Statue of someone thinking

Auguste Rodin’s famous sculpture, The Thinker, is a great example of a man engaging in reflection. The man is sitting on a rock and by his posture demonstrates that he is deep in thought, reflecting on something. He is engaged in a singular activity; there is no one else with whom he can discuss his thoughts. In contrast, reflexivity, the subject of this month’s blog, is a group activity and is really the heart of the video reflexive ethnography (VRE) process. Iedema distinguishes between reflection and reflexivity, calling reflection a personal, focused, and purposive activity. He claims that reflexivity is a group-level activity, describing it as “collaborative in nature, diffuse in focus, open-ended in purpose, and immediate in effect.”1 Iedema says that during “reflexivity sessions” participants jointly review select footage and collaboratively analyze it, enabling them to help interpret and learn from the videos.1

There are two theoretical perspectives that provide the foundation for reflexivity, both of them from sociology. The first is the theory of social constructionism that posits exchanges between two or more people creates a shared reality and knowledge that did not exist before their interactions.2 Communication (which is the process that clinicians engage in during their activities) leads to the purposeful creation of knowledge because by communicating with one another individuals develop shared understanding, gaining insights that previously may not have existed.3 By reviewing video of their activities, reflexivity helps uncover this new knowledge because in the moment clinicians can be so engrossed in what they are doing that they may be unaware of everything that is happening. The second theoretical perspective comes from social psychology (which has both sociological and psychological emphases). Social psychology says that when people are in the same situation they conform to one another’s behaviors and habits, so that over time the habits and behaviors become ingrained as the culture: “this is how we do it.” But in becoming ingrained the behaviors and habits also become invisible and thus difficult to modify. Filmed activities are visible activities, and during reflexivity sessions clinicians can stop the film, rewind, jump forward, to identify activities that are praise-worthy as well as where some activity starts to go off the rails but more importantly, why, so that during discussion solutions can emerge.

Before one can conduct a reflexivity session though, conditions have to be set in place for reflexivity to occur because reflexivity has to be engendered, according to Iedema. How does one go about setting up conditions that are conducive to reflexivity? Two considerations are needed: the people, and the place. In most cases the same considerations that you would give to preparing for focus groups would apply here, although there are some differences. For example, try to keep the number of participants in each reflexivity session to around 5 – 8, numbers similar to what would be ideal for focus groups. Of course we’re talking about busy clinicians, so the “ideal” may not be feasible, and you may have to hold reflexivity sessions with fewer or greater numbers of participants. In preparing for people to come to reflexivity sessions ask yourself if participants will be from the same group of clinicians or if they represent more than one group of healthcare professionals? Depending on the clinical practice that is being examined, it may make sense to include people from different groups, or it may be better to hold separate reflexivity sessions for each group. For example, in a study exploring communication between physicians and nurses it might be best to hold separate reflexivity sessions with each group because of hierarchical and power differences that may make it difficult for nurses to speak up when they are in the same room as physicians. The hierarchical/power differential affects other groups as well. Nurses may feel uncomfortable speaking up in front of their supervisors, or nurse aides may not want to say much in front of nurses. For most inter-disciplinary clinical practices, having representatives from all groups may provide the richest perspective.

In thinking about the place, the goal is to manipulate the environment in such a way that peoples’ minds are free to focus on the video and discuss what they are seeing, rather than be distracted by extraneous factors. First, a room needs to be big enough to hold the number of people who are likely to attend the reflexivity session. Packing people into a small room practically cheek-to-jowl may be very uncomfortable for many who feel that their personal space is being invaded. Alternatively, when a room that is too large is used people may spread out or cluster in the back, which makes it difficult to engage everyone in dialogue. Chairs should be set up in a way that makes it easy for everyone to see the projection screen. Having to turn around or crane one’s neck to see a screen is not conducive to comfort and distracts the mind from the main purpose of the session. Different than for focus groups, you may want to lower blinds/curtains on windows to keep sunlight from flooding the room and washing out images on the screen. If snacks are provided (an incentive for people to come) make sure that packaging is not noisy. Just think about the noise that opening a bag of potato chips makes compared to a cookie that comes on an open tray. Lots of noisy crinkling sounds will adversely affect the audio quality of what is said by the group, and that should be captured by video (ideally) or audio recording.

Clinicians are usually very interested in reflexivity sessions because they look forward to seeing themselves and others on film. Video review together stimulates reflexivity “because there is shared deliberation of video that enables clinicians to apprehend and frame themselves, their practices, and circumstances in new ways, thus building the capacity for meaningful clinical practice change.”1 To generate reflexivity participants are first asked to describe what happened in the video, if there were any surprises, or if there was anything that the video did not show.4 If that prompt does not get the discussion started, then their attention is brought to cues expressed by verbal and non-verbal language to jump-start a conversation. It is helpful for the facilitator of the reflexivity session to view the film ahead of time and have some idea of what is on it.

In summary, reflexivity is all about making the complexity of our everyday actions explicit and bringing them forward for review and deliberation. As Iedema says, “When clinicians review footage of their own work, their attention is drawn to the complexities that become apparent in what they do together: the heady mix of historical, contextual, and systemic confounders, the multitude of unacknowledged conditions and unintended consequences, and the host of taken-as-give personal and professional habits and routines.”5

Chapters 5 and 6 in Iedema and colleagues’ new book4 are devoted to the preparation for and conduction of reflexivity sessions, so rather than rehash the authors’ excellent suggestions, here is a link to the book:

1. Iedema R. Creating safety by strengthening clinicians’ capacity for reflexivity. BMJ Qual Saf. 2011;20(Suppl 1):i83-6. doi:10.1136/bmjqs.2010.046714
2. Berger P, Luckmann T. The Social Construction of Reality. New York, NY: Anchor Books, a Division of Random House, Inc.; 1966.
3. Thomas A, Menon A, Boruff J, Rodriguez AM, Ahmed S. Applications of social constructivist learning theories in knowledge translation for healthcare professionals: A scoping review. Implement Sci. 2014;9(1):54. doi:10.1186/1748-5908-9-54
4. Iedema R, Carroll K, Collier A, Hor S-Y, Mesman J, Wyer M. Video Reflexive Ethnography in Health Research and Healthcare Improvement: Theory and Application. 1st ed. Boca Raton, FL: Taylor & Francis Group, LLC; 2019.
5. Iedema R. Research paradigm that tackles the complexity of in situ care: Video reflexivity. BMJ Qual Saf. 2019;28:89-90. doi:10.1136/bmjqs-2018-008778

January Blog – Reflexivity