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- v.9(6); 2022 Nov
- PMC9584480
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Nurs Open. 2022 Nov; 9(6): 2908–2914.
Published online 2021 Jul 24. doi:10.1002/nop2.999
PMCID: PMC9584480
PMID: 34302437
Monica Peddle
1
Author information Article notes Copyright and License information PMC Disclaimer
Abstract
Aims
Reflexivity is central to the construction of knowledge in qualitative research. This purpose of this paper was to outline one approach when using reflexivity as a strategy to ensure quality of the research process.
Design
In this exploratory research, reflexivity was established and maintained by using repeated questionnaires, completed online. Using the approach presented by Bradbury‐Jones (2007) and Peshkin's I’s, the aim of the research was to identify the researcher's values, beliefs, perspectives and perceptions prevalent in the research.
Methods
Qualitative data were collected in online reflexive questionnaires, completed monthly by the researcher from January 2017 to December 2018. Data analysis used interpretive and reflective reading and inductive processes.
Results
Seventeen questionnaires were analysed. Data indicated use of questionnaires enabled and detailed development of specific strategies to ensure trustworthiness. Importantly, reflexivity, supported by questionnaires, brought about transformation through self‐awareness and enlightenment.
Keywords: nursing research, qualitative research, reflexivity, trustworthiness
1. INTRODUCTION
Reflexivity is the process of reflecting critically on oneself as a researcher (Bradbury‐Jones,2007) and is central to the construction of knowledge in qualitative research (Narayanasamy,2015). It requires the process of knowledge construction to be the subject of investigation (Flick,2013). Reflexivity assists researchers to consider their “continuing engagement with participants and revelations of the self as the researcher enters the various stages of the research process” (Narayanasamy,2015, p. 238). It acknowledges the partnership between the participants and researcher (Narayanasamy,2015), the impact that the participants and the researcher have on each other (Darawsheh,2014) and the need to understand what the effects were and how they impacted on the data (Patton,2015). During reflexivity, the research process and end product are examined relative to the researchers’ praxis, role and social position (Flick,2013).
Reflexivity is also a process that can be transformative for the researcher, developing personal self‐awareness and enlightenment (Narayanasamy,2015). This process can be challenging, as the researcher has to act ethically and employ skilful and illuminative insight through a process of “critical self‐reflection on one's biases, theoretical predispositions, preferences” (Engward & Davis,2015). However, despite the importance of reflexivity, it is suggested that reflexive accounts in nursing research are “under‐addressed” (Narayanasamy,2015).
Reflexivity can be viewed as a criterion, a tool or a strategy of rigour in qualitative studies (Darawsheh,2014). When viewed as a criterion, reflexivity is a marker of quality and is used to increase the confidence, congruence and credibility of findings (Darawsheh,2014). When viewed as a tool reflexivity promotes quality of qualitative research, impacting on the judgement of the significance of the findings (Patton,2015). When viewed as a strategy, reflexivity enables the researcher to ensure credibility of data, dependability of the study and conformability of findings (Darawsheh,2014). This paper will outline one approach when using reflexivity as a strategy to ensure quality of the research process.
In this paper, I will use the first person to outline the personal self‐reflective process used to examine my perceptions, that are the origins of my own voice and perspectives (Patton,2015). This paper will outline the strategies I used to create “a continual internal dialogue and critical self‐evaluation of [my] positionality, and active acknowledgement and explicit recognition that this position may affect the research process and outcome” (Berger,2015, p. 220). Examining my own thoughts, actions and assumptions allowed me to bring these to a conscious level and develop an awareness of how these may influence the research process (Darawsheh,2014). Furthermore, reflexivity supported credibility by making the decisions made and the research process transparent (Darawsheh,2014; Patton,2015).
1.1. Background
1.2. Research project summary
The purpose of the research project in which this reflexivity was situated was to explore the influence of virtual patients on the development of non‐technical skills in first‐ and third‐year nursing students. Non‐technical skills are defined as the cognitive, social and interpersonal skills that contribute to safe and efficient task performance (Flin etal.,2013). Research now recognizes that non‐technical skills such as communication, teamwork and leadership are critically important in safe patient care in the clinical setting (Flin etal.,2013). However, literature identifies there is a deficit in undergraduate health professional education curricula of explicit teaching and learning activities and resources enabling development of NTS critical for maintaining patient safety in clinical practice (DeTata,2015).
The Virtual Simulated Patient Resource (VSPR) (www.vspr.net.au is a free interprofessional web‐based resource that provides undergraduate health professionals the opportunity to engage in simulation based, interactive learning activities to develop and apply foundational knowledge and skill of non‐technical skills. Knowledge and skill are developed in online modules and applied to realistic virtual patient scenarios using a simulation based and “play your own adventure game” approach. The resource is student centred where the learner controls and manages their learning experience from the “driver's seat” to meet their individual needs. Integration of the resource is based on constructivist theory supported by Kolb's Experiential Learning Model (1984). The author has led the design, development, implementation and research of the Virtual Simulated Patient Resource.
Using a case study methodology, the influence of virtual patients on the development of non‐technical skills in first‐ and third‐year nursing student was explored. A purposive convenience sample was used with first‐ (n=45) and third‐year (n=31) nursing students across two education facilities in Victoria, Australia. Ten focus groups and one individual interview were conducted with first‐year students and 6 focus groups and one individual interview, with third‐year students. Data analysis used framework analysis.
1.3. Methods
A descriptive exploratory approach was employed in this research. Qualitative data that promoted self‐reflection were collected using repeated questionnaires, completed online using Qualtrics. The research question posed was as follows: what are the nature of my values, beliefs perceptions and perspectives prevalent in the research?
1.4. Data collection
Online reflective questionnaires enabled an examination of the internal dialogue and a critical self‐evaluation of my skills, commitment and framing in and towards the research enabling me to be self‐aware. This approach to reflexivity allowed application of skills and attributes to support further exploration of the phenomenon under investigation whilst controlling subjectivity, so as not to impart my views or perceptions on the participants’ data (Darawsheh,2014).
I utilized three avenues to capture my consciousness and self‐commentary when immersed in the research – participants, audience and researcher (Patton,2015). According to Patton (2015), reflexivity intersects with perspective of those studied, considering how do they know what they know, what has influenced their world view and how do I perceive them? Additionally, outlining the perspectives of the researcher, who is an instrument in qualitative inquiry, to identify what prior knowledge, values and beliefs they bring to the research, and current thoughts and perceptions on the research process and findings is important. Finally, the perspectives of those who will critique and use the findings assists in examining what is clear or unclear or what remains unanswered. The repeated questionnaires enabled me to scrutinize the participants, the audience and myself as the researcher to support a deliberate and planned internal examination of my position relative to the research and the values that I brought to the research. Additionally, it enabled me to consider how these perspectives may have shaped the data. This reflexivity allowed me to capture my self‐commentary during the research and articulate how I was making sense of the data.
The qualitative reflective questionnaire comprised six questions as outlined in Table1. The time taken to complete the questionnaire was relative to what was occurring in the research at that time. At times, responses were short and sharp with clearly defined statements whilst at others, responses were more reflective and thoughtful taking more time. I completed these online questionnaires monthly.
TABLE 1
Reflexive questionnaire
| Reflexive questionnaire |
|---|
|
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1.5. Data analysis
The aim of the analysis of the reflective qualitative questionnaire entries was to identify the nature of my values, beliefs, perceptions and perspectives prevalent in the research. This approach uses Peshkin's I’s (Bradbury‐Jones,2007). Peshkin's I’s refers to the work undertaken by Peshkin (1988), who by recording his thoughts and feelings and then systematically analysing the entries, was able to identify the subjective I’s that may have influenced his research. The outcomes of the research suggested that being aware of your subjectivities in research can improve outcomes.
Analysis of reflective questionnaire responses used interpretive and reflexive reading (Bradbury‐Jones,2007). The first step involved a “process of reading the data for meaning and representation” followed by an inductive process, where I recognized themes that represented the different kinds of values, beliefs, perceptions and perspectives prevalent in the research (Bradbury‐Jones,2007). The nature of these I’s identifies my position in the research and the influence of my internal perspectives on the data.
1.6. Ethics
Ethical approval for the qualitative research in which this reflexivity was situated to ensure trustworthiness was obtained (Ethics approval ID number: CF12/3958 – 20,120,018,910).
1.7. Findings
Questionnaire data were captured from January 2017 to December 2018 during a period of intense data collection, analysis, synthesis and reporting. Reflective questionnaire data were downloaded from Qualtrics in February 2019. A total of 17 responses were recorded. Presented below are the nature of the values, beliefs, perspectives and perceptions identified in the analysis, supported by excerpts from the questionnaire (Table2).
TABLE 2
Values, Beliefs, Perspectives and Perceptions present in the research
| Values | The value of being unsettled highlights importance of feeling of confusion and discomfort that triggers synthesis during the research. |
| The value of being challenged indicates the usefulness of testing and confronting oneself. | |
| Beliefs | The champion admits to the construct that non‐technical skills are important in safe clinical practice. |
| Perspectives | My structured perspective identifies the need for a planned, controlled and coordinated approach. |
| My impatient perspective identified my eagerness and hurried approach to the research. | |
| Perceptions | The development of insight describes the development of skills and competence in research. |
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1.8. Values– Unsettled and Challenged
The worth of being unsettled evidenced by feelings of turbulence, confusion, discomfort, clarity and productivity highlights the value of these feelings to prompt resolution and synthesis of data. It was curious to note how feedback and criticism impacted with being unsettled and aligned with moments of clarity or ambiguity of the research progress.
When emotions were framed in a more negative stance, thoughts about the data were perplexing, unsure and disrupted. Criticism of process or outcome caused feelings of doubt and a lack of direction in how to advance the research.
Questionnaire entry 3/5/2017: “Feeling a little perplexed since meeting yesterday. Thought I was on top of everything and then again derailed by a very confusing meeting.”
However, when emotions were framed positively including invigoration and empowerment thoughts about the data were clear but questioning.
Questionnaire entry 20/2/2017: “Starting to feel invigorated about potential insights into the learning experience of student and VSPR.”
Questionnaire entry 29/5/2017: “Really enjoying this component of my PhD research. It feels more like real research than the other two stages I have completed.”
Questionnaire entry 9/6/2017: “Feeling empowered and on track.”
Additionally, constructive feedback, strengthened confidence and synthesis of ideas supporting progress.
Questionnaire entry 6/7/2017: “Have felt some real support recently with really helpful feedback and suggestions on how to manage and reduce the data to make it more meaningful. Have actually learnt a lot.”
I experienced a level of challenge not previously encountered when engaging with and in and making sense of the data. However, data revealed the usefulness of that challenge to delve in, work with and wrestle with the data to discover patterns and themes. Curiously reflexive questionnaire data highlight how this challenging experience evolved from one of discomfort to having fun.
Questionnaire entry 6/7/2017: “I love the data. The complexity that it has revealed regarding the VSPR interactions is exciting and I am really looking forward to delving into the ‘how’ data.”
Questionnaire entry 1/8/2017: “The data is rich and interesting. Love working with it and trying to understand what it is telling me.”
Questionnaire entry 22/8/2019: “Love the qualitative data. It is rich and descriptive and the wrestle with the themes etc. is fun!”
1.9. Beliefs – The champion
The Champion highlights my belief that quality non‐technical skills in clinical practice support safe patient care. It emphasizes my confidence that introducing these fundamental concepts early and explicitly in curricula will enable development of these skills in novice practitioners and support preparation for practice. It clearly states upfront my position relative to the importance of the skills and declared my beliefs that the VSPR would be an effective resource to develop these skills.
Questionnaire entry 11/1/2017: “I believe that NTS are important and should be developed early on in undergraduate education. This enables students to be aware of these skills in practice and gives them opportunities to critique practice, reflect on skills demonstrated and integrate and develop their own skills, as a result. I believe that virtual learning offers an alternative to face to face and can be as effective in most areas. I have a small area of doubt if this is true for NTS as there are emotions and feelings also involved with these which can be hard to replicate in online learning. I believe that VSPR is an innovative resource to develop student awareness of practice and what to expect. It presents practice as not perfect and real.”
The Champion enabled me to declare my position relative to non‐technical skills and VSPR and to be aware of how this position would resonate with the data as I progressed with the research. Being conscious of my position prompted me to pause and consider the data to ensure the data were always “front and centre.” I was mindful to confirm findings were consistent with, and grounded in, the data and to be watchful of the potential of my stance to influence interpretations of the data.
Questionnaire entry 9/6/2017: “Insight by some participants is fantastic. However, is that because I am hearing what I want to hear? Need to be careful here of subjectivity. Always ensure the data is front and centre.”
Questionnaire entry 10/7/2017: “I know that some of it will change when I discuss but feeling confident that the overarching themes are congruent and make sense of what the data indicates.”
1.10. Perspectives – Structured and Impatient
The Structured perspective emphasizes the desire I have for organization and clarity. Whilst I appreciate and value abstract thought and aspire to be visionary, introspective and immerse myself into the art of qualitative synthesis, in the beginning the ability to participate in this in‐depth thinking appeared beyond me. The reflexive questionnaire data document the struggle experienced during the research to think deeply about the data and what it means.
Questionnaire entry 20/2/2017: “Limited progress this week ‐ thinking interrupted and no depth to activities completed.”
Questionnaire entry 22/6/2017: “Hmm ‐ perplexed with thought in trying to decipher the themes in the data.”
However, as I progressed further into the research, I identified factors that supported and promoted deep thinking whilst supporting a structured perspective. Quarantining time and space both physically and mentally encouraged active participation in and contemplation of deep thought.
Questionnaire entry 22/2/2107: “Hmm perplexed with thought in trying to decipher the themes in the data. Loving the challenge.”
Questionnaire entry 5/11/2017: “Ok taking its time as this part requires real thinking, rereading and more thinking.”
The Impatient perspective characterizes the inner need to achieve and “get the job done.” It wanted to “kick goals.” At times, this perspective encouraged moving rapidly from one part of the data to the next with emergent findings being considered definitive. At other times, this perspective was a barrier to further reflection and contemplation of all opportunities. Whilst the Impatient and Structured perspectives may be considered complementary, they presented a risk to deep thinking with the opportunity to affect the credibility of the research. Deliberate attention was needed to take my time to revisit and reflect, promoting more thoughtful and innovative insights and to remember this is an iterative process.
Questionnaire entry 19/5/2017: “I am trying to work hard to progress the outputs. Feeling really pleased.”
Questionnaire entry 14/2/2018: “Need to kick some goals today for the how paper and get a draft happening.”
Questionnaire entry 3/5/2017: “Remember to take my time and that it will be an iterative process.”
1.11. Perceptions – Insight
Data in the reflexive questionnaire reveal the growth of insight and awareness of the data, and the development of my analytical skills and self‐confidence. The reflexive questionnaire data emphasizes the significance of being able to examine one's performance and identify areas for improvement to ensure deep and detailed data are obtained that focuses on answering the research questions. The excerpts below reflect the growth and development of insight through the research, from identifying anxieties with the quality of data, to when I gained clarification into and an understanding of the research process.
Questionnaire entry 20/2/2017: “Perplexing that I did not do a good job moderating the focus group. Data is limited in its depth. The questions in the interview guide will need to be reviewed as it appears to investigate more along the lines of what is the impact rather than how student learn. Research data could be deeper if moderation techniques developed.”
Questionnaire entry 3/5/2017: “The data analysis process is now clear to me and that the framework analysis approach will be used as part of the case study to see how the VSPR scenarios address prior theory established from the literature.”
Questionnaire entry 9/6/2017: “Understanding what I am doing and why. Have some clarity to the research process.”
A “light bulb” moment was the realization and comprehension of the applicability and fit of the research procedures being completed with the chosen research methodology. Through the insight developed, I was able to draw together separate components of the research into one unified case study creating a holistic piece of work answering the research questions and adding new knowledge.
Questionnaire entry 6/3/2017: “The use of the case study approach really resonates and makes sense. It ties in the rest of my research and will hopefully present my findings and the thesis as a holistic piece of work.”
Questionnaire entry 6/3/2017: “I think that the approach of case study with VSPR as the case really fits with the thesis. The data will enable thick and rich description of the learning involved with VSPR and present it so that themes from the review can be utilised across the research. The data sources should help provide triangulation as required in case study research.”
Further to insight into skills and knowledge of research was the development of insight into myself evidence by self‐assurance and self‐possession, enabling me to uphold a position of clarity in challenging discussions. This reflexive questionnaire data highlight the development of awareness of and into the research and viewing myself as being capable and a growing sense of pride in being true to the data.
Questionnaire entry 6/3/2017: “This component is really taking shape and actually feel a little proud I could pull it together.”
Questionnaire entry 19/5/2017: “I am more confident in what I am doing and the rationales for why. Have been able to hold my own over the last few weeks and feeling like I am finally coming to grips with this research thingy.”
2. DISCUSSION
The findings of this study suggest that the use of a deliberate and planned strategy through a repeated reflective questionnaire can promote reflexivity. Data indicate that this structured approach enables bringing to the surface thoughts, actions and assumptions of the researcher which reveals how the self‐commentary and internal examination of the researcher develops and its potential to influence the research. Additionally, data suggest that a repeated questionnaire can detail the specific strategies implemented that ensure trustworthiness of the research. These findings align with the position presented by Johnson etal.,(2020) that highlights for reflexivity to be critical to the trustworthiness of a study; it should be an active and ongoing application throughout the study. Furthermore, the use of a thoughtful, deliberate and planned application is supported as an approach to best achieve trustworthiness (Johnson etal.,2020). Importantly, reflexivity, that is supported by a deliberate and planned approach, can support researcher transformation through self‐awareness and enlightenment (Narayanasamy,2015).
This structured and deliberate approach recorded the thoughts, decisions, emotions and actions that produced themes and categories during the research. By using a questionnaire to promote reflexivity, assumptions about the research topic, the research and the participants were able to be questioned (Luttrell,2019). This approach enabled decisions made to be openly examined (Sydor,2019). It afforded the ability to distinguish factors that implicitly and explicitly influenced the research which is important in reflexivity (Engward & Davis,2015). Similarly, the organization and construction of the data were able to be interrogated with interpretations of data collected examined (Engward & Davis,2015).
Interestingly, inherent in these findings is the importance of quarantining and observing time for the researcher to go back, reread and reflect on data to ensure findings are grounded in the data obtained. Developing and implementing a deliberately structured and methodical approach to reflexivity require the regular quarantining of time and space, both physically and mentally, for focussed reflection (Bradbury‐Jones,2007). This strategy ensured that the data aligned with and were coherent with themes and categories identified (Nowell etal.,2017).
It is suggested that being systematic and orderly is not conducive to creative qualitative research and reflexivity (Bradbury‐Jones,2007). Additionally, the concept of developing deep understanding and internalization of reflexivity appears at odds with a structured and systematic approach (Dodgson,2019). However, the finding of this research indicates that deliberate repetition and practice can develop familiarity and readiness for deep thought, ensuring adequate deliberation of data and consideration of all options. This finding is supported by Dodgson (2019) who identifies it is the researcher responsibility to succinctly and clearly address issue of reflexivity in qualitative research. This approach supports conviction and strength of findings in qualitative research (Bradbury‐Jones,2007).
Notably, a reflective questionnaire using the avenues of participants, audience and researcher can capture researcher emotions and thoughts on the different stakeholders during various stages of the research. Whilst it is important to track events and record actions, it is likewise important to identify the roles and personas a researcher assumes in research as part of reflexivity (Sydor,2019). This approach can enable periods of negativity characterized by perplexing, unsure and disrupted thinking, to be recognized and addressed, transforming the research (McCabe & O'Connor,2014). During times when negativity prevails, it is important that researchers discover new ways of actively engaged in and interpreting the data “through the practice of awareness” and actively undertake complex data analysis and synthesis (McCabe & O'Connor,2014).
Finally, the insight, understanding and awareness developed through focussed reflection and deliberation enabled by a systematic and repeated reflective questionnaire permits the acknowledgement of the holistic nature of the research method, data and findings. Congruence between the research aims, methods and design affords an assessment of the strength of the research (Noyes etal.,2018). To produce trustworthy findings, the development of a critical consciousness in the researcher influences the strength of the research, the researcher role, along with the capability and aptitude to undertake the research (Luttrell,2019). This approach to maintaining reflexivity in qualitative research can be exciting and transformative.
2.1. Strengths and limitations
The research reported in the paper provides an important contribution to establishing trustworthiness in qualitative research by offering an innovative approach to promoting reflexivity. A strength in the research reported in this paper is the attention to methodical rigour when using established data collection approaches and questionnaires, over a sustained period of time. Questionnaires are a recognized method to gain data on attitudes, values beliefs and experiences (Johnson & Christensen,2019). Additionally, the data in the questionnaire represent authentic responses gathered during a time of significant data collection, analysis and synthesis.
However, caution is warranted in generalizing these findings to wider populations as like other studies using qualitative data, the findings are particular to this research. The use of a structured and deliberate approach to reflexivity is time consuming and required commitment to see the approach to conclusion. Whilst the questionnaire was developed based on literature, it did not undergo any external review or testing. Finally, it is acknowledged that the research reported in this paper represents the researcher's perspectives.
3. CONCLUSION
Using the repeated questionnaire as a deliberate and planned strategy to support reflexivity enabled examination of values, beliefs, perceptions and perspectives in the research and how they may have influenced the research. The data obtained in the questionnaire enabled strategies to be developed to ensure credibility of data, dependability of the study and confirmability of findings (Darawsheh,2014). This deliberate systematic approach enabled bringing to the surface thoughts, actions and assumptions to reveal how the researcher's self‐commentary and internal examination develops and its potential to influence the research. This transparent approach to reflexivity supports transparency in the research process and promoted investigation into the construction of knowledge during the research process. The identification of effective strategies in qualitative nursing research that ensures quality research process are maintained, producing trustworthy outcomes, will assist audiences in judging the trustworthiness of research outcomes.
3.1. Impact
What problem did the study address?
Reflexivity in qualitative research is an important strategy to ensure trustworthiness of the research. However, reflexive accounts are underreported in nursing research.
What were the main findings?
The use of a questionnaire enabled and detailed the specific strategies implemented to ensure trustworthiness of the research.
Where and on whom will the research have impact?
The processes and findings reported in this paper provide useful strategies to support nurse researchers engage with reflexivity in qualitative nursing research.
CONFLICT OF INTEREST
No conflict of interest has been declared by the author.
ACKNOWLEDGEMENTS
None.
Notes
Peddle, M. (2022). Maintaining reflexivity in qualitative nursing research. Nursing Open, 9, 2908–2914. 10.1002/nop2.999 [PMC free article] [PubMed] [CrossRef] [Google Scholar]
Funding information
No funding was received to support this research. MP conceived of, designed, implemented and drafted the work presented in this manuscript. The data sets generated during and/or analysed during the current study are not publicly available
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