Taking a different (re)view

Elgin

One of the oft cited benefits of higher education is the shift in perception that comes with taking a wider view. I remember it from my Master’s degree – it was harder to take things at face value, issues were approached with a more critical lens and research projects were developed left right and centre! We all agree… there is just something that happens when you take comfortable, preconceived ways of doing things and give them a good shake with a whole load of new stuff. Change happens.

Change – it is generally understood in health care (and in life) – to be inevitable. It is also seen as difficult, sometimes resisted, and often hard to implement. In the last blog I talked about how reflexivity can lead to a literally changed mind.  What I have been feeling, these last few weeks, is the result of that changed mind in an environment that hasn’t changed.

The paper I’ve been co-authoring on discrimination in LGBTQ health care (and how to make things better) has made it to the peer review stage. As an associate editor, I know the value and the limitations of the process. I’ve wrangled some terrible reviews – some that are so short they are of no practical use, some that are (to be honest) really, really rude and some that list 56 typos and grammatical errors but tell me nothing about the actual publishability of the paper.  Of course this is #notallreviewers! Most are hardworking, experts in their fields who generously give up their limited spare time to help advance their profession. The trouble is, we’re not an especially academic profession (yet) and most of us (me included) are making this up/learning as we go.  Anyway, you can see where this is going! One review was respectful, polite, well considered and had some great suggestions for change that were very helpful. Reviewer 2 (it’s always Reviewer 2!) questioned the need for the paper because there are anti-discrimination policies in workplaces – so surely I am exaggerating? Gay people don’t experience this – at least not to the degree that we are claiming! Despite using references from many studies and position papers, the paper was really more of a “political manifesto” than anything else.  Woah!

Reading reviews is always an emotional experience! The first response is often “they just don’t get it”. I tend to skim the comments, leave it for a few days, read again, leave a day or so and then start to work on the changes. That takes some of the emotion out of it, allowing you to see where the reviewers have valid points, and (sometimes) where you still feel the original should stand. I did this last week – and still have a hard time with Reviewer 2. It comes down to (I think) the fact that I am standing in the same spot, dealing with the same issues at work but with a different set of eyes. I can see that – yes, there are policies, but oppression is institutionalised. I think, what this boils down to, is a general blindness about types of oppression and how they work. To a (I am taking a wild guess here) straight person, the fact that some people do have problems and are treated differently because of their sexual orientation or gender identity is antithetical to how the system is supposed to work.  Yes, of course HCPs are usually kind, compassionate people but they work within a system that professes patient centred care but does a poor job of treating patients as individuals.

And – I get it! It took a concentrated 8 months at UBC for me to even begin to see outside my ordered, comfortable, health care-centric box. As a white woman, I am highly privileged – and had the privilege to be able to ignore the not-so-privileged experiences of other groups. As a queer woman, I thought not being able to marry who I wanted, having multiple barriers in place for parenthood and doing the exhausting dance of being both in and out of the closet was just my thing to deal with. Turns out it really wasn’t. So Reviewer 2, I understand you! But just because you haven’t seen it, doesn’t mean it doesn’t exist.

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Reflection, reflexivity and changing your mind

Whitehorse

Back in the classroom (which seems very far away most days while running on the work-family treadmill) we’ve almost finished our research class. Usually when I decide to “do research” I’ll pick a method based on:

  1. What I and a few other people think that the problem is
  2. What I am comfortable doing (hint: usually not involving too many numbers) and
  3. Who I can rope in to co-investigate/help/support/provide food

It’s a tried and true method, and has led to a few published papers and (maybe) some changes in how things are done. I was shocked and stunned to realise that this process (EVEN IF I WRITE IT DOWN) wouldn’t pass a doctoral candidacy exam! Additionally, rather than the empirical, positivistic, small-frame-of-acceptable-ways-to-do-things research we all know and love – I need to start looking at things from the assumption that, perhaps, there isn’t just one truth and that it’s actually OK to have and even (gasp) incorporate our values and positionality as researchers. This research class has been circling around that idea and showing us how theory (like feminism) and method (like ethnography) work together. We’re not there yet, but one thing we keep coming back to is reflexivity.

A quick search shows reflection and reflexivity are terms often used synonymously, I’ve mashed them together in the past and as an educator – I really thought I had this whole reflection thing nailed down. The act of reflection –  thinking about a disruptive event or problem and turning it over and over in your mind has long been assumed to be fundamental to learning. From Dewey to Kolb to Schön, reflection is what guides us along the path from novice to expert in circles and cycles of do, reflect, do differently, reflect again (Dewey, 1933; Kolb, 1984; Schön, 1983). But reflection and reflexivity are not really the same thing. Reflection leads to learning but the learner doesn’t really change. Reflexivity, on the other hand, achieves learning but also changes the learner as a result. Perhaps if successful reflection (in educational terms) results in a change of practice, reflexivity results in a literal change of mind?

In research terms, the move from reflection to reflexivity might involve shifting how we view the collecting of data from something that is entirely neutral to recognizing that as researchers we actively construct knowledge with our participants. In my role as associate editor for qualitative research for JMIRS, I use a checklist to help screen submissions. As a practitioner of “qualitative lite” research myself, I need all the help I can get to ensure we accept good and trustworthy articles. The one I use is one of the most common, the Standards for Reporting Qualitative Research (SPQR) from the authoritative journal Academic Medicine. These guidelines are designed to comfort the majority of medical editors who are staunch upholders of the positivistic hegemony and need to see a checklist. This is what the SPQR has to say about reflexivity:

“Members of the research team often form relationships with participants and analytic processes are highly interpretive in most qualitative research. Therefore, reviewers and readers must understand how these relationships and the researchers’ perspectives and assumptions influenced data collection and interpretation” (p. 2).

In reality, what I find many authors submit (when they discuss reflexivity at all) is a sort of shortened biography describing their professional role and how they attempted to “bracket” their values and ideas throughout the research. Most accounts lack any examination of the researcher’s reactions or the interplay of the back and forth relationship with the participants. This is still the “researcher as a neutral observer” idea from the positivistic approach under a different guise.

What we’re reading about in class (and what I love the idea of) is much deeper – it is research as a process of mutual collaboration with the participants using “cycles of mutual reflection and experience” to create the data together (Finlay, 2002b.p. 218). Examples include co-operative inquiry or interactive interviewing.  This type of investigation goes way beyond reflection, and plumbs the murky depths of reflexivity to expose the values, motivations, assumptions that may never have been brought to the surface.  But, we are warned, there is a fine line between reflexivity and self-indulgent mental meanderings when the whole process becomes all about us. Finlay (2002b) warns us to eschew the “infinite regress” – the falling inward that paralyzes the process and loses us in the downward spiral of our own navel gazing.

It’s a fascinating process – even as part of the pre-research stage we should be mulling over our “motivations, assumptions, and interests in the research” (Finlay, 2002a. p. 536). This blogging, the classroom discussions, talking it over with my friends, tweeting and journaling are all attempts to do this, to pull something coherent out of the initial ideas and concepts that are the raw stuff of my future dissertation and to find the right balance between infinite regress and simplistic reflection.

This was heavily influenced by:

Finlay, L*. (2002a). “Outing” the Researcher: The Provenance, Process, and Practice of Reflexivity. Qualitative Health Research, 12(4), 531–545

Finlay, L. (2002b). Negotiating the swamp: the opportunity and challenge of reflexivity in research practice. Qualitative Research, 2, 209-230.

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*Linda Finlay – occupational therapist researcher and academic superstar!