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

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.

Disentangling residents' engagement with communities of clinical practice in the workplace.

Maximising the potential of the workplace as a learning environment entails understanding the complexity of its members' interactions. Although some articles have explored how residents engage with supervisors, nurses and pharmacists individually, there is little research on how residents enter into and engage with the broader community of clinical practice (CoCP). To this end, we designed a constructivist grounded theory study that took place at Universidad Javeriana in Bogotá, Colombia. We conducted semi-structured interviews with 13 residents from different training levels and disciplines during the first weeks of their new rotations. During the interviews, we used the Pictor technique as a visual aid to collect data. Using iterative data collection and analysis, constant comparison methods and theoretical sampling, we constructed the final results. When entering a CoCP, residents experienced recurring and intertwined processes including: exploring how their goals and interest are aligned with those of the CoCP; identifying the relevant CoCP members in the workplace environment; and understanding how these members could assist their successful engagement with the community's practices. Residents entered a CoCP with the intention of either having a central or a peripheral trajectory in it. The final resident participation and role resulted from negotiations between the resident and the CoCP members. Optimising workplace learning includes being mindful as to how each member of the healthcare team influence residents' engagement on practice, and on understanding the nuances of residents' participatory trajectories while interacting with them. Understanding such nuances could be key to align CoCPs' learning affordances and residents' goals and intentions.

Unravelling residents' and supervisors' workplace interactions: an intersubjectivity study.

CONTEXT: Successful engagement between residents and supervisors lies at the core of workplace learning, a process that is not exempt from challenge. Clinical encounters have unique learning potential as they offer opportunities to achieve a shared understanding between the resident and supervisor of how to accomplish a common goal. How residents and supervisors develop such a mutual understanding is an issue that has received limited attention in the literature. We used the 'intersubjectivity' concept as a novel conceptual framework to analyse this issue. METHODS: We conducted a constructivist grounded theory study in an anaesthesiology department in Bogota, Colombia, using focus groups and field observations. Eleven residents of different training levels and 18 supervisors with varying years of teaching experience participated in the study. Through iterative data analysis, collection and constant comparison, we constructed the final results. RESULTS: We found that residents and supervisors achieved a shared understanding by adapting to one another in the process of providing patient care. Continuous changes in the composition of resident-supervisor dyads exposed them to many procedural variations, to which they responded by engaging in various adaptation patterns that included compliance by residents with supervisors' directions, negotiation by residents of supervisors' preferences, and the sharing of decision making. In the process, the resident played an increasingly key role as a member of the supervisory dyad. Additionally, experiencing these adaptation patterns repeatedly resulted in the creation of a working repertoire: an attuned working code used by the members of each supervisory dyad to work together as a team. CONCLUSIONS: The development of shared understanding between residents and supervisors entailed experiencing diverse adaptation patterns which resulted in the creation of working repertoires. Seeing supervisory interactions as adaptation processes has essential theoretical and practical implications regarding workplace learning in postgraduate settings. Our findings call for further exploration to understand learning in postgraduate education as a social process.

Dealing with the tension: how residents seek autonomy and participation in the workplace.

CONTEXT: The workplace can be a strenuous setting for residents: although it offers a wealth of learning opportunities, residents find themselves juggling their responsibilities. Even though supervisors regulate what is afforded to residents, the former find it difficult to strike the proper balance between residents' independence and support, which could create tensions. But what tensions do residents experience during clinical supervision and how do they cope with them to maximise their learning opportunities? Understanding how residents act on different affordances in the workplace is of paramount importance, as it influences their learning. METHOD: Residents from different levels of training and disciplines participated in three focus groups (n = 19) and 10 semi-structured interviews (n = 10). The authors recruited these trainees using purposive and convenience sampling. Audio-recordings were transcribed verbatim and the ensuing scripts were analysed using a constructivist grounded theory methodology. RESULTS: Residents reported that the autonomy and practice opportunities given by their supervisors were either excessive or too limited, and both were perceived as tensions. When in excess, trainees enlisted the help of their supervisor or peers, depending on how safe they recognised the learning environment to be. When practice opportunities were curtailed, trainees tried to negotiate more if they felt the learning environment was safe. When they did not, trainees became passive observers. Learning from each engagement was subject to the extent of intersubjectivity achieved between the actors involved. CONCLUSIONS: Tensions arose when supervisors did not give trainees the desired degree of autonomy and opportunities to participate. Trainees responded in various ways to maximise their learning opportunities. For these different engagement-related responses to enhance workplace learning in specialty training, achieving intersubjectivity between trainee and supervisor seems foundational.