflection.

This study identified how PGY2s, who are responsible for near-peer teaching in clinical settings, learn through teaching. It also explored what factors are associated with teaching and learning through teaching in clinical settings. PGY2s had several educational roles, including transferring knowledge, adjusting the learning environment, supporting reflection, evaluating through observation, and facilitating communication among senior doctors, other professionals, and PGY1s. Through such teaching, PGY2s were learning a wide range of competencies as doctors. The results revealed that these processes of learning through teaching in such healthcare settings can be integrated by using the community of practice theory and reflection as a framework.

PGY2s were learning diverse competencies as doctors while performing various roles as educators within the clinical setting. According to Harden and Lilley [ 22 ], the role of medical educators can be divided into eight categories: informant/coach, facilitator/mentor, curriculum developer/implementer, assessor, role model, manager, researcher, and professional. Based on these eight categories, the roles that PGY2s played in the clinical practice were as follows: informants and coaches through the provision of knowledge and support in clinical practice; facilitators and mentors through the support of reflection and step-by-step teaching of procedures; curriculum developer/implementer, albeit on a small scale; evaluator, through feedback based on observation; role model, through setting the example of oneself; administrator, through the role of adjusting the learning environment; researcher, in the sense of reflecting on and trying to improve one’s own educational practice; and professional, regarding their hard work to improve as a doctor. The competencies that residents acquire by the end of their clinical training in Japan are medical knowledge, procedures and patient care, patient safety and quality improvement, lifelong learning, medical practice in society, communication, interprofessional team practice, professionalism, and research skills. This study shows that PGY2s can learn through teaching about all competencies, except for research skills, which they are not usually involved in as part of clinical practice. This ability to learn a range of competencies by teaching is suggested by reports that, in peer-tutorial courses, students learned competencies in broad areas [ 23 ]. The current study suggests that various competencies can be learnt through teaching, not only in classroom teaching as in the aforementioned studies but also in workplace-based learning settings. In addition, this study also describes how such learning occurs.

Dandavino et al. [ 6 ] argue that teaching is a process in which metacognitive awareness, deliberate practice with feedback, and self-explanation interact with each other to further the learning of the person teaching. These three processes are said to be interrelated and can be stimulated or inhibited by social interactions and contextual factors [ 6 ]. Metacognitive awareness refers to the internal and external motivations stimulated by the teaching position, leading to self-regulated learning; PGY2s are driven by the internal motivation to appear as good supervisors when transferring knowledge and serving as role models to PGY1s, to reflect on their own experiences and reconstruct their knowledge through self-regulated learning. Deliberate practice with feedback indicates that teaching is an act of consciously practising thought processes and procedures, and furthermore, feedback is applied by giving it when teaching. The PGY2s who took on a teaching role in this study became aware of the quirks in the procedures they were performing and relearned standard procedures to feed back to themselves when teaching clinical procedures. The self-explanation effect refers to the fact that when teaching, one must first explain to oneself the content that one is trying to teach and that the knowledge is reconstructed when one realizes one’s lack of understanding or gaps in knowledge as a result of this process. In this study, PGY2s were verbalising their tacitly learned experiences and explaining them to themselves as well as to the learners when they were transferring knowledge, assisting in teaching, and reflecting on the procedures. In this process, the knowledge that PGY2s had learned tacitly was reconstructed. This concrete depiction of the process of learning through teaching also embodies how this process is stimulated or inhibited by social interactions and contextual factors.

This study identified the factors (in terms of context and social interactions) that influence PGY2s’ teaching and learning through teaching in specific clinical settings, a topic less explored in previous research on teaching in clinical settings. Jones et al. [ 24 ] conducted focus group discussions with medical students, educational stakeholders, and GP speciality trainees with teaching responsibilities and found that learners valued the experience of learning from educators in different positions and at different ages and that the experience of learning from a near-peer teacher was important. The study found that GP speciality trainees who were engaged in near-peer teaching had a greater understanding, through the teaching process, of the content they were teaching. In a study of a program of teaching students by interns at the patient’s bedside and analysing the feedback forms, it was found that near-peer teaching was well accepted by both learners and educators who became near-peer teachers; interns felt that teaching helped them to develop not only as educators but also as doctors [ 25 ]. Although these previous studies have revealed that near-peer teachers learn through teaching in clinical practice, they were conducted in semi-laboratory environments prepared for teaching; therefore, the factors influencing the process of learning through teaching that occur spontaneously in clinical practice were difficult to explore. In this study, although some hospitals had established a system of care with an awareness of near-peer teaching, this was more implicit than institutionalised. Further, it was not confirmed whether near-peer teaching occurred in clinical practice and whether near-peer teachers learned through teaching; this study found that whether they learned through teaching was influenced by a variety of factors. Therefore, it was possible to analyse the structure of teaching and learning through teaching in clinical practice as requiring a system that encourages sufficient communication to address common tasks, sufficient competence, and practitioner responsibility on the part of the near-peer teacher. Additionally, it is important to note that learning is influenced by reflection and aspirations for expert visions. This exploration led to the development of a model to explain learning through teaching in clinical practice.

This study suggests that for learning through teaching to occur in healthcare settings, the construction of communities of practice is necessary; further, learning is influenced by reflection and images of experts within the community of practice. The use of the lens of community of practice in exploring learning in clinical practice has yielded meaningful findings. For example, Hindi et al. [ 18 ] research experiential learning in pharmacy education in general practice using community of practice as a lens and analyse how learners enter the community of practice. The importance of community in near-peer teaching has also been mentioned, although a scoping review on informal near-peer teaching does not use the term community of practice [ 1 ]. Regarding community of practice, this study suggests that effective interaction and learning occur when the components of the community of practice, domain/community/practice, are aligned and a community of practice is established. The study also suggests the importance of reflection in learning in communities of practice as well as showing that the act of teaching others facilitates this and the image of an expert within the community of practice influences the direction of learning. These are important findings for enhancing learning processes and practices in healthcare settings in the future.

Limitations

This study draws on interviews with residents to illustrate how they learn through teaching, and it has succeeded in depicting the process of learning through teaching. However, given the study sample and the qualitative research design, more multifaceted findings could be obtained in the future by combining this study’s findings with quantitative studies and interviews with supervisors.

All interviewees were Japanese residents undergoing training in Japan. The image of the supervisor and the relationship between the supervisor and learner varies across cultures, particularly in Asian countries such as Japan, where there is a strong authority gradient between the supervisor and learner [ 26 ]. This affects the process of learning through teaching; thus, its application in other countries including the West needs to consider such cultural factors. Additionally, this study focused on PGY2s and PGY1s in Japanese hospitals; thus, caution should be exercised in applying these findings to other environments, different levels of training, or international settings. Nonetheless, the present findings are linked to prior theories, increasing the transferability of this theory.

Additionally, the author involved in the interviews was a supervisor at the hospital, which may have influenced the interviews due to the authority gradient. In this study, to minimise this influence, the researchers assured the interviewees that the interview was confidential and that what they shared would not affect their evaluation. Furthermore, as a supervising physician, the interviewer was able to ask questions based on his understanding of residents’ situations and working environments, which allowed us to elicit deeper insights.

This study clarified the processes by which PGY2s play diverse roles as educators in the clinical setting and through which they acquire various competencies as physicians. This study revealed that the formation of a community of practice is necessary for near-peer teaching to occur in a medical setting, that teaching channels learning through reflection, and that the image of the expert that one aspires to be directs learning.

Data availability

The datasets generated and/or analysed during the current study are available from Additional File 1 .

Abbreviations

a post-graduate year 1 resident

a post-graduate year 2 resident

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Acknowledgements

We are grateful to all the participants who engaged in our study. In addition, we would like to thank Editage ( www.editage.com ) for the English language editing. This paper utilised ChatGPT for certain sections during the process of translating Japanese manuscripts into English.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Takeshi Kondo

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Noriyuki Takahashi

Department of Medical Education, Saku Central Hospital, Saku, Japan

Muneyoshi Aomatsu

Center for Medical Education, Graduate School of Medicine, Nagoya Unversity, Nagoya, Japan

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All authors meet the ICMJE authorship criteria. TK designed the research, conducted the interviews, and wrote the manuscript. NT and MA critically examined the data analysis process and developed the model with KT. HN supervised the study and finalized the model with TK.

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12909_2024_5814_MOESM1_ESM.xlsx

Supplementary Material 1: ID and transcription of the interviews. This file contains English translations of all interviews, along with the IDs of each section and the identification of the interviewees.

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Kondo, T., Takahashi, N., Aomatsu, M. et al. To teach is to learn twice, revisited: a qualitative study of how residents learn through teaching in clinical environments. BMC Med Educ 24 , 829 (2024). https://doi.org/10.1186/s12909-024-05814-3

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DOI : https://doi.org/10.1186/s12909-024-05814-3

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Managing neurodiversity in workplaces: a review and future research agenda for sustainable human resource management.

1. Introduction

2. literature review, 2.1. neurodiversity—origins of the concept and statistics, 2.2. neurodiversity in the labour market, 2.3. managing neurodiversity in workplaces—organizational barriers and needs, 3. materials and methods.

• What are the research directions and gaps in the topic of managing neurodiversity in workplaces mentioned in the literature?
• What are future research directions in the field of managing neurodiversity in workplaces with reference to Methodology, Theory, and Contexts?

5. Discussion and Conclusions

Author contributions, data availability statement, conflicts of interest.

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Rollnik-Sadowska, E.; Grabińska, V. Managing Neurodiversity in Workplaces: A Review and Future Research Agenda for Sustainable Human Resource Management. Sustainability 2024 , 16 , 6594. https://doi.org/10.3390/su16156594

Rollnik-Sadowska E, Grabińska V. Managing Neurodiversity in Workplaces: A Review and Future Research Agenda for Sustainable Human Resource Management. Sustainability . 2024; 16(15):6594. https://doi.org/10.3390/su16156594

Rollnik-Sadowska, Ewa, and Violetta Grabińska. 2024. "Managing Neurodiversity in Workplaces: A Review and Future Research Agenda for Sustainable Human Resource Management" Sustainability 16, no. 15: 6594. https://doi.org/10.3390/su16156594

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