benefits of qualitative research in education

Qualitative research in education : Background information

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Educational Research Basics by Del Siegle

Qualitative research.

Although researchers in anthropology and sociology have used the approach known as qualitative research  for a century, the term was not used in the social sciences until the late 1960s. The term qualitative research is used as an umbrella term to refer to several research strategies. Five common types of qualitative research are grounded theory , ethnographic , narrative research , case studies , and phenomenology.

It is unfair to judge qualitative research by a quantitative research paradigm, just as it is unfair to judge quantitative research from the qualitative research paradigm .

“Qualitative researchers seek to make sense of personal stories and the ways in which they intersect” (Glesne & Peshkin, 1992). As one qualitative researcher noted, “I knew that I was not at home in the world of numbers long before I realized that I was at home in the world of words.”

The data collected in qualitative research has been termed “soft”, “that is, rich in description of people, places, and conversations, and not easily handled by statistical procedures.” Researchers do not approach their research with specific questions to answer or hypotheses to test. They are concerned with understanding behavior from the subject’s own frame of reference. Qualitative researcher believe that “multiple ways of interpreting experiences are available to each of us through interacting with others, and that it is the meaning of our experiences that constitutes reality. Reality, consequently,  is ‘socially constructed'” (Bogdan & Biklen, 1992).

Data is usually collected through sustained contact with people in the settings where they normally spend their time. Participant observations and in-depth interviewing are the two most common ways to collect data. “The researcher enters the world of the people he or she plans to study, gets to know, be known, and trusted by them, and systematically keeps a detailed written record of what is heard and observed. This material is supplemented by other data such as [artifacts], school memos and records, newspaper articles, and photographs” (Bogdan & Biklen, 1992).

Rather than test theories, qualitative researchers often inductively analyze their data and develop theories through a process that Strauss called ” developing grounded theory “. They use purposive sampling to select the people they study. Subjects are selected because of who they are and what they know, rather than by chance.

Some key terms:

Access to a group is often made possible by a gate keeper . The gate keeper is the person who helps you gain access to the people you wish to study. In a school setting it might be a principal.

Most qualitative studies involve at least one key informant . The key informant knows the inside scoop and can point you to other people who have valuable information. The “key informant” is not necessarily the same as the gate keeper. A custodian might be a good key informant to understanding faculty interactions. The process of one subject recommending that you talk with another subject is called “ snowballing .”

Qualitative researchers use rich-thick description when they write their research reports. Unlike quantitative research where the researcher wished to generalize his or her findings beyond the sample from whom the data was drawn, qualitative researcher provide rich-thick descriptions for their readers and let their readers determine if the situation described in the qualitative study applies to the reader’s situation. Qualitative researchers do not use the terms validity and reliability. Instead they are concerned about the trustworthiness of their research.

Qualitative researchers often begin their interviews with grand tour questions . Grand tour questions are open ended questions that allow the interviewee to set the direction of the interview. The interviewer then follows the leads that the interviewee provides. The interviewer can always return to his or her preplanned interview questions after the leads have been followed.

Qualitative researchers continue to collect data until they reach a point of data saturation . Data saturation occurs when the researcher is no longer hearing or seeing new information. Unlike quantitative researchers who wait until the end of the study to analyze their data, qualitative researcher analyze their data throughout their study.

Note:   It is beyond the scope of this course to provide an extensive overview of qualitative research. Our purpose is to make you aware of this research option, and hopefully help you develop an appreciation of it. Qualitative research has become a popular research procedure in education.

Del Siegle, PhD [email protected] www.delsiegle.info

Qualitative Research on Science Education in Schools

• First Online: 12 January 2022

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• Michaela Vogt 4 &
• Katja N. Andersen 5  

Part of the book series: Challenges in Physics Education ((CPE))

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Specific features in the three steps of theoretical framing, data collection and data analysis characterise qualitative research on science education. As a general tendency, the qualitative paradigm contributes to research results that are gained by the interpretation of non-numerical data collected through a rather open, not hypothesis-driven, process-like research (Bortz and Döring in Research methods and evaluation: for human and social scientists. Springer Medizin, Heidelberg, 2016 ; Lamnek and Krell in Qualitative social research: With online material. Beltz, Weinheim, 2016 ). Beyond this pragmatic shortcut to the paradigmatic perspective, it should be emphasised that the following contribution is based on a fundamental understanding of qualitative research in the sense of a multidimensional modular system. The individual components of this system can be used and combined flexibly. However, this must happen based on the solid foundation of theory and the principled orientation towards the object of research or research questions. This contribution presents and discusses current trends in qualitative research on science education in schools. The chapter focusses on the four steps (a) theoretical groundwork for a research project in didactics, (b) data collection implying sampling, methods and technical support, (c) data analysis with its diverse methods and criteria of quality and (d) the interpretation of the analysed data related to the theoretical framework as well as to the research field.

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Acknowledgements

We would like to thank Philipp Mayring (Alpen-Adria Universität Klagenfurt, Austria) and Astrid Huber (Private Pädagogische Hochschule der Diözese Linz, Austria) for carefully and critically reviewing this chapter.

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Vogt, M., Andersen, K.N. (2021). Qualitative Research on Science Education in Schools. In: Fischer, H.E., Girwidz, R. (eds) Physics Education. Challenges in Physics Education. Springer, Cham. https://doi.org/10.1007/978-3-030-87391-2_17

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Article contents

Observing schools and classrooms.

• Alison LaGarry Alison LaGarry University of North Carolina at Chapel Hill
• https://doi.org/10.1093/acrefore/9780190264093.013.983
• Published online: 29 July 2019

Qualitative observation is an attempt to view and interpret social worlds by immersing oneself in a particular setting. Observation draws on theoretical assumptions associated with the interpretivist paradigm. Thus, researchers who engage in qualitative observations believe that the world cannot be fully known, but must be interpreted. Observation is one way for researchers to seek to understand and interpret situations based on the social and cultural meanings of those involved. In the field of education, observation can be a meaningful tool for understanding the experiences of teachers, students, caregivers, and administrators.

Rigorous qualitative research is long-term, and demands in-depth engagement in the field. In general, the research process is cyclical, with the researcher(s) moving through three domains: prior-to-field, in-field, and post- or inter-field. Prior to entering the field, the researcher(s) examine their assumptions about research as well as their own biases, and obtain approval from an Institutional Review Board. This is also the time when researcher(s) make decisions about how data will be collected. Upon entering the field of study, the researcher(s) work to establish rapport with participants, take detailed “jottings,” and record their own feelings or preliminary impressions alongside these quick notes. After leaving an observation, the researcher(s) should expand jottings into extended field notes that include significant detail. This should be completed no later than 48 hours after the observation, to preserve recall. At this point, the researcher may return to the field to collect additional data. Focus should move from observation to analysis when the researcher(s) feel that they have reached theoretical data saturation.

• education research
• qualitative
• observation
• ethnography

Introduction

Observation, as a concept, can refer to many things. Yet, in terms of social research and ethnography, observation is the act of “record[ing] the ongoing experiences of those observed, through their symbolic world” (Denzin, 2017 , p. 185). It is an attempt to view and interpret social worlds by immersing oneself in a particular setting—a way to “see from the inside” (Emerson, Fretz, & Shaw, 2011 , p. 3). Observation draws on theoretical assumptions of the interpretivist paradigm, and is associated with methodologies such as ethnography, narrative inquiry, discourse analysis, grounded theory, phenomenology, and symbolic interactionism. It is one of many ways for researchers to understand situations based on the meanings of those involved. The particular approach to observation presented here considers the process and implications of observations in educational settings such as schools and classrooms.

The Interpretivist Paradigm

All research methods and methodologies are based on assumptions about reality and knowledge. In order to understand how one might study a particular research question or explore a phenomenon, it is important for researchers to examine their beliefs about whether the world around them can be objectively known. Researchers who approach their work from the interpretivist paradigm believe that the world cannot be objectively understood, and does not exist independently of thoughts or ideas. Since there is no objective truth, the world must be interpreted (Glesne, 2016 ). Further, the goal of such research is not just to interpret the social world, but to do so through the lens of actors in that particular setting or context. Through observation, then, qualitative researchers “access . . . others’ interpretations of some social phenomenon” and also use their own lens to interpret the actions and motivations of others (Glesne, 2016 , p. 9).

Because interpretivist qualitative research, as described in this article, is centered on interpretation, it is not considered “objective” research. Throughout the observation process, the researcher’s identity and subjectivity are always implicated. Interpretivist research engages participants’ multiple ways of knowing and making meaning, at the same time engaging socially constructed meanings agreed upon by society. Thus, while interpretations may be unique to individuals, to some degree, it is also possible to access the “perspectives of several members of the same social group about some phenomena,” which can “suggest some cultural patterns of thought and action for that group as a whole” (Glesne, 2016 , p. 9). In order to collect substantial evidence of such cultural patterns, interpretivist researchers prioritize significant, long-term engagement in the field. While one might observe and use the techniques described in this article on a short-term or ad hoc basis, sustained presence in the field and interaction with participants are vital for interpreting cultural understandings unique to the context.

Nearly every researcher has experienced schooling in some manner, making informal “insider” status somewhat universal for researchers who choose to study education. This amplifies researcher subjectivity such that most researchers entering the field have an a priori vision of what the student experience is like, and how educators are, or should be, in an educational setting. For those who have experienced traditional schooling, their experience is not insignificant, spanning more than a decade of their lives. Additionally, some education researchers are former educators, adding a further layer of knowledge and experience that influences how they engage in observation-based qualitative research. All this is to say that the cultural meanings that each of us bring to bear on educational research are heavily laden with our own schooling experiences and the social powers that shape them. This can be both a benefit and a reason for increased attentiveness or caution.

Another concern regarding observation in the field of education is that there are significant contextual implications for observations in classrooms. Thus, the term is doubly fraught with meaning. Generally, when teachers (or students) think about being observed, they assume judgement. While a fear or wariness about researcher judgement is not uncommon in observational research, the apprenticeship model for teachers invokes observation as a form of evaluation with real professional consequences. This is the case for pre service teachers and in-service teachers alike. In conjunction with student achievement, observation ratings may also be tied to teacher performance evaluations and merit pay. This discursive and symbolic conundrum can be problematic for qualitative researchers both in terms of gaining entry into the field, and also in terms of managing their own biases toward judgement. In conducting observation in classrooms, the aura of evaluation is ever-present. This is not to say that observation, as associated with educational evaluation, is bad. There are vast benefits to apprenticeship, directed feedback, legitimate peripheral participation (Lave & Wenger, 1991 ), and experiential learning (Dewey, 1938 ). When it comes to qualitative research, however, there is a necessary translation that must occur to orient both the reflexive approach of the researcher, and the understanding of the teacher or students being observed.

While interpretivist participant observation engages the subjectivity of the researcher, novice researchers are encouraged to take field notes as objectively as possible, reserving analysis and interpretation for a later phase. That said, our experiences as researchers in the field always engage some level of analysis as we integrate what we see and experience into our own extant frames of reference. Denzin ( 2017 ) reminded researchers that participant observation “entails a continuous movement between emerging conceptualizations of reality and empirical observations. Theory and method combine to allow the simultaneous generation and verification of theory” (p. 186). This article presents a methodological perspective on how one might conduct participant observation in educational settings, while paying particular attention to the movement between empirical or “objective” observation, subjective interpretation, and further evaluation. While the article focuses primarily on observation rather than analysis, it is necessary to consider how a researcher navigates the continuous push in the field to detach (concrete observation) and connect (understanding emerging concepts). The article thus includes some discussion of preliminary analysis and how it may be recorded.

It is always tricky to lay out methodological procedure when, in reality, the process is layered, cyclical, or non-linear (Spradley, 1980 ). For the researcher interested in observation, it is important to keep in mind the idea of “movement between” as stated by Denzin ( 2017 ). A vital skill for expert qualitative observation is to actually exist and think “between.” This allows for subjectivity and emic or insider understandings to inform, but not supersede, concrete thick descriptions (Geertz, 1973 ) of interaction in the field. This skill takes significant practice and mentorship. The included examples describe the process of a novice researcher, to show how one might begin to build capacity for observation and subsequent interpretation. Following the discussion of methodological procedure, there is a brief discussion of implications and encouragements for the use of ethnographic observation in educational settings.

Methodological Cycles of Observation

This section breaks the methodological process of observation in school settings into three domains: Prior-to-field , in-field , and post- or inter-field . These domains can be viewed as somewhat cyclical in nature and, realistically speaking, are not always discrete. As the researcher becomes more embedded in the research setting, more familiar with the context, and more adept at the “move between” description and analysis, the lines between the domains become blurry. So while one may separate these domains for the sake of explanation, they should be taken not as singular, but rather as guiding moments in the process of qualitative observation.

In the prior-to-field domain, the researcher examines or states their own epistemological stance toward the work, as well as their own biases toward the setting or subject matter. This reflexive work not only sets the tone for the in-field domain, but also allows the researcher to consider appropriate research questions. In the post- or inter-field domain, the researcher revisits their in-field observations to again navigate between the concrete field notes taken and their own subjective interpretations. This domain also provides opportunity to further focus observation and refine the research questions. Additionally, researchers may consider this an apt moment to check with participants for their own interpretations of interactions observed.

Prior-to-Field

Observation is more than simple data collection and, despite differing epistemological orientations, nearly all sources agree that observation-based research should be rigorously conducted. In other words, data gathered through observation or ethnography is “more than casually observed opinion” (Angrosino & Rosenberg, 2011 , p. 468). In more recent iterations of ethnographic methodology, observation is highlighted as a site of interaction. In this postmodern context, researcher subjectivity is acknowledged—rendering the researcher a participant, co-constructor, and co-negotiator of meaning at the study site. Angrosino and Rosenberg ( 2011 ) stated, “our social scientific powers of observation must, however, be turned on ourselves and the ways in which our experiences interface with those of others in the same context if we are to come to an understanding of sociocultural processes” (p. 470). This discussion of the nature of observation-based research is a vital starting point since it orients the researcher to the cultural meanings of the study site and encourages them to acknowledge their own subjectivity. As in post-critical ethnography (Noblit, Flores, & Murillo, 2004 ), this orientation serves to situate the project as theory and methodology that are inextricably intertwined. This means that the researcher needs to be aware of the experiences, meanings, and biases they bring to the field.

From a sociological standpoint, each of us moves in the world based on a number of more or less abstract identity markers that influence how others interact with us. A particular caution for educational researchers exists in the vast differences we know that students have in their schooling experiences. These differences are often based on social markers such as race, ethnicity, socioeconomic status, gender, sexuality, and religion. Schooling, as an institution, mirrors and even amplifies the social hierarchies of society such that some are distinctly privileged in educational settings, while others experience oppression and disadvantage. So, to build on the assertion that nearly all education researchers have “insider” experience with schooling, it is important to note that these experiences can differ greatly. Sometimes parallel or similar experiences may limit the view of the researcher in that they may see only their own experiences, and may not look beyond that feeling to truly engage what others might experience. Additionally, differing experiences or social positioning may result in misinterpretation of cultural meaning. Thus, educational researchers must prioritize the move between social meanings of their own and those of participants observed. This is one reason, in particular, why it is so important to record concrete sensory detail in the field.

When a researcher records concrete details, they are recording what is seen . If a researcher were to record only what they think about the events taking place in the field, this judgement (for that is what it is) may supplant other potential meanings that may be discovered. Recording concrete sensory details allows the researcher the space to later move between their own subjectivity and those of the participants—particularly during the process of writing expanded field notes. This process takes time and practice. Indeed, it takes a vigilant researcher to parse out the expectations overlaid on educational research settings by their own experiences from the experiences of others. In consideration of the ways that a researcher might begin to identify and examine their own biases, a good starting point is Sensoy and DiAngelo ( 2017 ). In their book Is Everyone Really Equal: An Introduction to Key Concepts in Social Justice Education , the authors guide the reader through an approachable exploration of concepts such as power, oppression, prejudice, discrimination, privilege, and social construction. Each of these concepts is vital for understanding researcher biases and how they influence interpretations in the field. In general, this examination process is referred to in the field as reflexivity, or “critical reflection on how researcher, research participants, setting, and research procedures interact with and influence each other” (Glesne, 2016 , p. 145). Pillow ( 2003 ) pointed out that this reflective process does not absolve the researcher of their own biases, yet has important ramifications for the analysis and findings.

Those who have trained and served as educators may have particular insight to offer in the field of educational research. They may understand the field in more depth, having recently experienced the nuance and pressures of policy. To those who say that prior experience in the field may bias the investigation—it does. However, all researchers are biased in that they experience the world in a particular manner and ascribe specific cultural and social meanings to settings and events. It is also necessary to acknowledge here that effective use of this depth of understanding for qualitative observation does not come without caution.

Prior to entering the field, researchers may make preliminary decisions about their level of involvement, participation, and immersion. While older iterations of ethnographic methodology encouraged the observer to participate as little as possible, this can hinder the researcher’s ability to truly understand indigenous meanings of the social situation being observed. Certainly, the lesser-involved researcher will have greater opportunity to record copious notes. However, simply being present in the setting does have an effect on participants and may alter the way that they act or interact. Furthermore, researchers need not see the roles of participant and researcher as two poles. Rather, it is useful to think of these as two ends of a continuum, where the researcher(s’) role is never static.

While research ethics are not the primary focus of this article, it would not be appropriate to advocate for observation without mentioning that participants’ rights and confidentiality should be considered at every step of the process. Prior to entering the observation setting, the researcher must obtain approval from an Institutional Review Board (IRB). This is particularly important for research in schools, where participants may be minors and parental consent for participation may be required. Once approval is granted, the researcher should obtain consent from participants and provide a disclosure of nature of the study and time requirements for engaging in the study. Additionally, participants should be reminded that they can opt out of the study at any time. The IRB will also provide explicit guidelines on how all sensitive or identifiable data should be stored to protect participants’ identity.

Another key decision to make prior to entering the field is how field notes will be recorded. While notes can certainly be recorded on paper, or using a word-processing program on a laptop, pervasive use of personal digital technology (smartphones, tablets, etc.) has transformed the available options for documenting the field. As long as one has received approval for photo or video documentation from IRB, digital photography is instantaneous and can help document the research setting in greater detail. Digital videos can record activities and interactions such that the researcher can return to these when expanding field notes for further verification or perspective. Aside from simple dialogue, voice recorders can also record soundscapes , a growing area of qualitative research analysis (Gershon, 2013 ). There are also a number of app-based note-taking and qualitative-analysis programs helpful for observational research, including: Atlas.ti Mobile, Evernote, EverClip, MAXApp (corollary to MAXQDA), and Indeemo. Additionally, Google Could now offers a free speech-to-text function that can capture dialogue in more detail than one might be able to do on paper or by typing.

The choice of note-taking platform should take into account participants’ wishes, as well as the needs inherent to the setting. This decision is not just a simple question of what will work best for the researcher and their research product. Returning to the prior discussion of educator evaluation, teachers may associate note-taking—on paper or electronically—with recording judgement. When I have mentored student teachers, they have expressed that the tapping sound produced by typing on a laptop can increase their anxiety exponentially. While these considerations may sound superficial, the comfort level of participants is of utmost importance for the researcher in establishing themselves as collegial, and not intrusive. In fact, I have found it to be useful to ask a classroom teacher how they would prefer for me to record my observations. Regardless of their choice, I always assure them that I am “documenting” the events taking place, and not recording judgement.

Before moving on, it is worth noting that any prior-to-field decision-making may shift and evolve throughout the process of the research engagement. Qualitative research, by nature, seeks to understand meaning from the perspective of the actors in a particular context. Thus, the researcher must be willing to follow threads of understanding or thought, even if they are unexpected. For example, one may plan for low participation (Spradley, 1980 ) in the setting, but one day during the field visit the teacher may invite the researcher to lead a group of students through a math activity. In the interest of building rapport and trust with the participants, it may be necessary to move to a higher level of participation in response to this invitation. This will be discussed in further detail relating to the in-field domain. Emerson et al. ( 2011 ) stated that a good participant observer must be both “sensitive and perceptive about how they are seen by others” (p. 4). If the participants see the researcher as detached, unhelpful, or otherwise standoffish, this can affect their level of comfort and shift the insights they choose to share. Changes in the researcher’s level of participation should be recorded in field notes, and do not negate the reliability of eventual findings. In fact, participants may share additional insights with researchers who show interest in their perspectives, actions, and thoughts.

This section details two major considerations for researcher(s) embarking upon in-field observations: What to look for, and how to record what is seen. This is obviously oversimplified, but these two considerations will help to organize the process of collecting qualitative data via observation. These decisions can be made by an individual researcher or by research teams working together to investigate a particular setting or phenomenon.

What Should the Researcher Look For?

The first thing a novice researcher often asks about observation in the field is “What should I be looking for?” This question is loaded, and takes some time to unpack. While there may be something that the researcher hopes will happen, it is important to focus explicitly on what does happen, and how it happens. One of the first skills that a participant observer must begin to hone is explicit awareness of a situation (Spradley, 1980 ). This awareness can be compared to that of a wide-angle camera lens that takes in as much as possible. The goal, Spradley stated, is to overcome the “selective inattention” most people employ to conduct daily tasks and interactions (p. 55). This explicit awareness is not solely directed outward. Spradley also noted that the researcher must increase their introspectiveness so that they are better able to see and reflect upon the cultural frames and meanings associated with that which is observed.

Using the metaphor of a wide-angle lens, one common way to begin observation is through descriptive observation . In this case, the researcher approaches the observation with very general questions in mind. For example: “What is happening here?” or “What is going on?” These broad, open questions allow for the researcher to see and feel the setting as it is, without overlaying a priori meanings or assumptions.

Table 1. Spradley’s Descriptive Question Matrix

Source: . Spradley ( 1980 , pp. 82–83).

Spradley ( 1980 ) outlined a “Grand Tour” as a procedure for descriptive observation. In this overview, the researcher would take note of various facets of the setting and participants including:

The first three facets are presented in bold (author’s emphasis) because these three form a meaningful starting point for any observation, and the remaining six provide additional nuance. A diagram can be useful for illustrating the set-up of the space, mapping objects as well as actors. After examining each of these facets of the setting, Spradley recommended creating a descriptive question matrix wherein the researcher integrates observations from two or more of the facets to examine how they might interact. For example, consider how a student who is disabled might interact with a space that is not accessible for mobility. More detail is provided in Table 1 .

Emerson et al. ( 2011 ) also advocated for a wide-angle lens and prioritized the senses in helping to establish initial impressions. They expanded on the facets listed by Spradley, encouraging the researcher to consider physical space and environment in terms of characteristics such as size, space, noise, and layout. It terms of actors in a setting, they also suggested observing such characteristics as perceived race and gender, dress, comportment, and proximity to other actors. Moving beyond these facets, Emerson et al. also advocate that the researcher ask the question “What is significant or unexpected?” in the field. In other words, what seems out of place or out of the expected flow? Such unexpected moments are often of the most interest, and also represent some of the most significant cultural learning for the researcher. For instance, do the actors in the field react as though the same event is unexpected? If not, the researcher will need to examine the event, activities preceding the event, and those following the event to work to understand the significance. It is also important to register one’s own feelings, as the researcher, when observing in the field. Then, in working to understand one’s own reactions, feelings, and biases in comparison to those in the field, one may reveal cultural meanings unique to the context. It is important to note that the researcher should not take their own feelings as findings. Rather, they should move beyond their own reactions toward an analysis of what those in the setting may find significant (Emerson et al., 2011 ).

Focused observation takes place after the researcher has been in the field for some time, and serves to limit the inquiry in a meaningful manner. Whereas in descriptive observation, the research questions were general, in focused observation the researcher engages more structural questions (Spradley, 1980 ). For example: What are all the ways that a teacher asks a student to focus on their work? Focused observations may be conducted as surface or in-depth investigations. According to Spradley, surface investigations examine a number of cultural domains in some depth. In-depth observations are just that, observations where the researcher selects one domain and examines it thoroughly. These cultural domains may be selected based on personal interest, suggestion by informant, theoretical interest, or other strategic reasoning (Spradley, 1980 ). Additionally, this can lead the researcher to a potential taxonomy of events or codes occurring at the site ( selective observation ).

While Spradley’s approach can be useful and meaningful, there is also room to hone the initial general research question of “What is happening here?” to a more structured prompt that does not demand taxonomic reduction. An example of such a prompt engages the significant or unexpected events described by Emerson et al. ( 2011 ). In this case, the researcher might choose to further examine a particular event or occurrence, asking the questions: When this event happens, how does it happen? What else is happening? What changes? This way, the researcher is not limited to types of interaction, but can also consider the means by which these interactions take place and the dynamics that are set into motion.

Recording Field Notes

Field notes are the first phase of documenting happenings as data via observation—a method of inscription or textualization which later serves as a basis for iterative analysis. Further, according to Emerson et al., “Field notes are distinctively a method for capturing and preserving insights and understandings” ( 2011 , p. 14). There is no best way to record field notes, and none approaches a truly objective accounting of the events that occurred. One observer may choose to record significant events or key phrases that another observer does not choose to record. Thus, when conducting research in teams, it is useful to cross-check notes with others who observed the same events. This can be done in formal calibration meetings or informal conversations post-observation. Cross-checking can also be performed as a type of member check with participants, where the researcher might ask if anything was missed. Subjectivity is always implicated, since each observer filters events through their own cultural meanings and understanding of the social world. Yet, researchers observing in social settings are still encouraged to record what they see as concretely as possible. Taking a step back, researchers must decide the appropriate method for recording notes in the field. In the moment, researchers will need some method to record jottings, which are “a brief written record of events and impressions captured in key words and phrases” (Emerson et al., 2011 , p. 29). These quickly written or typed fragments are used to help the researcher as they later create detailed expanded field notes.

A researcher may choose to take notes on paper or another electronic device. When permission is appropriately obtained, the researcher may also create video or audio recordings of the setting. Even when a recording is made, the researcher should still take jottings when possible as a source for both back up and further detail. The choice of paper or electronic device should be made based on the setting and the researcher’s level of participation in the field. In any case, the method used should be as unobtrusive as possible and should not disturb the events taking place. The researcher may choose to take jottings down openly—so that participants can see them writing or typing—or in a hidden manner (Emerson et al., 2011 ). The decision of how to record jottings in the field is also dependent on a number of other factors, including the nature of the research questions, the skill of the researcher, the mobility required by the setting, availability of power or Internet, and the language of the researcher as compared to the participants.

As events in a research setting unfold, the researcher should take down short notes in order to later remember the events when assembling expanded field notes. These jottings may be fragments of interactions, keywords, phrases, or verbatim quotes (when possible). For example:

Music Education Class Participants: 1 Instructor, 8 Students (college-aged), 1 researcher 2:15 p.m . Instructor (Dr. Hart) tells class they are making a chart about assumptions Hope: Learning takes place in a building Hart: So, learning should look a certain way Hope: No! Not what I meant Hart says translating to fit in chart Hope: No, no! (shakes head and looks at me) Me: I think she is saying that learning could happen outdoors, or at home . Hope: Yes!! Hart writes “Learning should look a certain way” on chart, ignoring our protestations Hope frowns scrunches eyebrows together. Looks down at phone . 1

Jottings may also consist of drawings and diagrams that document the space. Jottings should always show time and date, and it is useful to check the clock and record the time every 5–10 minutes or so throughout the observation. This will help later, when considering and analyzing the pace of events. The question of when a researcher should take down jottings is also worth consideration. If the researcher is involved in a conversation, or is an otherwise active participant in the situation or events, they should prioritize this interaction over note-taking. Tact and rapport are vitally important to qualitative observation, and sometimes note-taking may come across as if the researcher is rude or not listening. Wait for breaks or lulls in the conversation to record jottings. If your participation requires that you move around a room or other space, it may be best to use a small notebook or electronic tablet that is easily carried.

Our inclination as educational researchers is often to provide evaluative feedback on the performance of the educator being observed. When recording field notes, it is important to resist this urge. Jottings should include as much detail as possible, using descriptive and concrete language. Emerson et al. ( 2011 ) suggest the following recommendations on how one might document what is observed. First, one should describe all key components of the setting, using concrete sensory details that would help a third-party reader gain a reasonable vision of the actors and events. Rather than stating that a participant looked defeated, for instance, it would be more appropriate to record the details of their bearing that lead you to believe this is the case. In this example, the researcher might record: The participant’s eyes were cast down toward the ground and their shoulders were hunched forward . Additionally, researchers should avoid characterizing events through generalization or summary in field notes, since these represent a form of analysis or judgement. The purpose in avoiding generalization at this phase is to leave the possibility open for alternative interpretation once the full data set is established. It is possible that later events may clarify or alter the meaning of a particular social act.

Feelings and emotions will always be present in a research setting, and should be acknowledged and recorded. Emerson et al. ( 2011 ) noted that it can be informative to describe actors’ emotional expressions and responses to the events occurring throughout the observation. They also recommend that the researcher record their own impressions and feelings about the events. Having recorded these feelings and responses, the researcher can compare their own reactions to those of the participants in order better to understand the cultural and social meanings unique to that setting and those actors. However, the impressions and feelings of the researcher do represent a form of analysis, and should be specifically recorded as such.

In field notes, the researcher should differentiate between the types of information they record so that it will be recognizable when they return to the jottings to expand them into completed field notes. Concrete descriptions of sensory details and verbatim interactions should be recorded in one manner or place, and impressions or personal feelings should be recorded differently. For example, some researchers choose to separate these types of jottings into two columns in their notebook before entering the field. Others use the comment function in word-processing software to separate analytic commentary from notes. These parallel notes can also be recorded using the advanced functionality of apps such as Evernote and MAXApp.

Both types of recording are important, and serve to help the researcher remember what they were seeing and feeling while in the field. These reminders will serve as recall prompts when the researcher goes to expand their field notes into full notes, and later when they use those notes to create analytic memos.

Post-Field or Inter-Field

This domain is dually named to highlight the fact that qualitative participant observers should complete multiple observations over a significant length of time. A single observation is not sufficient for allowing the researcher to understand contextual cultural meanings, and most qualitative methodologists encourage in-depth, long-term engagement in the field. Thus, the inter-field domain name refers to the idea that researchers will likely need to enter and exit the field a number of times. Expanded field notes, notes-on-notes, and memos should be created in between visits to help focus the study. At some point, examination of field notes and other qualitative data (i.e., interviews, documents) will start to seem redundant. In other words, the researcher(s) will begin to see the same phenomena occurring, with nothing new arising in successive observations. In other words, they have reached the point of data saturation (Glesne, 2016 ). There is not a set number of observations, or a pre determined length of field observation, necessary for rigorous qualitative observation. Rather, the researcher(s) must determine this point of theoretical saturation for themselves.

Expanded Field Notes

The process of observation does not stop once the researcher leaves the field. One cannot possibly record every detail of the observation in the moment, so jottings should be re-read and expanded after the fact. In order to preserve detail with the freshest memory, a number of sources recommend that the researcher read over jottings and expand them into fully realized field notes within 24 to 48 hours. This expansion process involves recreating a record of the events and interactions observed in full, rich detail (Geertz, 1973 ). In the field, the researcher may not have had time to record these happenings fully, but the jottings serve to jog the memory so that the researcher can later recall the field more fully. Expanded field notes may take the form of prose (paragraphs), a script of dialogue, figures, or diagrams. Time notations from jottings should be preserved in expanded field notes, and researcher asides or commentaries should also be kept separate from concrete sensory observations. Here is an example of field notes expanded from the jottings provided in the section “ Recording Field Notes ”:

Music Education Class Participants: 1 Instructor, 8 Students (college-aged), 1 researcher 2:15 p.m . The instructor, Dr. Hart asks the students what assumptions we make about learning. Hope, a white woman, raises her hand and says, “We assume that learning takes place in a building.” I feel that I understand what she’s saying and nod in agreement. Though I’ve nodded my head somewhat unconsciously, I notice that Hope has seen me agreeing with her. Dr. Hart says: “Yes, we assume that a school should look a certain way.” She says “No, that’s not what I mean!” and looks at me. Dr. Hart says that he’s going to translate her meaning a bit so that it will fit the chart they’ve been creating, and that, basically, it’s the same meaning anyway [paraphrased]. Hope looks disconcerted, with her eyebrows scrunched together. She is also shaking her head to left and right (as if to disagree) and frowning. She tries to reiterate her point, [paraphrase] “I am saying that learning experiences don’t need to happen in a building.” She again looks at me and I feel compelled to speak up. I say, “I think I know what you’re saying, you mean that you don’t have to be inside a school to learn, that you can learn outdoors, and at home with your family.” She says, “Yes! That’s what I mean!” Dr. Hart says “Oh, Ok!” but then asks John to write-up his original statement of “Schools look a certain way.” Hope slouches in her chair and rounds her shoulders, picks up her phone and begins to type .

In a first visit to a setting, it may be useful to assign pseudonyms or codes to participants to help with de-identifying participant data throughout the field notes. In addition to assigning such codes, the researcher should keep a code book or identifying document, preferably stored separately.

Expanded field notes should include as much detail as possible. Emerson et al. ( 2011 ) elaborated on this descriptive writing strategy that “calls for concrete details rather than abstract generalizations, for sensory imagery rather than evaluative labels, and for immediacy through details presented at close range” (p. 58). By necessity, this means that field notes will be long and labor intensive, with the added pressure that the researcher should record them as soon as possible to avoid losing detail. It is important not to skip this step of the process. It is easy to forget the particularities of the social field over time, and expanded field notes preserve complexity and richness of the data. Additionally, expanded field notes are vital when collaborating with other researchers, as they allow the others to experience a full description of events even if they were not present.

Notes-on-Notes

While writing expanded field notes, the researcher will inevitably begin to develop preliminary commentary and impressions. These impressions should not be considered findings when they arise from a single observation. Rather, they should be noted clearly so that the researcher may confirm or disconfirm their impressions in subsequent observations, interviews, or document analysis. To do this, researchers should create a short memo containing notes-on-notes for each field observation. Such a memo should move beyond impressions and begin to comment or theorize on what is observed. That said, notes-on-notes should not be considered findings until they have been compared to observations and triangulated with other types of data. Notes-on-notes can help to focus and narrow the research questions, and aid in moving the research project from descriptive to focused observation. Additionally, they may help in generating interview guides for focus groups or individual interviews where preliminary findings can be confirmed or ruled out. This is also a place for the researcher to record their own feelings in more detail. For example, if the researcher is experiencing frustration because they are not able to observe interactions between particular participants, they may note this frustration in the notes-on-notes memo. Notes-on-notes need not be lengthy; sometimes a paragraph or two is enough to express whatever should be noted for follow-up or later confirmation.

The process of qualitative observation is cyclical. Expanded field notes, along with the corresponding notes-on-notes, will most often direct the researcher back to the field to gather further information. The requisite information may represent a broadening of perspective, or a narrowing, depending on the setting and participants. Experienced researchers often begin the analytic process immediately upon entering a field of study, parsing out codes and themes in the data that they can further clarify (and sometimes quantify) as the study progresses. Analysis and coding are not included in this article, though the authors cited herein offer great insight on that topic.

Encouragements

One of the most encouraging aspects of observational research in educational settings is the opportunity to build partnerships and rapport with those who are currently working in the field. Very often there is a perceived divide between academics and P–12 teachers who work in classrooms. Again, the importance of developing rapport, basic trust, as well as collegiality cannot be overstated. Meaningful partnerships across these perceived divides are one of the most productive potential sites for educational change and reform to occur. These are the sites where, together, we might exert the most influence over policy, equity, and curriculum.

Rapport building should be genuine. It is not advisable to fake an interest in a site of study or associated stakeholders simply to benefits one’s own research agenda. Such an approach echoes the exploitative measures of early ethnographers, and is considered highly unethical. Thus, a skill that we have not yet explored regarding qualitative observation in educational settings is the ability of the researcher to seek and build meaningful, ethical relationships with those they study. The conundrum here then becomes that when we establish real relationships with participants, our subjectivity is engaged on yet another level. However, the benefits largely outweigh any potential pitfalls.

Moving beyond the stereotypical idea of one observer recording the events of a classroom, another opportunity is that of participatory action research. By engaging stakeholders in the design and execution of the research, the research may address issues that are pressing or of great importance to participants. This serves to generate educational change regarding issues that are of urgent concern to those engaged in the field on a day-to-day basis. A particular arena of possibility here involves engaging students in research.

Final Thoughts

To summarize, observation in educational settings is a detailed and rigorous process. This process involves self-reflection, attention to concrete and sensory details, and, most important, the ability to build rapport with participants. This article has detailed one methodological perspective and approach toward qualitative observation in educational settings. This approach can be used in both traditional and nontraditional educational settings, provided that the researcher maintains flexibility and an introspective approach to observation and, later, analysis. Cornerstone observational studies such as Ladson-Billings’s ( 2009 ) The Dreamkeepers , Lareau’s ( 2011 ) Unequal Childhoods , and Willis’s ( 2017 ) Learning to Labour provide useful examples of the insights that can be gleaned from observation.

The reflective “move between” one’s own subjectivity and that of participants is truly the generative site of observational research (Denzin, 2017 ). When done well, this moving in between can reveal similarities and differences, and can help people to take the time to understand diverse experiences, rather than approaching them from a stance of judgement and evaluation. Truly, observational research is a place where we have the opportunity to focus deeply on the experience of others. This is not just to walk in their shoes, but to understand the forces and meanings that influence their daily lives. These are some of the most exciting moments of potential change that qualitative research has to offer.

Methodological Texts

• Emerson, R. M. , Fretz, R. I. , & Shaw, L. L. (2011). Writing ethnographic fieldnotes (2nd ed.). Chicago, IL: University of Chicago Press.
• Spradley, J. P. (1980). Participant observation . New York, NY: Holt, Rhinehart, and Winston.

Representative Studies

• Ladson-Billings, G. (2009). The dreamkeepers: Successful teachers of African American children . San Francisco, CA: John Wiley & Sons.
• Lareau, A. (2011). Unequal childhoods: Class, race, and family life . Berkeley: University of California Press.
• Willis, P. (2017). Learning to labour: How working class kids get working class jobs . New York, NY: Routledge.
• Angrosino, M. , & Rosenberg, J. (2011). Observations on observation: Continuities and challenges. In N. K. Denzin & Y. S. Lincoln (Eds.), The SAGE handbook of qualitative research (4th ed., pp. 467–478). Thousand Oaks, CA: SAGE.
• Denzin, N. K. (2017). The research act: A theoretical introduction to sociological methods . New York, NY: Routledge.
• Dewey, J. (1938). Experience and education . Indianapolis, IN: Kappa Delta Pi.
• Geertz, C. (1973). Thick description: Toward an interpretive theory of culture. The interpretation of cultures (pp. 3–30). New York, NY: Basic Books.
• Gershon, W. S. (2013). Vibrational affect: Sound theory and practice in qualitative research. Cultural Studies?↔Critical Methodologies, 13 (4), 257–262.
• Glesne, C. (2016). Becoming qualitative researchers: An introduction (5th ed.) New York, NY: Pearson.
• Lave, J. , & Wenger, E. (1991). Situated learning: Legitimate peripheral participation . Cambridge, U.K.: Cambridge University Press.
• Noblit, G. W. , Flores, S. Y. , & Murillo, E. G. (2004). Postcritical ethnography: Reinscribing critique . Cresskill, NJ: Hampton Press.
• Pillow, W. (2003). Confession, catharsis, or cure? Rethinking the uses of reflexivity as methodological power in qualitative research. International Journal of Qualitative Studies in Education , 16 (2), 175–196.
• Sensoy, O. , & DiAngelo, R. (2017). Is everyone really equal? An introduction to key concepts in social justice education . New York, NY: Teachers College Press.

1. Expanded field notes from these jottings are included in the section “ Expanded Field Notes .”

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Qualitative research essentials for medical education

Sayra m cristancho.

1 Department of Surgery and Faculty of Education, Schulich School of Medicine and Dentistry, Western University, Canada

2 Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, Canada

Mark Goldszmidt

3 Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Canada

Lorelei Lingard

Christopher watling.

4 Postgraduate Medical Education, Schulich School of Medicine and Dentistry, Western University, Canada

This paper offers a selective overview of the increasingly popular paradigm of qualitative research. We consider the nature of qualitative research questions, describe common methodologies, discuss data collection and analysis methods, highlight recent innovations and outline principles of rigour. Examples are provided from our own and other authors’ published qualitative medical education research. Our aim is to provide both an introduction to some qualitative essentials for readers who are new to this research paradigm and a resource for more experienced readers, such as those who are currently engaged in a qualitative research project and would like a better sense of where their work sits within the broader paradigm.

INTRODUCTION

Are you a medical education researcher engaged in qualitative research and wondering if you are on the right track? Are you contemplating a qualitative research project and not sure how to get started? Are you reading qualitative manuscripts and making guesses about their quality? This paper offers a selective overview of the increasingly popular domain of qualitative research. We consider the nature of qualitative research questions, describe common methodologies, discuss data collection and analysis methods, highlight recent innovations, and outline principles of rigour. The aim of this paper is to educate newcomers through introductory explanations while stimulating more experienced researchers through attention to current innovations and emerging debates.

WHAT IS QUALITATIVE RESEARCH?

Qualitative research is naturalistic; the natural setting – not the laboratory – is the source of data. Researchers go where the action is; to collect data, they may talk with individuals or groups, observe their behaviour and their setting, or examine their artefacts.( 1 ) As defined by leading qualitative researchers Denzin and Lincoln, qualitative research studies social and human phenomena in their natural settings, attempting to make sense of or interpret these phenomena in terms of the meanings participants bring to them.( 2 )

Because qualitative research situates itself firmly in the world it studies, it cannot aim for generalisability. Its aim is to understand, rather than erase, the influence of context, culture and perspective. Good qualitative research produces descriptions, theory or conceptual understanding that may be usefully transferred to other contexts, but users of qualitative research must always carefully consider how the principles unearthed might unfold in their own distinct settings.

WHAT QUESTIONS ARE APPROPRIATE FOR QUALITATIVE RESEARCH?

Meaningful education research begins with compelling questions. Research methods translate curiosity into action, facilitating exploration of those questions. Methods must be chosen wisely; some questions lend themselves to certain methodological approaches and not to others.

In recent years, qualitative research methods have become increasingly prominent in medical education. The reason is simple: some of the most pressing questions in the field require qualitative approaches for meaningful answers to be found.

Qualitative research examines how things unfold in real world settings. While quantitative research approaches that dominate the basic and clinical sciences focus on testing hypotheses, qualitative research explores processes, phenomena and settings ( Box 1 ). For example, the question “Does the introduction of a mandatory rural clerkship increase the rate of graduates choosing to practise in rural areas? ” demands a quantitative approach. The question embeds a hypothesis – that a mandatory rural clerkship will increase the rate of graduates choosing to practise in rural areas – and so the research method must test whether or not that hypothesis is true. But the question “ How do graduating doctors make choices about their practice location? ” demands a qualitative approach. The question does not embed a hypothesis; rather, it explores a process of decision-making.

Qualitative research questions:

Many issues in medical education could be examined from either a quantitative or qualitative approach; one approach is not inherently superior. The questions that drive the research as well as the products that derive from it are, however, fundamentally different. Consider two approaches to studying the issue of online learning. A quantitative researcher might ask, “ What is the effect of an online learning module on medical students’ end-of-semester OSCE [objective structured clinical examination] scores? ”, while a qualitative researcher might ask “ How do medical students make choices about using online learning resources? ” Although the underlying issue is the same – the phenomenon of online learning in medical school – the studies launched by these questions and the products of those studies will look very different.

WHAT ARE QUALITATIVE METHODOLOGIES AND WHY ARE THEY IMPORTANT?

Executing rigorous qualitative research requires an understanding of methodology – the principles and procedures that define how the research is approached. Far from being monolithic, the world of qualitative research encompasses a range of methodologies, each with distinctive approaches to inquiry and characteristic products. Methodologies are informed by the researcher’s epistemology – that is, their theory of knowledge. Epistemology shapes how researchers approach the researcher’s role, the participant-researcher relationship, forms of data, analytical procedures, measures of research quality, and representation of results in analysis and writing.( 3 )

In medical education, published qualitative work includes methodologies such as grounded theory, phenomenology, ethnography, case study, discourse analysis, participatory action research and narrative inquiry, although the list is growing as the field embraces researchers with diverse disciplinary backgrounds. This paper neither seeks to exhaustively catalogue all qualitative methodologies nor comprehensively describe any of them. Rather, we present a subset, with the aim of familiarising readers with its fundamental goals. In this article, we briefly introduce four common methodologies used in medical education research ( Box 2 ). Using one topic, professionalism, we illustrate how each methodology might be applied and how its particular features would yield different insights into that topic.

Common qualitative methodologies in medical education:

Grounded theory

Arguably the most frequently used methodology in medical education research today, grounded theory seeks to understand social processes. Core features of grounded theory include iteration, in which data collection and analysis take place concurrently with each informing the other, and a reliance on theoretical sampling to explore patterns as they emerge.( 4 ) While many different schools of grounded theory exist, they share the aim of generating theory that is grounded in empirical data.( 5 ) Theory, in this type of research, can be thought of as a conceptual understanding of the process under study, ideally affording a useful explanatory power. For example, if one were interested in the development of professionalism among senior medical students during clerkship, one might design a grounded theory study around the following question: “ What aspects of clerkship support or challenge professional behaviour among senior medical students? ” The resulting product would be a conceptual rendering of how senior medical students navigate thorny professionalism issues, which might in turn be useful to curriculum planners.

Phenomenology

This methodology begins with a phenomenon of interest and seeks to understand the subjective lived experience of that phenomenon.( 6 ) Core features of phenomenology include a focus on the individual experience (typically pursued through in-depth interviewing and/or examinations of personal narratives), inductive analysis and a particular attention to reflexivity.( 7 ) Phenomenological researchers typically enumerate their own ideas and preconceptions about the phenomenon under study and consider how these perceptions might influence their interpretation of data.( 8 ) A phenomenological study around professionalism in senior medical students, for example, might involve interviewing several students who have experienced a professionalism lapse about that experience. The resulting product might be an enhanced understanding of the emotional, social and professional implications of this phenomenon from the student’s perspective, which might in turn inform wellness or resilience strategies.

Ethnography

Ethnography aims to understand people in their contexts, exploring the influence of culture, social organisation and shared values on how people behave – their routines and rituals. Core features of ethnography include reliance on direct observation as a data source, and the use of sustained immersive engagement in the setting of interest in order to understand social dynamics from within.( 9 , 10 ) An ethnographic approach to studying how professional attitudes develop in senior medical students might gather data through observations of ward rounds, team meetings and clinical teaching sessions over a period of time. The resulting product – called an ethnography – would describe how professional values are socialised in junior learners in clinical settings, which could assist educators in understanding how the clinical experiences they programme for their learners are influencing their professional development.

Case study research seeks an in-depth understanding of an individual case (or series of cases) that is illustrative of a problem of interest. Like clinical case studies, the goal is not generalisation but a thorough exploration of one case, in hopes that the fruits of that exploration may prove useful to others facing similar problems. Core features of case study research include: thoughtful bounding or defining of the scope of the case at the outset; collection of data from multiple sources, ranging from interviews with key players to written material in policy documents and websites; and careful attention to both the phenomenon of interest and its particular context.( 11 ) A specific professionalism challenge involving medical students could provide fodder for a productive case study. For example, if a medical school had to discipline several students for inappropriately sharing personal patient information on social media, a case study might be undertaken. The ‘case’ would be the incident of social media misuse at a single medical school, and the data gathered might include interviews with students and school officials, examination of relevant policy documents, examination of news media coverage of the event, and so on. The product of this research might trigger similar institutions to carefully consider how they might approach – or prevent – a similar problem.

As these four examples illustrate, methodology is the backbone of qualitative research. Methodology shapes the way the research question is asked, defines the characteristics of an appropriate sample, and governs the way the data collection and analysis procedures are organised. The researcher’s role is also distinctive in each methodology; for instance, in constructivist grounded theory, the researcher actively constructs the theory,( 12 ) while in phenomenology, the researcher attempts to manage his or her ‘pre-understandings’ through either bracketing them off or being reflexive about them.( 13 ) Interested readers may wish to consult the reference list for recently published examples of research using grounded theory,( 14 ) phenomenology,( 15 ) ethnography( 16 ) and case study approaches( 17 ) in order to appreciate how researchers deploy these methodologies to tackle compelling questions in contemporary medical education.

WHAT ARE SOME COMMON METHODS OF QUALITATIVE DATA COLLECTION?

The most common methods of qualitative data collection are interview – talking to participants about their experiences relevant to the research question, and observation – watching participants while they are having those experiences. Depending on the research questions explored, a research design might combine interviews and observations.

Interview-based methods

Interviews are typically used for situations where a guided conversation with relevant participants can help provide insight into their lived experiences and how they view and interpret the world around them. Interviews are also particularly useful for exploring past events that cannot be replicated or phenomena where direct observation is impossible or unfeasible.

Participants may be interviewed individually or in groups. Focus group interviews are used when the researcher’s topic of interest is best explored through a guided, interactive discussion among the participants themselves. Therefore, when focus groups are used, the sample is conceptualised at the level of the group – three focus groups of five people constitutes a sample of three interactive discussions, not 15 individual participants. Because they centre on the group discussion and dynamic, focus groups are less well-suited for topics that are sensitive, highly personal or perceived to be culturally inappropriate to discuss publicly.( 18 )

Unlike quantitative interviews, where a set of structured, closed-ended (e.g. yes/no) questions are asked in the same order with the same wording every time, qualitative interviews typically involve a semi-structured design where a list of open-ended questions serves to guide, but not constrain, the interview. Therefore, at the interviewer’s discretion, the questions and their sequence may vary from interview to interview. This judgement is made based on both the interviewer’s understanding of the phenomenon under exploration and the emerging dynamic between the interviewer and participant.

The primary goal of a qualitative interview is to get the participants to think carefully about their experience and relate it to the interviewer with rich detail. Getting good data from interviewing relies on using creative strategies to avoid the common trap of getting politically correct answers – often called ‘cover stories’– or answers that are superficial rather than deep and reflective.( 19 ) A common design error occurs when researchers are overly explicit in their questioning, such as asking “ What are the top five criteria you use to assess student professionalism? ” A better approach involves questions that ask participants to describe what they do in practice, with follow-up probes that extend beyond the specific experience described. For example, starting with “ Tell me about a recent experience where you assessed a student’s professionalism ” allows the participant to relay an experience, to which the interviewer can respond with probes such as “ What was tricky about that? ” or “ How typical is that experience? ”

Another common strategy for prompting participants to engage in rich reflection on their experience and perceptions is to use vignettes as discussion prompts. Vignettes are often artificial scenarios presented to participants to read or watch on video, about which they are then asked probing questions.( 20 ) However, vignettes can also be used to recreate an authentic situation for the participant to engage with.( 21 ) For instance, in one interview study, we presented participants with a vignette in the form of the research assistant reading aloud a standard patient admission presentation that the interviewees would typically hear from their students on morning ward rounds. We then asked the participants to interact with the interviewer as though he or she was a student who had presented this case on morning rounds. Recreating this interaction in the context of the interview served as a stepping stone to questions such as “ Why did you ask the student ‘x’? ” and “ How would your approach have differed with a different student presenter, e.g. a stronger or weaker one? ”

Direct observation

Observation-based research can involve a wide spectrum of activities, ranging from brief observations of specific tasks (e.g. handover, preoperative team briefings) to prolonged field observations such as those seen in ethnography. When used effectively, direct observation can provide the researcher with powerful insight into the routines of a group.

Getting good data from observational research relies on several key components. First, it is essential to define the scope of the project upfront: limited budgets, the massive amount of detail to be attended to, and the ability of any individual or group of observers to attend to these make this essential. Good observational research therefore relies on collaboration between knowledgeable insiders and those with both methodological and theoretical expertise. Sampling demands particular attention; an initial purposive sampling approach is often followed by more targeted, theoretical sampling that is guided by the developing analysis. Observational research also typically involves a mix of data sources, including observational field notes, field interviews and document analysis. Audio and video may be helpful when the studied phenomena is particularly complex or nuances of interaction may be missed without the ability to review data, or when precision of verbal and nonverbal interactions is necessary to answer the research question.( 22 )

Field notes are often the dominant data source used for subsequent analysis in observational research. As such, they must be created with great diligence. Usually researchers will jot down brief notes during an observation and afterwards elaborate in as much detail as they can recall. Field notes have an important reflective component. In addition to the factual descriptions, researchers include comments about their feelings, reactions, hunches, speculations and working theories or interpretations. The content of field notes, therefore, usually includes: descriptions of the setting, people and activities; direct quotations or paraphrasing of what people said; and the observer’s reflections.( 23 ) Field notes are time-consuming when done well – even a single hour of observation can lead to several hours of reflective documentation.

An important aspect to consider when designing observation-based research is the ‘observer effect’, also known as the Hawthorne effect, more recently reframed as ‘participant reactivity’ by health professions education researchers Paradis and Sutkin.( 24 ) The Hawthorne effect is conventionally defined as “ when observed participants act differently from how they would act if the observer were not present ”.( 25 ) Researchers have implemented a number of strategies to mitigate this effect, including prolonged embedding of the observer, efforts to ‘fit in’ through dress or comportment, and careful recording of explicit instances of the effect.( 24 ) However, Paradis and Sutkin found that instances of the Hawthorne effect, as conventionally defined, have never been described in qualitative research manuscripts in the health professions education field, perhaps because, as they speculate, healthcare workers and trainees are accustomed to being observed. Based on this, they argued that researchers should worry less about mitigating the Hawthorne effect and instead invest in interpersonal relationships at their study site to mitigate the effects of altered behaviour and draw on theory to make sense of participants’ altered behaviour.( 23 ) Combining interviewing and observation is also common in qualitative research ( Box 3 ).

Combining interviews and observations:

WHAT ARE THE COMMON METHODS OF QUALITATIVE DATA ANALYSIS?

Qualitative data almost invariably takes the form of text; an interview is turned into a transcript and an observation is rendered into a field note. Analysing these qualitative texts is about uncovering meaning, developing understanding and discovering insights relevant to the research question. Analysis is not separated from data collection in qualitative research, and begins with the first interview, the first observation or the first reading of a document. In fact, the iterative nature of data collection and analysis is a hallmark of qualitative research, because it allows the researcher’s emerging insights about the study phenomena to inform subsequent rounds of data collection ( Box 4 ).

The iterative process of analysis:

Data that has been analysed while being collected is both parsimonious and illuminating. However, this process can extend indefinitely. There will always be another person to interview or another observation to record. Deciding when to stop depends on both practical and theoretical concerns. Practical concerns include deadlines and funding. More importantly, the decision should be guided by the theoretical concern of sufficiency.( 26 ) Sufficiency occurs when new data does not produce new insights into the phenomenon, in other words, when you keep hearing and seeing the same things you have heard and seen before.

Qualitative data analysis is primarily inductive and comparative. The overall process of data analysis begins by identifying segments in the data that are responsive to the research question. The next step is to compare one segment with the next, looking for recurring patterns in the data set. During this step, the focus is on sorting the raw data into categories that progressively build a coherent description or explanation of the phenomenon under study. This process of identifying pieces of data and grouping them into categories is called coding.( 14 ) Once a tentative scheme of categories is derived, it is applied to new data to see whether those categories continue to exist or not, or whether new categories arise – this step determines whether sufficiency has been reached. The final step in the analysis is to think about how categories interrelate. At this point, the analysis moves to interpreting the meaning of these categories and their interrelations.( 12 )

The process for data analysis laid out in this section is a basic inductive and comparative analysis strategy that is suitable for analysing data for most interpretive qualitative research methodologies, including the four featured in this paper – phenomenology, grounded theory, ethnography and case study – as well as others such as narrative analysis and action research. While each methodology attends to specific procedures, they all share the use of this basic inductive/comparative strategy. Overall, analysis should be guided by methodology, but different analytical procedures can be creatively combined across methodologies, as long as this combining is explicit and intentional.( 27 )

WHAT ARE SOME CURRENT INNOVATIONS IN QUALITATIVE RESEARCH?

Understanding the complex factors that influence clinical practice and medical education is not an easy research task. Many important issues may be difficult for the insider to articulate during interviews and impossible for the outsider to ‘see’ during observation. Innovations to address these challenges include guided walks,( 28 ) photovoice( 29 ) and point-of-view filming.( 30 ) Our own research has drawn intensively on the innovation termed ‘rich pictures’ to explore the features and implications of complexity in medical education.( 31 ) In one study, we asked medical students to draw pictures of clinical cases that they found complex: an exciting case and a frustrating one.( 32 ) Participants were given 30–60 minutes on their own to reflect on the situation and draw their pictures. This was followed by an in-depth interview using the pictures as triggers to explore the phenomenon under study – in this case, students’ experiences of and responses to complexity during their training.

Such innovations hold great promise for qualitative research in medical education. For instance, rich pictures can reveal emotional and organisational dimensions of complex clinical experiences, which are less likely to be emphasised in participants’ traditional interview responses.( 33 ) Methodological innovations, however, bring new challenges: they can be time-intensive for participants and researchers; they require new analytical procedures to be developed; and they necessitate efforts to educate audiences about the rigour and credibility of unfamiliar approaches.

WHAT ARE THE PRINCIPLES OF RIGOUR IN QUALITATIVE RESEARCH?

Like quantitative research, qualitative research has principles of rigour that are used to judge the quality of the work.( 34 ) Here, we discuss principles that appear in most criteria for rigour in the field: reflexivity, adequacy, authenticity, trustworthiness and resonance ( Box 5 ).

Principles of rigour in qualitative research:

The main data collection tool in qualitative research is the researcher. We talk to participants, observe their practices and interpret their documents. Consequently, a critical feature of rigour in qualitative data collection is researcher reflexivity: the ability to consider our own orientations towards the studied phenomenon, acknowledge our assumptions and articulate regularly our impressions of the data.( 35 ) Only this way can we assure others that our subjectivity has been thoughtfully considered and afford them the ability to judge its influence on the work for themselves. Qualitative research does not seek to remove this subjectivity; it treats research perspective as unavoidable and enriching, not as a form of bias to purge.

Every qualitative dataset is an approximation of a complex phenomenon – no study can capture all dimensions and nuances of situated social experiences, such as medical students’ negotiations of professional dilemmas in the clinical workplace. Therefore, two other important criteria of rigour relate to the adequacy and authenticity of the sampled experiences. Did the research focus on the appropriate participants and/or situations? Was the size and scope of the sample adequate to represent the scope of the phenomenon?( 36 ) Was the data collected an authentic reflection of the phenomenon in question? Qualitative researchers should thoughtfully combine different perspectives, methods and data sources (a process called ‘triangulation’) to intensify the richness of their representation.( 37 ) We should endeavour to draw on data in our written reports such that we provide what sociologist Geertz has termed a sufficiently ‘thick’ description( 38 ) for readers to judge the authenticity of our portrayal of the studied phenomenon.

Qualitative analysis embraces subjectivity: what the researcher ‘sees’ in the data is a product both of what participants told or showed us and of what we were oriented to make of those stories and situations. To some degree, a rhetorician will always see rhetoric and a systems engineer will always see systems. To fulfil the rigour criteria of trustworthiness, qualitative analysis should also be systematic and held to a principle of trustworthiness, which dictates that we should clearly describe: (a) what was done by whom during the inductive, comparative analytical process; (b) how the perspectives of multiple coders were negotiated; (c) how and when theoretical lenses were brought to bear in the iterative process of data collection and analysis; and (d) how discrepant instances in the data – those that fell outside the dominant thematic patterns – were handled.

Finally, the ultimate measure of quality in qualitative research is the resonance of the final product to those who live the social experience under study.( 4 ) As qualitative researchers presenting our work at conferences, we know we have met this bar if our audiences laugh, nod or scowl at the right moments, and if their response at the end is “ You nailed it. That’s my world. But you’ve given me a new way to look at it ”. The situatedness of qualitative research means that its transferability to other contexts is always a matter of the listener/reader’s judgement, based on their consideration of the similarities and differences between the research context and their own. Thus, there is a necessity for qualitative research to sufficiently describe its context, so that consumers of the work have the necessary information to gauge transferability. Ultimately, though, transferability remains an open question, requiring further inquiry to explore the explanatory power of one study’s insights in a new setting.

WHAT ELSE IS THERE TO KNOW?

This overview of qualitative research in medical education is not exhaustive. We have been purposefully selective, discussing in depth some common methodologies and methods, and leaving aside others. We have also passed over important issues such as qualitative research ethics, sampling and writing. There is much, much more for readers to know! Our selectivity notwithstanding, we hope that this paper will provide an accessible introduction to some qualitative essentials for readers who are new to this research domain, and that it may serve as a useful resource for more experienced readers, particularly those who are doing a qualitative research project and would like a better sense of where their work sits within the broader field of qualitative approaches.

• Open access
• Published: 18 April 2024

Integrating training in evidence-based medicine and shared decision-making: a qualitative study of junior doctors and consultants

• Mary Simons   ORCID: orcid.org/0000-0001-9627-7861 1 , 4 ,
• Georgia Fisher   ORCID: orcid.org/0000-0002-7252-7800 1 ,
• Samantha Spanos   ORCID: orcid.org/0000-0003-3734-3907 1 ,
• Yvonne Zurynski   ORCID: orcid.org/0000-0001-7744-8717 1 ,
• Andrew Davidson   ORCID: orcid.org/0000-0001-8449-3727 2 ,
• Marcus Stoodley   ORCID: orcid.org/0000-0002-4207-8493 3 ,
• Frances Rapport   ORCID: orcid.org/0000-0002-4428-2826 1 &
• Louise A. Ellis   ORCID: orcid.org/0000-0001-6902-4578 1  

BMC Medical Education volume  24 , Article number:  418 ( 2024 ) Cite this article

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In the past, evidence-based medicine (EBM) and shared decision-making (SDM) have been taught separately in health sciences and medical education. However, recognition is increasing of the importance of EBM training that includes SDM, whereby practitioners incorporate all steps of EBM, including person-centered decision-making using SDM. However, there are few empirical investigations into the benefits of training that integrates EBM and SDM (EBM-SDM) for junior doctors, and their influencing factors. This study aimed to explore how integrated EBM-SDM training can influence junior doctors’ attitudes to and practice of EBM and SDM; to identify the barriers and facilitators associated with junior doctors’ EBM-SDM learning and practice; and to examine how supervising consultants’ attitudes and authority impact on junior doctors’ opportunities for EBM-SDM learning and practice.

We developed and ran a series of EBM-SDM courses for junior doctors within a private healthcare setting with protected time for educational activities. Using an emergent qualitative design, we first conducted pre- and post-course semi-structured interviews with 12 junior doctors and thematically analysed the influence of an EBM-SDM course on their attitudes and practice of both EBM and SDM, and the barriers and facilitators to the integrated learning and practice of EBM and SDM. Based on the responses of junior doctors, we then conducted interviews with ten of their supervising consultants and used a second thematic analysis to understand the influence of consultants on junior doctors’ EBM-SDM learning and practice.

Junior doctors appreciated EBM-SDM training that involved patient participation. After the training course, they intended to improve their skills in person-centered decision-making including SDM. However, junior doctors identified medical hierarchy, time factors, and lack of prior training as barriers to the learning and practice of EBM-SDM, whilst the private healthcare setting with protected learning time and supportive consultants were considered facilitators. Consultants had mixed attitudes towards EBM and SDM and varied perceptions of the role of junior doctors in either practice, both of which influenced the practice of junior doctors.

Conclusions

These findings suggested that future medical education and research should include training that integrates EBM and SDM that acknowledges the complex environment in which this training must be put into practice, and considers strategies to overcome barriers to the implementation of EBM-SDM learning in practice.

Peer Review reports

The practice of evidence-based medicine (EBM) requires clinicians to incorporate their own expertise, the best research evidence, and patient preferences when making decisions about patient care [ 1 ]. Since its introduction, approaches to teaching EBM skills have focused on the use of critical appraisal to determine the highest level of evidence, largely overlooking clinician expertise and patient preferences [ 2 , 3 ] and disregarding the established central role of person-centered care and shared decision-making (SDM), where clinician and patient make care decisions together [ 4 ]. This disparate approach may be connected to the way that EBM has been traditionally taught during medical training, where education about person-centered care and SDM has occurred in a separate educational silo to EBM education [ 2 , 5 , 6 ]. In recent years, a potential solution has been proposed: teaching EBM and SDM together, where evidence is applied using SDM skills [ 7 , 8 ].

Some educators and practitioners have identified the potential benefit of incorporating the principals of SDM into EBM training, so that education centers on the patient as well as the evidence [ 9 , 10 ]. However, very few published studies provide empirical data on how this can be successfully done [ 8 , 11 ]. In an Australian study, researchers ran a single EBM-SDM workshop for medical and allied health student-clinicians [ 12 ], where SDM was introduced as part of the students’ compulsory EBM course. In this study, participants who underwent SDM training in addition to reading SDM material scored significantly higher on measures of ability, attitudes, and confidence in incorporating SDM into EBM when compared to participants who read SDM material alone. In a more recent study, researchers from the same institution conducted a half-day EBM-SDM workshop to train primary care practitioners in using SDM with EBM to improve decision-making for patient care [ 13 ]. In this study, pre- and post- workshop observations of doctors’ skills in SDM were assessed via recorded consultations and pre- and post- workshop attitude questionnaires. The results from this pilot found that participants had increased positive attitudes towards SDM and improved SDM skills immediately after the half-day workshop [ 13 ], though the focus of this training was limited to general practice-focused clinical scenarios, did not incorporate a study follow-up, and omitted qualitative participant feedback. More recently, a scoping review of 23 studies found that while there has been increasing recognition by educators of the interdependence between EBM and SDM, only a minority of included studies explicitly incorporated EBM and SDM into training content [ 8 ].

We previously conducted a series of EBM training courses for junior doctors during which they were taught to apply evidence using SDM skills, namely, an EBM-SDM course. We ran a pilot mixed-methods evaluation, which indicated that while there was a significant increase in positive attitudes towards EBM after the course, there were also several barriers and facilitators that influenced the potential uptake and practice of EBM and SDM [ 14 ]. This is unsurprising, given that EBM training for junior doctors is beset by reports of failure to translate new skills and attitudes into clinical practice [ 9 ] and SDM is slow to be taken up among doctors in general [ 15 , 16 ]. The EBM literature has identified that the main reasons given by junior doctors for not practising EBM included: lack of time to learn [ 17 , 18 ] or practice EBM [ 19 ], workplace culture [ 20 ], and lack of prior training [ 20 ]. Separate SDM literature has identified that barriers to the practice of SDM perceived by doctors, including junior doctors, included time constraints [ 21 ], low levels of patient health literacy [ 22 ], workplace culture [ 23 ], and no opportunities to learn and practice SDM during clinical practice [ 24 ]. However, there are few investigations of barriers to the joint practice of EBM and SDM following their integrated training. As such, there is a need for more comprehensive qualitative evaluations of the outcomes of integrated EBM and SDM training, as well as a more in-depth understanding of the barriers and facilitators to their implementation in clinical practice.

Despite positive attitudinal changes towards EBM-SDM after training [ 13 , 14 ], it is likely that specific barriers prevent the provision of EBM-SDM training and the translation of new skills into clinical practice. It is important to further understand the nature of these barriers so that the impact of EBM and SDM practice can be fully realised. We were interested in examining the private hospital setting, and specific benefits or barriers this setting could introduce. Also of interest was the composition of junior doctor and consultant participant cohorts where most participants were undertaking surgical specialties or training, and its impact on influencing their responses and outcomes following training. In this study, we conducted interviews with junior doctors both before and after EBM-SDM training, and with their supervising consultants to further understand their perceptions and practice of EBM and SDM, and the associated barriers and facilitators.

This study aimed to answer the following research questions:

How does an integrated EBM-SDM course influence junior doctors’ attitudes toward, and practice of, EBM and SDM?

What are the barriers to junior doctors’ EBM-SDM learning and practice? What are the facilitators?

How do supervising consultants’ attitudes and influence impact on junior doctors’ opportunities for EBM-SDM learning and practice?

This study used an emergent qualitative design where data were collected via semi-structured interviews [ 25 ]. Social constructivist theory underpinned our study design to enable the exploration of how junior doctors and consultants created their own meanings, attitudes, and understanding about EBM and SDM, and a deeper understanding of their relationships with each other within this context [ 26 ]. The study centered around an EBM-SDM course that we conducted at an academic health sciences center. Phase 1 of this study involved conducting and analysing pre- and post-course interviews with junior doctors to understand their perceived barriers and facilitators to learning and practising EBM-SDM [ 27 ]. Thematic analysis of the initial interviews with junior doctors raised questions about the role of supervising consultant doctors in EBM-SDM learning and practice, specifically in terms of their support for training and practice opportunities for junior doctors. Thus, Phase 2 of the study used semi-structured interviews with consultants to further understand how their attitudes and influence might impact junior doctors’ opportunities for EBM-SDM learning and practice.

Study setting

The EBM-SDM training course took place at an integrated academic health sciences center (MQ Health) on an urban university campus, comprising a university-owned private hospital and specialty outpatient clinics [ 28 ]. The course was attended by junior doctors who worked at the center. In the Australian setting, junior doctors include new graduates or interns, residents undertaking prevocational training, registrars who are either accredited with a specialty training program or unaccredited, and fellows who have completed specialty training and are seeking sub-specialty training [ 29 ]. The EBM-SDM training course consisted of four 90-minute meetings, and covered all steps of the EBM process and the principles of SDM that are incorporated into the fourth EBM step. The course was conducted over an eight-week period to provide trainees with sufficient time in between meetings for reading, reviewing, and preparing material. The course was conducted five times during this study. Adult learning theory was used as a framework for the problem-based, collaborative learning environment where the teachers facilitated rather than directed learners [ 30 ]. During the course, junior doctors used their own patient cases to increase the course relevance to their practice and patient care [ 31 ]. Additional File 1 contains details of the structure and content of the EBM-SDM training course.

The junior doctors were on a single-term rotation, where they spent one year at the private hospital before returning to rotations in the public hospital system. They worked alongside a variety of other healthcare professionals, including consultants, allied health professionals, researchers, and educators, and were supervised by consultants, specialists from a range of medical and surgical disciplines, who provided individualised mentoring, opportunities for learning and research, and support to enter specialist training programs in Australia. Junior doctors could also take part in educational activities outside of their supervision with consultants, including the EBM-SDM course, to acquire and practice new skills.

Participant recruitment

Participants were recruited via purposive sampling [ 32 ] where doctors from a range of age groups and training backgrounds were approached to obtain a comprehensive sample. In Phase 1, participants were recruited from the university hospital’s training program for junior doctors. Using examples from the literature [ 33 ], an estimated number of 12 to 15 interviewees from the available pool of 30 junior doctors was considered appropriate to provide in-depth data, and to cover all the issues that could arise from interviews pre- and post- EBM-SDM training [ 32 ]. In a similar process, for Phase 2 we sought a sample of 10 consultants from the available pool of 20 who had current supervisory roles in the training of junior doctors at MQ Health. The junior doctors were approached as they enrolled in the EBM course, while the consultants were identified from a list of junior doctors’ supervisors provided by the faculty learning and teaching administration team and were sent individual emails inviting them to take part in the study.

Data collection

Demographic data.

A demographic survey was developed by four authors (MSi, FR, YZ, AD) and emailed to all consenting participants to record their age group, gender, position, country of medical training, period in which training occurred, and prior education in EBM and SDM.

Interview schedules

Interview questions were developed by the first author (MSi), then reviewed and amended with members of the author team (AD, FR, YZ). In Phase 1, two interview schedules were developed: pre-course and post-course. The pre-course interviews were designed to establish a pre-intervention baseline and explore how junior doctors understood and used both EBM and SDM, and their prior training experiences in each. The post-course interview questions examined changes in knowledge, attitudes, and practice of EBM and SDM and explored junior doctors’ perceptions of combined EBM-SDM training for learning and practice, their intentions to use knowledge gained, the influence of their supervising consultants on EBM and SDM practice, and possible barriers and facilitators to learning and using EBM. In Phase 2, interviews with consultants were designed to understand how they viewed EBM and SDM in their own practice, and their views on whether junior doctors should practice EBM and SDM. Interview questions also explored consultants’ views and experiences of combined EBM and SDM training, in influencing both clinical practice and medical education. See Additional File 2 for all interview schedules.

Interview pilot and sessions

In Phase 1, interview questions were designed and piloted with three junior doctors and were subsequently refined into the final interview schedules. In Phase 2, interviews were piloted with one consultant, after which the questions were modified for use with this cohort. Interviews took place in quiet locations with each junior doctor from 2019 until 2022, and with each consultant during 2021; they were conducted face-to-face in 2019, and via Zoom from 2020 due to the COVID-19 pandemic [ 34 ]. Author MSi conducted the interviews as 40-minute sessions. All interviewees were given the option to comment on their interview transcripts and study results. One interviewee returned for a second interview to capture additional data. Observational notes were taken by MSi to capture additional contextual factors (such as tone of voice) to assist with thematic analysis.

Data analysis

In Phase 1 of the study, junior doctors’ transcripts and field notes were thematically analysed [ 35 , 36 ] to identify, evaluate and report patterns or themes within the data in relation to the three research questions. The first author (MSi) transcribed and familiarised herself with the data. Iterative generation of codes and themes took place with other members of the authorship team (FR, YZ, LAE, GF, SS). Themes were inductively defined as new codes were generated and all themes and sub-themes were named. Transcripts were re-read, and themes reinterpreted until the team decided that data findings had been accurately described. These themes were then used in Phase 2 of the study as a framework to deductively analyse consultants’ interviews. We also included an ‘Other’ category to code any content that did not fit within the framework, and then inductively analysed this content to capture additional sub-themes from the consultant data.

Research team and reflexivity

MSi, a higher degree research student, developed and delivered the EBM-SDM training course with two other authors (MSt, AD). MSi also developed the interview schedules (with FR, AD, YZ) and conducted the interviews. All participants were informed of MSi’s involvement in the study. MSi has training qualifications in adult education and qualitative research methods, including group and individual interviewing techniques. She analysed the interview data with other authors (FR, YZ). MSi knew all study participants (except two consultants) through her work as a clinical librarian at Macquarie University and discussed with the other authors how her involvement in the study and familiarity with the participants may influence her perceptions and analysis of the interview data. FR, YZ, and SS are health service researchers, with extensive experience in qualitative research. As non-clinicians, they reflected on their experiences and expectations as patients, and as researchers, and how that may influence their interpretation of the interview data. GF and LAE are allied healthcare professionals by background and researchers who drew on their clinical and research skills and perspectives to interpret the interview data. AD and MSt are neurosurgeons with experience in training junior doctors and an interest in medical education and teaching EBM. They knew several study participants through their clinical and research work.

Ethical approval and study reporting

Ethics approval was obtained in 2019 to interview junior doctors from Macquarie University Human Research Ethics Committee (# 5201927419929), and in 2021 to add interviews with consultants (Ethics no: 52021274125020). The study was reported using COREQ guidelines (See Related Files).

Demographic information of participants

Demographic details of the junior doctors and consultants who participated in interviews are displayed in Table  1 . Of the 30 junior doctors who completed the EBM-SDM training, 12 participated in interviews. Of the 12 participating junior doctors, five were fellows, five were registrars, one was a resident, and one was an intern, and thus the junior doctor cohort represented a range of training levels and experience. Half of the junior doctors undertook their medical training in Australia and around two-thirds had some prior EBM instruction, although none had received training in SDM. Five junior doctors completed both pre and post interviews; those who only completed one interview cited time factors and clinical schedules as reasons for non-completion. Most junior doctors who completed the EBM-SDM training course but not the interviews cited time factors as reasons for their non-participation.

Ten consultants participated in interviews. Of these 10 consultants, three were Associate Professors and four were Professors. Five consultants had some prior EBM training, and none had any prior SDM training.

Themes and sub-themes

The study had three key research questions, and four major themes were identified around those questions. The themes, sub-themes, and links to the research questions are summarised in Table  2 . In the following results section, junior doctors’ quotes are indicated with “J” and a number; consultants’ quotes are indicated with “C” and a number.

Theme 1: EBM training, understanding, and practice

Four sub-themes were identified that related to perceptions and understanding of EBM training and practice: pre-course understanding and learning EBM, application to practice, training needs of junior doctors, and impact of medical speciality.

Understanding and training in EBM

Prior to the EBM-SDM course, most junior doctors equated EBM to research skills and knowledge-gain, e.g., “[EBM] …means medicine that has a foundation in scientific studies that have been rigorously peer reviewed and developed through a scientific method…” (J3). Some junior doctors linked EBM to a statistical outcome or risk measure, using it to give “ the risks of certain procedures … [and] the risks of conservative management versus operative management” (J4). Of the six junior doctors that trained in Australia, none recalled EBM training within a clinical setting or taught in a way that directly applied to practice. Instead, they reported that EBM training consisted of isolated lectures or projects: “but other than that, there was no course for EBM. It’s just lectures when I was in med[ical] school” (J5).

Five consultants indicated a lack of understanding of EBM practice when asked to prioritise its components: “ Literature-based EBM is the most important, anecdotal or doctors’ experiences is the least important, and what was the third one?” (C7), whilst others were more aware of EBM theory and practice, particularly as it applied to patient care: “ evidence-based medicine in its foundations is meant to tailor it to the particular patient and it is actually quite flexible” (C1).

Actual and intended practice of EBM

Junior doctors’ understanding of the practice of EBM broadened after the EBM-SDM course and was accompanied by increased acknowledgement of patient involvement in their care. One junior doctor described their increased awareness for future practice: “[the course made me wonder] how can I convey the message to patients and get them to be involved in deciding the management plan?” (J5). The greatest barrier to practising EBM was lack of time for learning and practice, with all junior doctors mentioning this during their interviews.

Training needs of junior doctors

Prior to the EBM-SDM training course, most junior doctors were looking forward to developing skills in searching and critically appraising evidence: “ I’d like a better understanding of what a good quality study is…if something is a RCT or cohort study that I want to be able to say, this is a good RCT or, this is a good cohort study” (J4). After the EBM-SDM training course, several junior doctors recommended further training to help them maintain and extend their skills. Some suggested EBM training should be provided for longer and include refresher training, and one suggested giving more emphasis to the SDM component “ because this is the practical part of putting it into our daily life, applying it to patients” (J5).

Impact of the medical speciality of consultants

Consultants’ specialisations impacted their practice of EBM. Those practising as physicians, including a neurologist and cardiologist, reported greater access to high-level evidence and guidelines, with one consultant claiming that “ cardiology is very algorithmic in a lot of ways, and that makes that easier…there’s only so many things you can do…. that kind of distils things” (C6). Consultants from surgical disciplines reported that lower levels of evidence were often drawn upon for decision-making, because “[in surgery] the evidence, sometimes is not like hard science…many times we base our decisions on grey literature, or on evidence that we acquire over time…or from the experience of our other senior colleagues” (C9).

Theme 2: attitudes towards EBM

Three sub-themes were interpreted within the data relating to attitudes towards EBM: attitudes towards the role of evidence in decision-making, attitudes towards patient involvement in care decisions, and attitudes towards junior doctors’ practice of EBM.

Attitudes towards the role of evidence in decision-making

Prior to the EBM-SDM training course, most junior doctors’ attitudes toward EBM were focused on the knowledge they could acquire for decision-making, research, and benchmarking their performance, such as “ recommendations that are based on that evidence to inform medical decision-making” (J3). After the course junior doctors were keen to practice their new EBM skills that had expanded to include finding and using evidence to explain care issues to patients. “It [explaining evidence] really makes them [patients] feel as though they’re being actively involved in the actual details of their specific case” (J3).

Consultant participants frequently discussed the pitfalls of using evidence to inform decisions, with one claiming that “[EBM has] got enormous weaknesses if people think that there’s evidence for everything; that is too simplistic and left brain” (C2). Furthermore, decisions were reportedly often informed by “ what you’ve been taught by your people training you and your mentors” (C5). Two consultants explained how they perceived EBM was negatively changing medical practice: “ [EBM] takes away some of the enjoyment out of practicing medicine individually, in the sense that some of the art has been lost” (T7). Other consultants pointed out advantages of EBM, including provision of high-quality evidence for decision-making that “gives me the ability to then converse with patients as to why we do things and why it would be most appropriate” (C1). Two consultants with prior EBM training discussed the conflict with senior colleagues that can often arise when EBM is practised, one stating that “ sometimes this evidence is not strong enough to change the opinion of some [senior] doctors or surgeons” (C9).

Attitudes towards patient involvement in care decisions

Junior doctors expressed mixed attitudes about patient involvement in decisions. Despite post-training beliefs that patient involvement “ will help to establish…better rapport with patients…because they’re more informed and there’s more trust” (J3), junior doctors also reported the “ need to simplify things for the patient who makes the decision about their life… other than just giving information” (J8). Six junior doctors did, however, plan for greater patient involvement after they completed the EBM-SDM course: “ I am now more inclined to include evidence-based discussions…in how I approach decisions that we present to patients…. I wouldn’t have really brought it up as a topic [previously]” (J3).

Consultants also reported mixed attitudes to patient involvement in their care, with one participant stating that “ it’s good that they’re enthusiastic about it but it’s bad that it’s this sort of modern attitude of ‘my opinion’s as good as your opinion’, even if my opinion is based on social media and newspaper reports” (C4). Six consultants expressed doubts about patients’ ability to grasp complex medical concepts for decision-making, to “ understand something as much as a clinician who’s been doing it for 10, 20, 30 years” (C8). Three consultants strongly endorsed patient involvement, mostly believing that “ at the end of the day … it’s the patient’s body, that they have to be comfortable with the treatment plan” (C1).

Consultant attitudes towards junior doctors’ practice of EBM

Consultants differed in their opinions on whether junior doctors should practice EBM. Five consultants believed there were few roles for junior doctors in evidence-based decision-making, one stating: “ they practice a very protocol driven medicine. And that’s just historical and that’s probably not a bad thing” (C2). The other five consultants, in contrast, stated that limited decision-making roles should exist for junior doctors: “ doctors at any stage should be able to assess the patient and so they can influence decision-making, based on that ” (C3).

Theme 3. Organisational culture and EBM

Two sub-themes were identified pertaining to the influence of organisational culture on practicing EBM: public versus private healthcare, and medical hierarchy.

Public vs. private healthcare

Junior doctors and consultants spoke of differences in EBM learning and practice between public and private healthcare settings. Six junior doctors reported that private healthcare settings, such as the academic health sciences center they were based in, facilitated the practice of EBM, because they had protected time for individual study and educational activities. This did not happen during their public hospital rotations, where junior doctors cited high patient numbers and associated workloads that were prioritised. One such junior doctor stated “ Today I’ve just been allocated a study day… I don’t actually think that happens in public hospitals” ( J4 ) .

Four consultants’ views aligned with those of junior doctors about greater protected time available for learning in private settings. Three consultants stated junior doctors had greater opportunities for patient decision-making in the public system, for example, in the emergency department of public hospitals where “ you see people who are coming in [to the emergency department] and often they’ll see the junior doctors before they even see the senior doctor ” (C6).

Medical hierarchy

Junior doctors and some consultants discussed the emphasis placed on following the instructions of the most senior consultants. Six junior doctors reported that they were rarely involved in decision-making, but rather, follow the consultant’s lead, regardless of whether the consultant’s decisions were evidence driven. Prior to the EBM-SDM course one junior doctor stated: “ I think in some of my other terms, if I had asked, they [consultants] would just say “this is just part of my experience” (J2). She maintained this view after the course, recalling one instance when querying a guideline put in place by a consultant: “ I know as a junior sometimes you get a bit of pushback if what you’re recommending is not guideline driven” (J2).

Two consultants reported that their decision-making capacity was also restricted by their senior colleagues, one consultant claiming that this was “the consequence of the traditional school and all the experience, based on the decades of “we always did it like that” (C9). Another consultant spoke of the difficulties faced by those consultants who completed their medical training before EBM was introduced:

If you look at some of the older clinicians you can be forgiven for thinking that they’re kind of stuck in, frozen in time, right? And that might be a generational thing, but because of this new focus on evidence-based learning and medicine in the nineties, these clinicians didn’t have the benefit of that. (C3.)

Three junior doctors reported that hierarchies were evident even among themselves, and not just between junior doctors and consultants, such that accredited registrars or fellows often held greater credibility than less experienced residents, interns, and unaccredited registrars. Two consultants stated that they only worked with fellows, not the more junior ranked doctors, whereas other consultants reported greater inclusivity of all junior doctors during decision-making, one stating: “ I am very, very open to accept the data or opinion [of a junior doctor] because it’s based on something which is more updated than what I know, and this is something that happens” (C9).

Theme 4: understanding and practice of SDM and its role in EBM

Three sub-themes were identified relating to the understanding and practice of SDM and its role in EBM: Understanding and practicing SDM, the effect of hierarchy on the practice of person-centered care and SDM, and the role of junior doctors in the learning and practice of SDM.

Understanding and practicing SDM

Prior to the EBM-SDM course, four junior doctors could not correctly define what SDM meant, and six described SDM as one-way communication of evidence to patients. After the course, they claimed a greater understanding of SDM as part of person-centered care, and that “ you need to have a good basis in EBM, to actually make sure the patient can be even involved in the discussion. So, the patient understands” (J4). Seven junior doctors believed that SDM and EBM should be taught together, whereas one did not agree: “ I think we don’t need to explicitly incorporate it, that it’s a given” (J1). Given that the training level of junior doctors was highly varied (i.e., from intern to fellow), there was variability in how they understood and approached SDM. For example, fellows, the most experienced of the junior doctors, described using evidence to provide recommendations to patients rather than eliciting patient preferences whilst referring to evidence. One fellow stated: “I think most patients are really welcoming if you tell them that people have done it before, the percentage of people who do good, for example, and those that don’t and they’re willing to accept that” (J10). Consultants conveyed mixed definitions of SDM; some saw it as informed consent, and others saw it as the transfer of information from doctor to patient. All consultants pointed out the difficulties of SDM, with one highlighting that “ it’s really hard to get somebody to the level where they can make some sort of an educated decision” (C8). One consultant commented on the differences in attitudes towards SDM between older and younger colleagues: “ younger clinicians are less likely to be as paternalistic [than older consultants], they’re more willing to accept that patients have their own thoughts, even if they’re unconventional and unrealistic” (C3). Surgeons and surgical trainees, comprising 72% of the study cohort, tended to view EBM and SDM as doctor-driven rather than patient-centered. For example, one neurosurgeon emphasised the important sources of evidence used for patient decisions: “So I always bring to the patient my experience, I bring the MDT [Multidisciplinary Team] meeting decision … and the literature” (C9). This contrasted with the perspective of non-surgical consultants. For example, a cardiologist highlighted the central role of the patient in the decision-making process: “I always think of evidence as the hard science and then for the decision-making process, about the application of that hard science to a particular context and … it’s in that paradigm, that the patient’s point of view is used to temper the evidence that you’re presenting” (C6).

Effect of medical hierarchy on junior doctors’ practice of person-centered care and SDM

Six junior doctors reported that, due to their place in the medical hierarchy, they tended not to practice SDM. One participant stated:

I actually try to hold off on doing that [practising SDM], personally, just because it’s more of a consultant discussion at that stage. When a consultant leaves the room, the patient does actually have more questions, and sometimes I just reiterate what the consultant has already said. (J4.)

Ten junior doctors planned to increase their communication and person-centered care skills after the EBM-SDM course, for example, using EBM to find evidence that reassures a patient; skills that could be implemented now and expanded later to incorporate SDM.

Consultant perceptions of the role of junior doctors in SDM

Four consultants were of the view that junior doctors should not practice SDM due to their junior level. One consultant reported that junior doctors sometimes played a patient advocate role because they “ often have an insight into some of those other levels [of patient care]” (C2). Another consultant considered providing junior doctors “the opportunity to be more involved in that [SDM] discussion” (C7) but cited time constraints as a barrier.

This study explored how integrated EBM and SDM training can impact attitudes, understanding and practice among junior doctors, and whether the attitudes and practice of their supervising consultants can influence those outcomes. Junior doctors demonstrated significant positive attitude changes towards EBM and SDM after the EBM-SDM course. Prior EBM training (during medical training or afterwards) was mostly didactic and focused on knowledge and skill acquisition which is a common finding in other studies that has not equipped junior doctors to practice EBM confidently in clinical settings [ 37 , 38 ]. Following our EBM-SDM course, not only did junior doctors’ knowledge and skills improve, but they frequently referred to the benefits of including patients in their discussions about care, which indicated that they had expanded their understanding of EBM to incorporate aspects of person-centered care. Their intentions to be more person-centered were frequently based on using evidence to effectively communicate risks and benefits to patients, rather than having SDM conversations with patients where all options were described, and decisions made together. However, there appeared to be a disconnect between the practice of SDM and the recognition of its practice. On several occasions, junior doctors facilitated SDM by answering patient questions after the consultant left the room, or by reiterating what the consultant said, but failed to recognise this as part of a SDM conversation with the patient.

Junior doctors also varied in their attitudes and practices of SDM. The more experienced junior doctors, the five fellows, tended to demonstrate a more doctor-centered rather than patient-centered approach to patient care than the less experienced junior doctors (i.e., residents). Junior doctors were at varying levels of their medical training, some of them closer to consultant-level practitioners than others, and may perceive and think about SDM differently depending on their training cohort. Furthermore, several fellows had worked as consultants in their home countries which may have influenced the doctor-centered patterns of decision-making commonly found among consultants. Thus, our study identified that junior doctors attitudes and practices of SDM are likely due to a lack of specific knowledge and understanding of SDM, limited prior training, as well as cultural conventions that may be associated with time and country of training.

Consultants varied greatly in their understanding of EBM and SDM, and their views on whether either should be practised by junior doctors. Senior consultants who completed medical training before the formal introduction of EBM in the 1990s [ 39 ] appeared to be unfamiliar with and less accepting of EBM and SDM and expressed a reluctance for junior doctors to engage in either. In contrast, younger consultants who had prior exposure to EBM training and practice tended to appreciate the benefits of EBM for junior doctors and patients. In another study of junior doctors and senior anaesthetists, interviews indicated there was a link between career stage and workplace settings and EBM attitudes [ 40 ]. In this study, senior anaesthetists (consultants) were reluctant to make decisions or change practice based on evidence in preference to their own experience and opinion [ 40 ]. Junior doctors regarded this as reluctance to change as due to older age, but the consultants saw it as surrendering their professional autonomy [ 40 ]. Thus, there may be a tendency among more senior doctors to resist practising EBM in favour of using their own decision-making preferences, that carry a risk of cognitive bias and are potentially suboptimal or obsolete decisions [ 40 , 41 , 42 ]. In addition, some studies have shown senior medical staff (consultants) have very little expertise in SDM with patients, thereby failing to become the role models in EBM-SDM that junior doctors need [ 43 ]. Senior doctors have also reported difficulty in using technology thus preferring to ask colleagues for advice [ 44 ].

In our study, more senior consultants appeared to dominate the medical workforce hierarchy and exclude junior doctors and patients from decision-making. These consultants believed that decision-making should be underpinned by their experience, knowledge, and their communities of practice. Thus, they did not prioritise decision-making linked to EBM and SDM and consequently educational opportunities for junior doctors under their supervision were reduced. These findings support those of other studies concerning the impact of medical hierarchies on junior medical staff, where power is recognised to sit with senior medical staff positioned at the top of the hierarchy, thereby reducing the autonomy of those positioned lower in the hierarchy, such as junior doctors [ 40 , 45 ]. This has been reported to be particularly evident in surgical specialties, where decision-making is dominated by senior surgeons’ experience rather than evidence [ 46 ]. Junior doctors learn to respect hierarchy from medical school, where they do not challenge authority to avoid unwanted impacts on their training and career progression [ 47 , 48 , 49 ]. The well-established medical hierarchy emerged as a barrier preventing junior doctors in our study from using evidence-based decision-making skills learned in the EBM-SDM course, particularly if the evidence contradicted strongly held views and practices of senior consultants.

Of note was that the present study was conducted during the COVID-19 pandemic, a difficult and uncertain time for all medical professionals. In the Australian context, junior doctors have reported restrictive workplace cultures and behaviours, including being overlooked and undervalued by senior doctors, which contributed negatively to their psychological well-being during COVID-19 [ 49 ]. This had important implications for doctors’ welfare, workforce retention, and safe patient care that needed to be addressed through “positive workplace cultural interventions to engage, validate and empower junior doctors” [ 50 ]. In contrast, junior doctors in our study, and in others, have reported that many consultants and senior medical staff were always supportive and approachable role models, not just during the pandemic, and helped to facilitate their trainees’ well-being and progress [ 47 , 51 ]. The potential contribution of such role models to facilitate and support EBM and SDM learning and practice may help to overcome some of the associated barriers [ 52 ].

Combining EBM and SDM training enabled junior doctors to realise there is more to EBM than the level of evidence, which was what most believed before the training. The combined course enabled them to consider how they would communicate the relevant evidence in a two-way conversation with the patient, and thus situated the principles of EBM within the broader context of patient needs and preferences. Several junior doctors had commented that their awareness and practice of improved communication skills with patients had increased after the course, lending support to the effectiveness of the combined course, and the likelihood that the learnings would be utilised in future. These outcomes also imply that EBM-SDM training has the potential to shift power dynamics within the medical hierarchy through expanding the skillset and abilities of junior doctors.

Another facilitator of combined EBM-SDM learning and practice reported in our study was the capacity of private healthcare facilities in Australia to provide protected time for educational activities. This contrasted with public healthcare facilities, where such opportunities are limited [ 53 ]. Our study took place within a neurosurgery department where a half-day is set aside each week for learning and teaching meetings, including the EBM-SDM course. The meetings were co-ordinated by consultants, thereby enabling junior doctors to learn and practice new skills with consultants’ support. In a similar way, consultants who recognise the benefits of EBM and SDM could act as unofficial champions, who provide further learning and teaching opportunities for junior doctors, whilst demonstrating and communicating those benefits to their senior colleagues. The idea of champions comes from literature demonstrating that colleagues or supervisors of junior clinicians can be a great source of assistance and support when it comes to learning and practicing skills associated with EBM [ 8 ]. Such champions or role models have been recommended as an integral part of EBM teaching because they demonstrate to learners the ‘how-to’ of the application of EBM principles to clinical practice and individual patients [ 54 ]. Within our study, this supportive culture, led by a champion or role model, was very beneficial. One of the neurosurgeon consultants took a keen interest in teaching EBM to junior doctors and he led by example, showing them how to use it in daily practice through patient care consultations, and ward rounds and by leading the EBM-SDM teaching during protected education time. The junior doctors responded with increased motivation to practice their EBM-SDM skills during educational meetings. This opportunity provided by a private healthcare facility could be an exemplar of EBM-SDM education in the Australian context that may be adapted by other institutions.

Future directions

A lack of prior learning and practice of EBM and SDM concepts among this sample of junior doctors echoes previous calls for improved basic and ongoing training in EBM and SDM skills [ 8 , 55 ]. The recently updated Australian specialist training program [ 56 ] has cited the inclusion of EBM and SDM as separate skill sets, with an emphasis on skills and knowledge acquisition. However, there is now a framework providing core competencies that can underpin an EBM curriculum incorporating SDM [ 57 ]. This is a promising initiative that could be adapted and used to meet the needs of institutions whilst identifying and managing barriers and facilitators to the learning and practice of EBM and SDM. Additionally, the capacity of consultants with prior EBM training and experience to act as champions of EBM-SDM could be further explored.

Future research opportunities include evaluation of the impacts of integrated EBM-SDM training content and strategies to determine optimal approaches for educators to adopt in both private and public settings. Future research should also focus on the efficacy of strategies to empower junior doctors to become more independent in using their EBM and SDM skills, such as training champions and consultants who want to help their junior doctor trainees develop skills and experience in EBM and SDM [ 52 , 58 ]. Finally, further investigation is warranted into the significance of undertaking medical training either before or after the introduction of EBM in the 1990s, and how this impacts the medical hierarchy, EBM-SDM training and practice opportunities for junior doctors, and patient care. These investigations could incorporate other qualitative methods such as ethnography to fully capture perceived dynamics and cultural conventions within medical disciplines.

Strengths & limitations

This study has contributed to our knowledge of combined EBM-SDM training in the Australian context. A strength of the study was its emergent design, where consultant interviews in Phase 2 were added after data were analysed from junior doctor interviews in Phase 1. This approach enabled consultant interview schedules to further elucidate the barriers and facilitators associated with EBM and SDM learning and practice that emerged during Phase 1. The study was also strengthened by including two diverse, but linked participant groups, the junior doctors, and their supervising consultants, thus facilitating the collection and analysis of more than one source of relevant data that addressed the study aims. However, the study is not without its limitations. First, the modest sample size of the study, exacerbated by COVID-19 restrictions and the impact of the pandemic on the medical workforce, reduces the study’s transferability to other cohorts and contexts. Second, junior doctors’ limited understanding of SDM after the course may reflect a limitation of the course. Although SDM was introduced and discussed in the course, little time was provided for deliberate SDM practice and feedback; an issue that can be rectified in future training and research. Third, more males than females participated in the study which may have influenced the pattern of results and is an area for further research.

Most junior doctors reported positive attitude changes following EBM-SDM training that encompassed plans to increase patient involvement in their care through better communication and evidence-based shared decision-making. However, time constraints and the influence of the medical hierarchy were significant barriers for most junior doctors when learning and practising EBM and SDM. Despite these barriers, supportive consultants and protected educational time facilitated the learning and practice of EBM and SDM within the context of our study. To counter the reported barriers at our institution there are opportunities available for some consultants to become champions who make protected time available for EBM-SDM learning and practice opportunities. These findings may inform future research and training where integrated EBM and SDM learning and practice could be adapted to the unique contextual and cultural influences of each institution.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

• Evidence-based medicine
• Shared decision-making

Consolidated criteria for reporting qualitative research

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Acknowledgements

The authors wish to thank the doctors who participated in the interviews reported in this paper.

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All authors contributed to the study conception and design. Material preparation and data collection were performed by MSi. Thematic analysis was performed by MSi, FR, YZ, GF, SS and LAE. MSt and AD prepared manuscript tables. The first draft of the manuscript was written by MSi, SS and GF. All authors contributed to each version of the manuscript. All authors read and approved the final manuscript.

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Ethics approval was obtained in 2019 to interview junior doctors from Macquarie University Human Research Ethics Committee (Ethics no: 5201927419929), and in 2021 to add interviews with consultants (Ethics no: 52021274125020). Informed consent was obtained from all individual participants included in the study.

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Simons, M., Fisher, G., Spanos, S. et al. Integrating training in evidence-based medicine and shared decision-making: a qualitative study of junior doctors and consultants. BMC Med Educ 24 , 418 (2024). https://doi.org/10.1186/s12909-024-05409-y

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