Medical Teacher

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A practical guide to reflexivity in qualitative

research: AMEE Guide No. 149

Francisco M. Olmos-Vega, Renée E. Stalmeijer, Lara Varpio & Renate Kahlke

To cite this article: Francisco M. Olmos-Vega, Renée E. Stalmeijer, Lara Varpio & Renate Kahlke
(2023) A practical guide to reflexivity in qualitative research: AMEE Guide No. 149, Medical
Teacher, 45:3, 241-251, DOI: 10.1080/0142159X.2022.2057287

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MEDICAL TEACHER
2023, VOL. 45, NO. 3, 241–251
https://doi.org/10.1080/0142159X.2022.2057287

AMEE GUIDE

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

Francisco M. Olmos-Vegaa , Ren
ee E. Stalmeijerb , Lara Varpioc and Renate Kahlked
a
Anesthesiology Department, Pontificia Universidad Javeriana, Bogot
a, Colombia; bDepartment of Educational Development and
Research, School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the
Netherlands; cDepartment of Medicine and Center for Health Professions Education, Uniformed Services University of the Health
Sciences, Bethesda, Maryland, USA; dDivision of Education and Innovation, Department of Medicine and Scientist, McMaster University,
Hamilton, Canada

ABSTRACT KEYWORDS
Qualitative research relies on nuanced judgements that require researcher reflexivity, yet reflexivity Reflexivity; qualitative
is often addressed superficially or overlooked completely during the research process. In this AMEE research; qualita-
Guide, we define reflexivity as a set of continuous, collaborative, and multifaceted practices tive methods
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 dif-
ferent 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 qualita-
tive 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, dem-
onstrating how reflexivity can be used to develop and communicate rigorous qualitative research.

Introduction
Practice points
As qualitative research has gained credibility in health pro-
 Qualitative researchers should capitalize on reflex-
fessions education (HPE) scholarship (Varpio and Meyer
ivity throughout their research process.
2017), the field’s understanding of rigorous research proc-
esses has been refined. In this orientation, markers for  Reflexivity should be oriented towards personal,
research rigor are fundamentally different from those com- interpersonal, methodological, and contextual
monly used in quantitative research (Tracy 2010; Varpio issues in the research.
et al. 2017). Whereas much of quantitative research strives  Reflexivity should involve concrete practices.
to reveal (or at least approximate) fundamental truths that  The entire research team needs to collaborate on
are as free as possible from researcher “bias” (Young and reflexivity processes.
Ryan 2020), qualitative research depends on subjectivity  Reflexivity should be multi-dimensional and pre-
(Rees et al. 2020). Qualitative researchers engage in reflex- sented throughout the whole manuscript when
ivity to account for how subjectivity shapes their inquiry. writing up research.
Reflexivity is tied to the researcher’s ability to make and
communicate nuanced and ethical decisions amid the com-
experience. In such cases, participants can be harmed and
plex work of generating real-world data that reflect the
data quality suffers. Engaging in reflexivity can help
messiness of participants’ experiences and social practices
researchers avoid such pitfalls (Finlay 2002a).
(Finlay 2002a). In other words, their subjective perspective
Unfortunately, reflexivity is often only vaguely understood
(or “bias”) is fundamentally intertwined with qualitative
by many and, as a result, is poorly addressed in most qualita-
research processes. And while the researcher’s perspective
has many positive impacts, failure to attend to reflexivity tive publications. This ambiguity can be mapped to several
can negatively impact the knowledge built via qualitative issues. For instance, there are many definitions of reflexivity,
research and those connected to it. For example, failing to each foregrounding different key issues (Schwandt 2014). As
account for unexpected power dynamics between partici- a result, navigating the reflexivity literature and the myriad of
pant and interviewer can lead to situations where some methods for applying it is a difficult task for many research-
participants feel pressured to disclose personal details that ers (D’Cruz et al. 2005; Finlay and Gough 2008). Furthermore,
they are not comfortable talking about, or feel silenced, reflexivity is anchored in an orientation that values subjectiv-
preventing them from sharing the fullness of their ity and requires researchers to explore their influence on

CONTACT Francisco M. Olmos-Vega [email protected] Anesthesiology Department, Pontificia Universidad Javeriana, Hospital Universitario San
Ignacio Carrera 7 40-62, Fourth floor, Bogot
a 110231, Colombia
This article has been corrected with minor changes. These changes do not impact the academic content of the article.
ß 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-
nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or
built upon in any way.
242 F. M. OLMOS-VEGA ET AL.

research, as its meaning is actively constructed through the representation; this is neither possible nor desirable (Rees
research process (Varpio et al. 2021). This orientation runs et al. 2020). Instead, we conceive of reflexivity as rooted in
counter to the post-positivist assumptions, tied to quantita- a respect for and a valuing of subjectivity. It is part of how
tive research, that have historically held sway in HPE (Varpio qualitative researchers account for the significance of the
et al. 2017). Given such issues, it is not surprising that HPE intertwined personal, interpersonal, methodological, and
scholars are often lost in a fog of uncertainty when it comes contextual factors that bring research into being.
to understanding what reflexivity is and how to use it. And
yet, despite this uncertainty, there is increasing recognition
that reflexivity is an essential aspect of qualitative studies What are the purposes of reflexivity?
(Barrett et al. 2020), so many researchers hesitantly wade There are several different goals held by researchers when
into the reflexivity waters. We believe that delineating a they engage in reflexivity, including neutralizing the influ-
nuanced definition of reflexivity and offering examples of the ence of their subjectivity, acknowledging it, explaining it,
concrete reflexive practices available can help HPE scholars or capitalizing on it (Gentles et al. 2014). These purposes
to develop and communicate rigorous qualitative research. point to different ways researchers might think about the
In this AMEE Guide, we hope to achieve that goal. To that relationships between their identity, context, and research.
end, we clarify what reflexivity means and entails, and we When it is positioned to neutralize the impact of researcher
offer specific methods of engaging in reflexivity while con- subjectivity, reflexivity refers to the researchers’ attempts to
ducting and disseminating research. We answer some of the take a tabula rasa approach—i.e. to adopt a blank slate, a per-
most common challenges HPE researchers face vis-a-vis spective of objective distance from which to study a phenom-
reflexivity: What is reflexivity? What are its purposes? What enon afresh. This neutralizing work is, for example, approached
types of reflexivity are important in HPE research? What strat- in transcendental phenomenology via “bracketing” (Gearing
egies can I use to practice reflexivity in my HPE research? 2004; Neubauer et al. 2019). Bracketing is a process through
How do I communicate reflexivity in my manuscript? What which researchers attempt to set aside any aspects of them-
are the most common critiques of reflexivity? selves (e.g. knowledge of pre-existing theories, personal views,
etc.) that might influence their study (Neubauer et al. 2019).
What is reflexivity? This neutralizing effort is still present in some branches of quali-
tative research. For example, grounded theory was originally
Many different definitions of reflexivity exist, and, as a result, grounded in post-positivism, and researchers were encouraged
researchers are often left unsure of what reflexivity is, let alone to come to their research as a ‘blank slate’ with no perspective
how to do it. To construct a comprehensive definition of reflex- or prior knowledge whatsoever (Glaser and Strauss 2017).
ivity that both respected the variety of definitions available and Transcendental phenomenology sought to ‘bracket’ the
appreciated the differences between them, we searched the researcher’s perspective and eliminate (as far as possible) its
qualitative methodological literature for publications focused influence on the research process (Neubauer et al. 2019).
explicitly on reflexivity. We then inductively analyzed them to However, this perspective has largely fallen out of favor with
identify congruences. Table 1 provides examples of some of modern qualitative researchers who see the goal of utterly neu-
the descriptions we encountered, which are incorporated in tralizing researcher influence as problematic and even impos-
the definition provided below. We then synthesized these find- sible (Levasseur 2003; Pillow 2003). To illustrate,
ings to develop the following comprehensive definition: anthropologists once attempted to frame themselves as out-
Reflexivity is a set of continuous, collaborative, and sider-researchers who could see a culture with fresh, indifferent
multifaceted practices through which researchers self- eyes (Paradis and Sutkin 2017). However, modern anthropolo-
consciously critique, appraise, and evaluate how their gists now acknowledge that these neutralizing attempts
subjectivity and context influence the research processes.
galvanized a hierarchy between researcher and participant by
Our definition highlights that reflexivity is an ongoing pro- positioning researchers as neutral observers who stood apart
cess that extends across the entire duration of a research from and above the studied population, and comprehended
endeavor. We emphasize its shared and cooperative nature; truths inaccessible to their participant-subjects (Pillow 2003;
reflexivity must be integrated into the research team dynamic Marcus 2011; Holmes 2020). Thus, in line with these develop-
to be most effective. We also stress the multifaceted nature of ments and those across other qualitative methodologies, we
reflexivity; it involves critical attention to personal, interper- leave behind the neutralizing purpose of reflexivity.
sonal, methodological, and contextual factors that influence Moving beyond neutralizing, the primary role of reflexiv-
the study being conducted. We recognize that this composite ity has also been seen as acknowledging subjectivity. With
framing of reflexivity is not often present in HPE’s qualitative this end in mind, reflexivity is conceived of as making expli-
research. In our field, we have tended to highlight the personal cit that researcher subjectivity has influenced each step of
aspect, describing each collaborator’s subjectivity. We contend the research endeavor (Russell and Kelly 2002). However,
that reflexivity is broader and more nuanced, so our definition simply acknowledging this influence does nothing to eluci-
and application must be revised to reflect that heterogeneity date the effect of that influence on the data, participants,
and complexity. context, or researcher. Therefore, we contend that framing
The reflexivity definition we propose is anchored in ori- the purpose of reflexivity solely as acknowledging
entations to research that embrace researcher subjectivity researcher influence is a weak conceptualization of it.
(e.g. subjectivism, social constructionism). We do not con- Some scholars, attempting to extend beyond acknow-
ceive reflexivity as an apology for the lack of objectivity in ledgement, have proposed that reflexivity’s purpose is to
a research project. From a constructionism perspective, the explain the researcher’s impact on the investigation. In this
goal is not to achieve an accurate or impartial orientation, thinking through and explaining their influence
 MEDICAL TEACHER 243

Table 1. Commonly cited definitions of reflexivity from the field of qualitative research.
Reference Definition
(Walsh 2003) “That which turns back upon (or takes account of) itself or the person’s self”
(Dowling 2006) “The analytic attention to the researcher’s role in qualitative research. A continuous self-critique and self-appraisal where the
researcher explains how his or her own experience has or has not influenced the stages of the research process.”
(Gentles et al. 2014) “The generalized practice in which researchers strive to make their influence on the research explicit -to themselves and to
their audience.”
(Finefter-Rosenbluh 2017) “A continual internal dialogue and critical self-evaluation of the researcher’s positionality (Pillow 2003), which leaves the
researcher changed in its wake (Mauthner and Doucet 2003).”
(Russell and Kelly 2002) “A process of honoring oneself and others in our work through an awareness of the relational and reflective nature of the task.”
(Finlay 2002b) “A thoughtful, conscious self-awareness that encompasses continual evaluation of subjective responses, intersubjective dynamics
and the research process itself”
(Kuehner et al. 2016) “A strategy of using subjectivity to examine social and psychosocial phenomena, assuming that social discourses are inscribed
in and social practices are embodied by the researcher.”
(Malterud 2001) “Attending systematically to the context of knowledge construction, especially to the effect of the researcher at every step of
the research process.”

on their research enables researchers to enhance the con- various reflexivity typologies (Finlay 2002a; Walsh 2003;
firmability (the degree to which the results could be con- D’Cruz et al. 2005), though none have gained prominence
firmed by other researchers) and transferability (the degree within HPE or beyond. In this AMEE Guide, we present
to which the results can be applied to other settings) of Walsh’s (2003) approach since it constitutes a broad and
the findings (Koch and Harrington 1998; Malterud 2001). comprehensive typology of reflexive practices relevant
However, when reflexivity’s purpose stops at simply throughout the life of a research project. We integrate our
explaining researchers’ influence, we risk limiting the description of each type of reflexivity with the purposes
potential value of subjectivity, often falling into an apolo- described above because each reflexivity can take a different
getic stance, confessing their subjectivities through the shape depending on the researcher’s goals. Typologies such
lens of “bias.” Thus, the approach to explaining reflexivity as Walsh’s need to be embedded within a broader under-
can devolve into mea culpa statements that undermine the standing of reflexivity, as an abstract concept (see definition
goals of qualitative research (Lingard 2015). and purposes provided above) and as a part of a research
Finally, many contemporary qualitative researchers strive project and manuscript (see application principles in the sec-
to capitalize on their subjectivity and consider it an integral tions to follow). According to Walsh, there are four overlap-
part of data generation (Finlay 2002b; Charmaz 2014; ping and interacting dimensions of reflexive processes:
Koopman et al. 2020). These researchers not only assume that personal, interpersonal, methodological and contextual. To
subjectivity cannot be erased from the research process, they make these processes as tangible and easily applicable as
believe that such efforts are detrimental to the research. From possible, we will use one of our studies (Olmos-Vega et al.
this perspective, a researcher’s influence is not something to 2018) to demonstrate how each type of reflexivity might
be neutralized, merely acknowledged, or explained away. On manifest in a research project and what questions research-
the contrary, since subjectivity is a productive result of all ers might ask themselves concerning each. We summarize
human interaction, it can be an asset to actively co-construct this study in Box 1 and then illustrate how reflexivity can be
data and results (Finlay 2002a; Koopman et al. 2020). In this applied after describing each of Walsh’s dimensions.
orientation, reflexivity is a means of capitalizing on the
researcher’s knowledge and identities. Two factors that pro-
Box 1. Summary of and reflexivity orientations applied in Unravelling resi-
pelled the central role of reflexivity in qualitative research dents’ and supervisors’ workplace interactions: an intersubjectivity study Olmos-
were the proliferation of projects that considered research’s Vega, F. M., Dolmans, D. H. J. M., Guzm
an-Quintero, C., Stalmeijer, R. E., &
social and political implications and the rise of participatory Teunissen, P. W. (2018).
methodologies (England 1994; Kuehner et al. 2016; Koopman Case A constructivist grounded theory study, conducted by the first
Summary author of this Guide (FOV), explored how residents and
et al. 2020). Participatory approaches in qualitative research supervisors came to a shared understanding of how to
include a range of methodologies that occupy common provide patient care jointly. The study took place in an
ground in enlisting participants as co-researchers (Finlay anesthesiology department in Bogotá, Colombia. 11
residents from different training levels and 18 clinical
2002b). In participatory research, both the researcher and the supervisors with varying years of teaching experience
participants are identified as reflexive beings (Bergold and participated. We conducted the study under a constructivist
Thomas 2012). This includes involving participants in a reflex- paradigm while using a sociocultural theoretical framework
to understand learning. The interdisciplinary research team
ive dialogue with the researchers and among themselves consisted of an anaesthesiologist pursuing a PhD in HPE
throughout the lifecycle of the project, which pushes the (FOV), an anthropologist, two educationalists, and an
researcher into confronting, modifying and honing their inter- obstetrician with expertise in workplace learning. The
principal investigator was a clinical supervisor in the
pretations of the data (Smith 1994). The idea of capitalizing anesthesiology department during data generation and
on researcher and participant subjectivities has since analysis and, as such, had previous working relationships
expanded beyond participatory research methods and, we with all the participants. The rest of the team were
outsiders to the research context; they had no prior
argue, can enhance reflexivity in any qualitative methodology. contact with the participants or the research field. We
generated data first through focus groups with residents
and supervisors and then through field observation. Focus
What Orientations can researchers use to engage groups with supervisors were held independently from
in reflexivity? those with residents. The first author moderated the focus
groups with an observer (the anthropologist). Then, the
With these different reflexivity purposes in mind, we can anthropologist conducted five months of non-participant
now differentiate between the types of reflexivity available to observation in the Operating Room, the outpatient clinic,
various hospital wards, and the labour ward.
researchers. Qualitative methodologists have proposed
244 F. M. OLMOS-VEGA ET AL.

Personal reflexivity significant of these are the relationships between researchers

and participants. A thoughtful approach to interpersonal
Personal reflexivity (Box 2) requires researchers to reflect on and
reflexivity involves recognizing and appreciating participants’
clarify their expectations, assumptions, and conscious and
unique knowledge and perspectives and attending to their
unconscious reactions to contexts, participants, and data (Walsh
impacts on the research process—e.g. how they interpret our
2003; Dowling 2006; Gentles et al. 2014). The researcher’s par-
questions. Conversely, the information and insights shared by
ticipation is a significant aspect of the research process that
participants will directly influence researchers’ decisions and
should be analyzed and interpreted. Engaging in personal
results. However, this recognition and appreciation do not
reflexivity should go beyond disclosing each investigator’s back-
stem from a neutral space; interpersonal reflexivity must
ground and training; it should include descriptions of how the
include an analysis of the power dynamics at play (Finlay
researcher’s prior experiences and motivations might influence
2002a). Though these dynamics are by no means universal or
the decisions made throughout the project (Finlay 2002b),
fixed, researchers often occupy power positions relative to
whether that influence is positive, negative, or neither. Personal
reflexivity ought to occur continuously across the duration of participants, as the interpreters of their views, arbiters of
the investigation and should be interwoven with all aspects of what counts as “valid” information, and holders of widely rec-
the project—i.e. from the project’s conception to research out- ognized credentials. Thus, data can only be understood as a
puts. Additionally, personal reflexivity should address the product of the unique power relationship between researcher
impact of the research on the researchers (Mauthner and and participants (England 1994; Finlay 2002b; Pillow 2003;
Doucet 2003; Finefter-Rosenbluh 2017). Engaging in a personal Burns et al. 2012). In this regard, interpersonal reflexivity over-
reflexive exercise can be a powerful learning experience (Mann laps with contextual reflexivity (discussed below) and requires
et al. 2009); it can reshape a researcher’s practices and catalyze a nuanced appreciation of power in the research context.
other kinds of change (Finlay 2002a; Koopman et al. 2020). One of the aims of acknowledging this dynamic might be to
However, it is also essential to consider potentially negative temper or manage its influence on participants and data.
impacts; for example, discussing loss and grief with participants
may trigger intense emotions for researchers who share those Box 3. Interpersonal reflexivity
experiences (Rowling 1999). Interpersonal I was an insider during my study of clinical supervision.
Reflexivity: But I was not just any insider: I was a clinical
Power supervisor in the department in which we conducted
Box 2. Personal reflexivity Ask yourself: the study. In other words, the participants were
Personal I (FOV) was the primary investigator in this study, what relationships colleagues I worked with and residents I supervised.
Reflexivity conducted as part of my PhD research in Health exist and how I also did my residency training in the same
Ask yourself: Professions Education. All of my colleagues and are they department, which meant that most of my
how are our residents were aware of this aspect of the study influencing the colleagues had been my supervisors at some point.
unique context. Being an insider researcher, many of my research and Consequently, my interactions in the research space
perspectives research ideas stemmed from personal experiences the people were influenced by experiences as a supervisor and
influencing and observations as a clinical supervisor. As a involved? What as a (former) resident. I had to carefully think
the research? supervisor, I often work closely with residents from power through and document how these existing
across the graduate medical education continuum. dynamics are relationships and my position in the context
Based on these experiences and informal at play? impacted my data and the context itself. For
conversations with my colleagues, I noticed the example, being known in the context gave me
complexities involved in arriving at a mutual access to many participants; however, I had to
understanding about how to work with residents. I mediate any pre-existing differences of opinion with
was disappointed by the lack of information or feelings about the supervisors and/or residents to
available in the literature to help guide my thinking. uncover their clinical supervision experiences. In
My supervisors' experiences enabled me to addition, I had to consider how existing power
appreciate the importance of looking at the dynamics were shaping my interactions with
supervisor-resident dyad as a unit of analysis. While residents—e.g. would they highlight the more
many care providers are working with residents, the positive experiences they had with me as a
construction of a shared understanding of how to supervisor, or would those who did not like my
offer care to a specific patient was deeply enmeshed supervisory style avoid participating in the study as a
in the dynamics of these dyads. By using this result of our previous encounters? Different dynamics
personal insight, I shaped my study to focus on shaped my interactions with supervisors—e.g. some
supervisory dyads. of my former supervisors could have felt pressure to
The first crucial step in my personal reflexivity involved ascribe to my views on supervision or may have felt
reflecting on how I usually work with my residents that they were being evaluated.
and managing my assumptions around how my
peers think about and experience supervision. During
data generation and analysis, I started to uncover
many nuances involved in working with residents in Another dimension of interpersonal reflexivity includes
supervisory dyads through the experiences of my how the relationships among the research team members
colleagues. I saw myself trying out new ways to unfold and impact the research (Barry et al. 1999; Russell
supervise my residents and adapt to their
uniqueness. As a result, I gained new supervisory and Kelly 2002). Reflexive research collaboration involves
tools and approaches that allowed me to adapt to active and ongoing exploration of the interplay between
each resident's needs and preferences in
team members’ motivations, expectations, and assump-
each situation.
tions, while examining how these perspectives and dynam-
ics can be leveraged or managed. It also includes reflecting
on and documenting disagreements on main research
Interpersonal reflexivity
issues, including differences in researchers’ paradigms and
Interpersonal reflexivity (Box 3) refers to how the relationships perspectives (Leggatt-Cook et al. 2011). Engaging in this
surrounding the research process influence the context, peo- type of interpersonal reflexivity is a collaborative effort
ple involved, and results (Walsh 2003). Likely the most involving all members of the research team.
 MEDICAL TEACHER 245

Methodological reflexivity which it is conducted in ways that are both intended and
unintended (Smith 1994; Reid et al. 2018). Ethical research
The third type of reflexivity is methodological reflexivity
seeks to positively impact the contexts in which it takes
(Box 4), where researchers critically consider the nuan-
place; new insights can be generated from how partici-
ces and impacts of their methodological decisions. It
pants’ reflections or engagement in the study affects their
often begins with thoughtful consideration of research-
practices and context (Bishop et al. 2002).
ers’ paradigmatic orientation(s) (Walsh 2003). A para-
digm is a worldview that informs research efforts and,
as such, reverberates throughout the research processes Box 5. Contextual reflexivity
and impacts results (Varpio and MacLeod 2020). Contextual Being contextually reflexive in our study entailed
Choosing or acknowledging a paradigm entails opening Reflexivity understanding the unique setting of the study—an
Ask yourself: anesthesiology department in a high-complexity, urban,
and foreclosing particular possibilities, so using meth- How are academic hospital. Supervisor-resident relationships in
odological reflexivity implies understanding the bounda- aspects of this context tend to be intense and continuous, often in
ries that a chosen paradigm imposes upon the research context a 1:1 ratio. This meant that supervisory dyads worked
influencing the together closely while caring for patients, which could
(Raven 2006). At the outset, researchers need to be research and be different from other disciplines, types of hospitals, or
reflexive about aligning their methodological choices people areas with fewer resources. The specific department we
with their paradigm and theoretical or conceptual involved? studied also encouraged a less hierarchical workplace
structure and culture. Therefore, it was necessary to
framework (Varpio et al. 2020). Researchers must also reflect on and report on how this context uniquely
remember that qualitative inquiry is embedded in and shaped interactions between supervisors and residents.
reactive to rich contexts, that is why methodological In addition to reflecting on how the context impacted
the research, I reflected on how my research impacted
decision making should not be set at the beginning of the context. I held informal conversations with some of
the research process. Instead, reflexive researchers are my colleagues during non-participant observation. We
constantly making decisions and reacting to their data discussed the feeling of being observed by a stranger
and how observation could feel like an evaluation.
or unforeseen circumstances (Varpio et al. 2020). Thus, Through these trust-building discussions, my colleagues
methodological reflexivity means focusing on the mean- often exchanged impressions about how they usually
ing of these decisions and ensuring that they are eth- worked with the residents. People repeatedly
questioned their decisions and practices while asking
ical, rigorous, and paradigmatically aligned. me the right way to do it. It was evident that this
study caused participants to reflect on their supervisory
choices and those of their peers.
Box 4. Methodological reflexivity
Methodological We conducted our study from a constructivist
Reflexivity paradigm, using a sociocultural theory (Billett’s Co- How can I harness reflexivity in my research?
Ask yourself: participation Theory) to inform our theoretical
How are we framework and constructivist grounded theory as Putting these reflexivity purposes and types into action
making methodology. This approach allowed us to explore a
requires planning and concrete practices. Given that reflex-
methodological social process through the participants' and
decisions and researchers’ voices, capitalizing on my role as an ivity is an ongoing process comprised of multiple dimen-
what are their insider co-constructing data. Although we believe sions, it is not surprising that there are several practices to
implications? this was the best methodological approach, it was
certainly not the only option. I remember that one
choose from, many of which might be used throughout
of the authors suggested using Actor-Network the research process (Finlay and Gough 2008). The meth-
Theory (ANT) to explore our findings. Although they ods we present below fall under two main umbrellas –
had agreed with the initial theoretical framework,
they felt we were missing essential elements in our
reflective writing and collaborative reflection.
analysis of field observations. By choosing ANT, a Reflexive writing is perhaps the best-known set of
socio-material framework, this author argued, we approaches to reflexivity. It includes forms of documenta-
could investigate how different material artefacts
(physical spaces, objects, or organizational protocols) tion such as researcher memos, field notes, and other writ-
influence supervisory dyads. After considerable group ten or recorded reflections occurring at any point in the
discussion, we decided to stick with our initial research process. Journaling might be used to bring inten-
theoretical framework since co-participation theory
would also allow us to focus on essential aspects of tion to the researchers’ perspectives and assumptions to
the interpersonal relationship between resident and the research process (Watt 2007; Ortlipp 2008; Mruck and
supervisor. Being methodological reflexive entailed Mey 2019). Memos and field notes might be used to docu-
understanding both the affordances and
shortcomings of our choices and making these ment critical interpersonal dynamics impacting participants
implications explicit in the manuscript. This example and their data; to record and probe decisions and to call
also demonstrates the need to evaluating attention to and build on moments of analytic insight
continously the alignment of our paradigm and
theoretical framework when making methodological (Birks et al. 2008); or to call attention to aspects of context
decisions in data generation and analysis. that may impact or be impacted by the study activities
(Lempert 2007). When taken up consistently and thought-
Contextual reflexivity fully, these processes can be an essential tool to bring
intention to what can be a nebulous process of examining
The last type of reflexivity is contextual reflexivity (Box 5); the assumptions, decisions, contexts, and power dynamics
it refers to locating a particular project in its cultural and at play in the research process. Additionally, they can pro-
historical context (Walsh 2003). It highlights how the vide a foundation and highlight gaps in the researchers’
research questions and their answers are embedded in and knowledge and thinking (Mruck and Mey 2019).
influenced by a social field of assumptions and practices The second set of reflexivity strategies is centered on
(Naidu and Sliep 2011). Contextual reflexivity also entails collaboration. The task of uncovering one’s blind spots is
understanding how research transforms the social field in challenging. How do you see what you cannot see?
246 F. M. OLMOS-VEGA ET AL.

Collaborative reflexivity acknowledges that qualitative personal experiences and the theories and research that
researchers rarely engage in reflexivity alone, in isolation have shaped their views on their topic (Crawley 2012). Self-
from the research team; instead, research collaborators interviews can be transcribed and analyzed in detail to
often rely on each other to ask difficult questions about enable researchers to constantly compare their experiences
assumptions and decisions (Bieler et al. 2021). Because of the topic to those of the participants (Gentles et al.
assumptions become most evident when viewed from the 2014). This exercise might be best conducted after devel-
point of view of others who do not share them, diversity of oping the initial study protocol and before or during data
perspectives and training on a research team can be quite generation. Researchers may even conduct self-interview
beneficial for reflexivity as well as a collaborative (or at more than once to understand how their beliefs have
least dialogic) relationship with participants (Barry et al. evolved throughout the study.
1999). However, power dynamics can threaten open com-
munication. Thus, building a solid foundation of trust and
a culture of mutual responsibility for ethical and rigorous
Reader-response exercise
research within a team and between team members and This exercise addresses how the researchers’ assumptions
participants, regardless of seniority and status, is necessary. might affect their interactions with participants (Mauthner
Such relationships allow space for all to question assump- and Doucet 2003). Reader response is conducted during
tions and decisions (Linabary et al. 2020). data analysis and involves including a layer of codes repre-
Collaboration and reflexive writing are not mutually senting how researchers react to and interpret participants
exclusive strategies–for example, team reflexive dialogue accounts in relation to their background and personal his-
may be grounded in individual or group reflective writing tory (Gilligan et al. 1990). It is helpful to have done a narra-
and collaboration. We also note strategies are likely to tive autobiography or a self-interview before this exercise
address more than one type/dimension of reflexivity. Thus, so that the researchers are already aware of their personal
there is no need to apply them all into a single project, reflexive stance. This exercise is paired with reflexive memos
and this list is by no means exhaustive. Instead, we offer to analyze reactions and interpretations in-depth after the
these strategies as exemplars to demonstrate concrete and coding exercise. These reactions may also form the basis of
practical ways to practice reflexivity. entries in a journal or other form of reflective writing. The
analysis may focus on how the power dynamics between
researcher and participant could have influenced both par-
Narrative autobiography
ticipants’ accounts and researchers’ reactions.
The narrative autobiography was initially developed in the
methodological literature surrounding autoethnography
Structured team-reflexive discussion
(Ellis 2004), but it is a powerful resource to tackle personal
reflexivity in any project. In this approach to reflective writ- One exercise that can help researchers to spark collabora-
ing, researchers write freely about their background and tive reflexivity is the team-reflexive discussion. During this
the motives that led them to conduct their research pro- exercise, each team member engages in reflective writing
ject, recording specific life experiences that might influence to answer personal reflexive questions such as those pro-
the research. Researchers aim to reflect on how their per- posed by Barry et al. (1999):
sonal experiences might influence their understandings of
participants’ accounts and how these insights could poten-  In what way might my experience shape my participa-
tially shape results (Koopman et al. 2020). We suggest shar- tion in the project?
ing this narrative with at least one other research team  What experiences have I had with qualitative research?
member to unearth issues that the author of the narrative  What is my orientation to qualitative research?
might overlook. Ultimately, this exercise will help research-  What results do I expect to come out of this project?
ers prepare for interactions with participants by disentan-  What theories do I tend to favor while analyzing data?
gling issues that might hinder rapport building (e.g.  What is my stake in the research? What do I hope to
assumptions on sensitive topics) (Gentles et al. 2014). We get out of it?
suggest doing this exercise while conceiving the study and  What are my fears?
during data generation. Narrative autobiography can serve
as one of the researcher’s first memos or entries in a reflex- All answers are then shared within the team and dis-
ive journal (Watt 2007; Barrett et al. 2020). cussed. This is a powerful way to understand each team
member’s position within the research and how this
ensemble could impact the results. We believe it is best to
Self-interview conduct this exercise early in the research process to maxi-
Writing the study protocol includes specifying how the mize its potential. However, many topics will likely need to
researcher will generate data, which often entails creating be discussed regularly in team meetings throughout
specific questions for interviews or focus groups. We rec- the project.
ommend those research team members who could be con-
sidered insiders to answer their questions and reflect on
Member reflection
their assumptions about the topic. Researchers could con-
duct a self-interview or be interviewed by another research Collaborative reflexive practice can (and likely should)
team member (Koopman et al. 2020). These self-interviews involve collaboration with participants. Early qualitative
are an excellent opportunity for researchers to explore work saw “member checking” as a way to validate the
 MEDICAL TEACHER 247

truth or accuracy of data (Varpio et al. 2017). However, the luxury of reporting the nuanced thinking and team-
more recently, qualitative researchers have taken up work behind every research decision. So instead, we recom-
“member reflection” as a more nuanced approach to mend focusing on decisions and dynamics that were most
“checking in” with participants and other stakeholders, tak- impactful in the research process, highlighting personal,
ing into account that data and interpretations are con- interpersonal, methodological, and contextual dimensions.
structed in context, and participants may change their
perspective or add new interpretations when they are re-
engaged (Tracy 2010; Ravenek and Rudman 2013). This
Introduction
approach is built on the assumption that our research is The introduction is a space where researchers lay out their
most credible if we return to participants or knowledge arguments and core ideas. Thus, they can demonstrate
users to work with them to build on our earlier interpreta- reflexivity by articulating alignment between their para-
tions of their contexts and ideas. Such processes can digm, theoretical or conceptual framework, and research
involve sending participants the raw data and/or researcher questions or purpose. This includes being transparent
interpretations for collaboration and feedback (Birt et al. about the researchers’ paradigmatic and theoretical presup-
2016), or booking follow-up interviews or focus groups to positions, allowing the reader to understand how this
allow participants to respond to results. Ethically, these stance influences the results (Varpio and MacLeod 2020).
reflexive processes offer participants a say in how their Having a clear picture of the paradigmatic stances of those
words are interpreted, ensuring that they can represent involved in the research, the reader can understand and
themselves and contribute meaningfully to research find- evaluate the results in that context. Additionally, research-
ings. For example, researchers could conduct follow-up ers should be aware of how the language they use can cre-
interviews to explore how the research has changed partic- ate contradictory messages. For example, researchers might
ipants’ views on the study subject or how their practices state in the introduction that they are taking a constructiv-
have been influenced (Naidu and Sliep 2011). This tool is ist stance but then talk about “mitigating bias” or meaning
generally done in the later stages of the research once ini- “emerging” from the data in other sections, suggesting a
tial data has been generated, though it could occur competing post-positivist belief that there is a truth that
throughout concurrent data generation and analysis. More can be “uncovered” (Varpio et al. 2017).
radical approaches to participant engagement might use
participatory research designs to engage knowledge users
and participants throughout the research lifecycle fully Methods
(Finlay 2002b). The methods section of any manuscript will likely offer the
most detail about authors’ reflexive practices. Regarding
How do I write a reflexive manuscript? personal reflexivity, we do not believe sections detailing
researchers’ backgrounds and perspectives constitute a
As we integrate strategies for reflexivity in our research, we robust reflexivity exercise. Instead, we call on researchers
must also work toward robust reporting practices that to demonstrate a robust sense of personal reflexivity by
enable the nuances of reflexive research to shine through, explaining how their perspectives impacted the study and
communicating the work’s credibility through transparency how they capitalized on those perspectives. Such descrip-
around the researchers’ perspectives and decisions. Part of tions need not be limited to the description of methods;
the impetus for writing this Guide stems from our own dis- instead, they can be carried throughout the manuscript.
appointing experiences reading, reviewing, and writing From an interpersonal perspective, reflexivity can be
reflexivity statements in manuscripts. In many cases, report- demonstrated by discussing the power differentials and
ing on reflexivity is isolated to a short paragraph such as dynamics between participants and researchers and within
“researcher characteristics and reflexivity.” Instead of this the research team. Authors should also discuss how these
reflexivity section delving into the intricacies of personal dynamics were considered in recruitment, data generation,
reflexivity, these portions of the text become short bio- analysis, and member reflection (Shulman 1990). Ethically,
graphical statements of each author’s affiliation and researchers should discuss how they attended to partici-
research orientation. Another problematic writing strategy pants’ preferences around anonymity and confidentiality.
for reflexivity has emerged in the limitations section, where Methodological reflexivity entails transparency around
the authors lament how their subjectivity may have pre- how methodological decisions were made. Methodological
vented them from engaging in objective research reflexivity is addressed by carefully describing study deci-
(Lingard 2015). sions and procedures and attending to how and why these
Rather than reporting reflexivity via a discreet paragraph decisions were made. For example, rather than writing “we
or as an apology for the researcher’s influence on the data, achieved saturation at 12 interviews,” reflexive reporting
we suggest that effective reporting should embrace requires the researchers to be more transparent about how
researcher subjectivity and address the nuances of deci- they decided that their data or analyses were sufficient for
sions throughout the research process. Walsh’s typology the purposes of their study (Mason 2010).
can be instrumental in structuring reflexive reporting prac- Finally, contextual reflexivity is often overlooked, particu-
tices woven throughout the manuscript, offering the reader larly in studies that do not involve time in the field. To dem-
an opportunity to journey through the practices and deci- onstrate contextual reflexivity and legitimate their findings,
sion-making that shaped the study. However, due to word researchers should articulate how they came to know their
count limitations, particularly for manuscripts submitted to context—what their relationship is to the context and how
HPE journals, we recognize that researchers may not have they sought to deepen their appreciation of its nuances and
248 F. M. OLMOS-VEGA ET AL.

capitalize on that knowledge in their data. As we noted researchers need to ascertain a good balance between par-
above, they may also include information on how the ticipant quotes and their description of the results (Holmes
research impacted the context, either positively or negatively. 2020). Also, practicing personal, interpersonal, methodo-
logical, and contextual reflexivity will aid in creating a
more balanced approach to reflexivity and the research it
Results
aims to strengthen.
Results sections are often thought of as strictly data presenta-
tion. However, we contend that the researchers’ voices and
Reflexivity as privilege
interpretations are intimately connected to the results and dis-
cussion sections; in other words, the results do not “emerge” Reflexivity is an act of bravery: the researcher needs to con-
by themselves but are instead constructed and interpreted front themselves with potentially uncomfortable truths about
(Varpio et al. 2017). Thus, researchers can demonstrate reflex- their assumptions and their research. Admitting to and dis-
ivity by clarifying where the data they present came from, cussing these uncomfortable truths might be more affordable
how it was interpreted, and how it is being used. Strategies for some than for others. Mauthner and Doucet (2003) reflect
for achieving this type of reflexivity might involve discussing on how completing their PhD’s, securing academic positions,
the balance of participant quotes and researchers’ description and becoming established in their respective fields created a
in the results (Holmes 2020), or demonstrating the extent to sense of safety that enabled them to confess confusions and
which findings are representative across a data set. ambiguities in their data analysis. Newer researchers may
worry that admitting confusion and ambiguity could reflect
Discussion poorly on their credibility and skills as researchers at a time
when they are very vulnerable to the assessments of others.
Like the results section, the discussion should reflect As such, an open dialogue about the practice of reflexivity
researchers’ active interpretive work and efforts to situate within the research team, modelling of vulnerability by senior
their findings in the broader literature. However, this should researchers, and discussions about reflexivity within research
not simply be an exercise of finding means of confirming networks might help normalize reflexivity centered on uncer-
the researchers’ interpretations. Instead, we argue that seek- tainty and mistakes in research processes.
ing out and presenting aspects of the literature that might
challenge researchers’ interpretations constitutes important
personal and methodological reflexive work. Reflexivity as a never-ending hall of mirrors
Perhaps most of all, we would like to end trite reporting
There is no one way to practice reflexivity. Depending on the
of study limitations that seek to meet post-positivist
epistemological stance of the researcher, different aspects of
expectations, offering apologies for a small sample size
reflexivity might be foregrounded over others (Day 2012).
that may seem small or for the study’s contextual specifi-
Although we, like Lynch (2000), see reflexivity as an
city. Instead, limitations can offer insights into the aspects
of the study population and context that are particularly ‘unavoidable feature’ in performing qualitative research, over-
important to help readers assess the transferability of the doing reflexivity might be likened to being stuck in a ‘hall of
study’s findings to other contexts. mirrors’ (Lynch 2000). One poses the questions: When have
we done enough reflexivity? When does it end? The disheart-
ening answer might be ‘never,’ especially if we see reflexivity
What are the criticisms of reflexivity? as a hallmark of rigorous research that continues throughout
the projects’ lifecycle. However, a way to check the suffi-
Despite the good intentions behind the practices of reflex-
ciency of reflexivity practices is to examine the final manu-
ivity, we must not close our eyes to some of the criticism
surrounding reflexivity as a practice. By addressing these script. To convey a clear message to the audience,
criticisms, we aim to equip the researcher with the neces- researchers need to keep sight of the alignment between
sary understanding to transform these potential problems the research question and the study’s theoretical and con-
into opportunities (Finlay and Gough 2008). ceptual grounding, provide clear justification for their meth-
odological choices, put forth a clear description of the
research context in the methods section, and balance the
Reflexivity as narcissism participant and researcher voices in the results section (Day
Researchers run the risk of overpowering the voice of the 2012). When grounded in concrete practices and transparent
participant (Weick 1999) when they narrowly focus on per- reporting, looking in the mirror does not have to feel like
sonal reflexivity and define reflexivity solely as a process of you are stuck in an Escher painting (Lynch 2000).
critical self-awareness, reflecting on how their background,
assumptions, positioning, and behavior impact the research Authors personal reflexivity
process (Finlay and Gough 2008). Weick (1999) labelled this
risk as a form of narcissism (p. 894) and pointed to the limi- We came to this Guide because of a mutual passion for
tations of personal reflexivity as it can create a ‘thin line thoughtful qualitative research processes. We were
between interesting insights and self-indulgence in reflexive troubled by a lack of theoretical and practical guidance on
accounts’ (Nadin and Cassell 2006). Therefore, in their reflexivity available to HPE researchers interested in doing
reflexive practices, we encourage researchers not to lose rigorous qualitative work. Thus, we did not attempt to take
sight of the participants’ voices. This is especially pertinent a neutral stance regarding the literature on reflexivity.
when writing the results section, as we explained earlier, as Instead, this Guide represents a combination of our
 MEDICAL TEACHER 249

knowledge and beliefs around effective reflexive practice standards in the HPE field through this Guide, cementing a
and a representation of the literature as we see it. solid foundation to consolidate the growing interest in
Our team developed expertise in qualitative research qualitative research. To close this Guide, we would like to
through international institutions and interdisciplinary pro- provide four take-home messages:
grams; thus, there are many differences in our perspectives.
However, we all position our research within subjectivist or  Make space and time for reflexivity by embedding it in
social constructionist paradigms, and our stances on reflex- all aspects of study design; construct a reflexivity plan
ivity deeply reflect this perspective. The language used in that includes tools and strategies to actualize reflexivity.
this Guide explicitly identifies this perspective. Dr Olmos- Unfortunately, reflexivity often gets lost in the pressing
Vega is an anesthesiologist with a PhD in HPE from issues of intensive data generation and pressure to
Maastricht University. He studies how students learn complete analyses. However, thoughtless decisions
through social and material interactions in the workplace threaten the integrity of qualitative research, and lack of
using sociocultural and socio-material theories. Since he documentation impairs the ability to report on nuanced
started supervising research projects, he felt frustrated by and reflexive research.
the lack of a clear guide to reflexivity that could be used by  Embed reflexivity within collaborations; reflexivity relies
researchers interested in qualitative research. This frustration on challenging assumptions and decisions in thoughtful
finally drove him to write this Guide. Dr Stalmeijer is an and collaborative ways. To do this, teams need time to
educationalist with a PhD in HPE from Maastricht University. build rapport and grapple with their decisions and
She has a background in quality management of education data together.
and her PhD focused on the evaluation of clinical teachers  Explore different types of reflexivity; venture beyond
using Cognitive Apprenticeship theory. She currently studies personal reflexivity to include interpersonal, methodo-
workplace learning and guidance using sociocultural theo- logical and contextual types in your study. Explore each
ries and focuses on foregrounding the interprofessional type’s nuances and decide which reflexivity aspect to
dynamics present during workplace learning. Dr Varpio’s explore in-depth according to your specific paradigm
doctoral degree is in English, focusing on rhetoric; her HPE and methodology.
career has been built on careful attention to philosophies  Embrace your subjectivity; abandon objectivity as a foun-
of science and how those philosophies impact research dational goal and embrace the power of your subjectivity
practices. Given this background and her active work as a through meaningful reflexivity practices. Reflexivity is not
qualitative HPE researcher, she advocates for the need to a limitation; it is an asset in your research.
clarify the foundational principles that uphold rigor across
different research paradigms and methodologies—including
reflexivity. Dr Kahlke holds a PhD in Education and trained Disclosure statement
at McMaster University, the University of Alberta, and the The authors report no conflicts of interest. The authors alone are
University of British Columbia. She uses sociocultural theory responsible for the content and writing of the article.
and branches of critical theory (such as Critical Race Theory)
to conduct her research on trainee and physician agency
and social justice in healthcare systems. She has a passion Disclaimer
for novel research strategies that can highlight participant The views expressed in this manuscript are solely those of the author
voices and manage power dynamics that threaten the social and do not necessarily reflect those of the Uniformed Services
justice aims of her work. This perspective deeply informs University of the Health Sciences or the United States Department
of Defense.
her views on interpersonal reflexivity. Drs. Kahlke, Varpio,
and Stalmeijer teach qualitative research methodology to
graduate students at both Masters and PhD levels and Funding
incorporate discussions on reflexivity in their teaching prac-
The author(s) reported there is no funding associated with the work
tice. Our team’s experience shaped this Guide, and we
featured in this article.
benefited this research and writing process, which reshaped
our understandings of reflexivity in our research and teach-
ing practice. To acknowledge that this article benefits from Notes on contributors
our collective expertise and subjectivities, we use the first-
Francisco M Olmos-Vega MD, MHPE, PhD, is Assistant Professor with
person plural “we” and “our” throughout this manuscript. the Department of Anesthesiology, Pontificia Universidad Javeriana
and Anesthesiologist at Hospital Universitario San Ignacio in
Bogot
a, Colombia.
Conclusion
Ren
ee E. Stalmeijer, PhD, is an Assistant Professor in the Department
In this AMEE Guide, we have advanced a clear and unified of Educational Development and Research, School of Health
definition of reflexivity. We have explored multiple facets Professions Education, Faculty of Health, Medicine and Life Sciences,
of reflexivity while giving readers tools and strategies to Maastricht University, Maastricht, the Netherlands.
address them. We believe this Guide can provide a straight- Lara Varpio, PhD, is Professor in the Department of Medicine and
forward approach to reflexivity practice for those interested Associate Director of Research in the Center for Health Professions
in qualitative research. It could also be used as a teaching Education, Uniformed Services University of the Health Sciences,
tool for research supervisors who want to introduce their Maryland, USA.
students and mentees to the world of qualitative research. Renate Kahlke is Assistant Professor, Division of Education and
Finally, we hope that we promote rigorous, high-quality Innovation, Department of Medicine and Scientist, McMaster Education
250 F. M. OLMOS-VEGA ET AL.

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