Reflexivity can be a complex concept to grasp when entering the world of qualitative research. In this paper, we aim to encourage new qualitative researchers to become reflexive as they develop their critical research skills, differentiating between the familiar concept of reflection and reflective practice and that of reflexivity. While reflection is, to all intents and purposes, a goal-oriented action with the aim of improving practice, reflexivity is a continual process of engaging with and articulating the place of the researcher and the context of the research. It also involves challenging and articulating social and cultural influences and dynamics that affect that context. As a hallmark of high quality qualitative research, reflexivity is not only an individual process, but one that needs to be considered a collective process within a research team and communicated throughout the research process. In keeping with our previous papers in this series, we have illustrated the theoretical concept of reflexivity using practical examples of published research As a group of researchers, clinicians and academics, we are drawn together to support and further the development of qualitative research in medical and health professions education.Bringing together our diverse disciplinary backgrounds, research experiences and positions, in writing a series of 'How to….'papers for The Clinical Teacher, we hope to support qualitative researchers, students and teachers. We have challenged ourselves to collaborate not solely on areas of common interest, but to explore issues in qualitative research that allow us also to learn from each other.

ObjectivesPatients are often provided with medicine information sheets (MIS). However, up to 60% of patients have low health literacy. The recommended readability level for health-related information is ≤grade 8. We sought to assess the readability of MIS given to patients by rheumatologists in Australia, the UK and Canada and to examine Australian patient comprehension of these documents.DesignCross-sectional study.SettingCommunity-based regional rheumatology practice.ParticipantsRandom sample of patients attending the rheumatology practice.Outcome measuresReadability of MIS was assessed using readability formulae (Flesch Reading Ease formula, Simple Measure of Gobbledygook scale, FORCAST (named after the authors FORd, CAylor, STicht) and the Gunning Fog scale). Literal comprehension was assessed by asking patients to read various Australian MIS and immediately answer five simple multiple choice questions about the MIS.ResultsThe mean (±SD) grade level for the MIS from Australia, the UK and Canada was 11.6±0.1, 11.8±0.1 and 9.7±0.1 respectively. The Flesch Reading Ease score for the Australian (50.8±0.6) and UK (48.5±1.5) MIS classified the documents as ‘fairly difficult’ to ‘difficult’. The Canadian MIS (66.1±1.0) were classified as ‘standard’. The five questions assessing comprehension were correctly answered by 9/21 patients for the adalimumab MIS, 7/11 for the methotrexate MIS, 6/28 for the non-steroidal anti-inflammatory MIS, 10/11 for the prednisone MIS and 13/24 for the abatacept MIS.ConclusionsThe readability of MIS used by rheumatologists in Australia, the UK and Canada exceeds grade 8 level. This may explain why patient literal comprehension of these documents may be poor. Simpler, shorter MIS with pictures and infographics may improve patient comprehension. This may lead to improved medication adherence and better health outcomes.

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The aim of this study was to assess health literacy (word recognition and comprehension) in patients at a rural rheumatology practice and to compare this to health literacy levels in patients from an urban rheumatology practice.Inclusion criteria for this cross-sectional study were as follows: ≥18-year-old patients at a rural rheumatology practice (Mid-North Coast Arthritis Clinic, Coffs Harbour, Australia) and an urban Sydney rheumatology practice (Combined Rheumatology Practice, Kogarah, Australia). Exclusion criteria were as follows: ill-health precluding participation; poor vision/hearing, non-English primary language. Word recognition was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). Comprehension was assessed using the Test of Functional Health Literacy in Adults (TOFHLA). Practical comprehension and numeracy were assessed by asking patients to follow prescribing instructions for 5 common rheumatology medications.At the rural practice (Mid-North Coast Arthritis Clinic), 124/160 patients agreed to participate (F:M 83:41, mean age 60.3 ± 12.2) whereas the corresponding number at the urban practice (Combined Rheumatology Practice) was 99/119 (F:M 69:30, mean age 60.7 ± 17.5). Urban patients were more likely to be born overseas, speak another language at home, and be employed. There was no difference in REALM or TOFHLA scores between the 2 sites, and so data were pooled. REALM scores indicated 15% (33/223) of patients had a reading level ≤Grade 8 whereas 8% (18/223) had marginal or inadequate functional health literacy as assessed by the TOFHLA. Dosing instructions for ibuprofen and methotrexate were incorrectly understood by 32% (72/223) and 21% (46/223) of patients, respectively.Up to 15% of rural and urban patients had low health literacy and <1/3 of patients incorrectly followed dosing instructions for common rheumatology drugs.There was no significant difference in word recognition, functional health literacy, and numeracy between rural and urban rheumatology patients.

This article employs Rittel and Webber’s ‘wicked’ problem as a heuristic device for enhancing understanding about National Assessment Program – Literacy and Numeracy (NAPLAN) testing in the Australian education context. Using a research project with seven independent schools in New South Wales, Australia, which analysed NAPLAN data from primary (elementary) students in years 3 and 5, this article highlights the ‘wicked’ nature of the problem of NAPLAN testing, and standardised testing more generally. The research project, as a catalyst for the article, evidenced a set of difficulties, particularly for smaller primary schools, and highlighted the ways in which these schools experienced many of the challenges that the literature indicates are evident in the current regimes of standardised testing. The article focusses on problematising NAPLAN’s use in Australia and uses the literature to critique its application. It then outlines Rittel and Webber’s criteria that determine whether a problem might be ‘wicked’ and applies this as a lens for considering NAPLAN testing. In problematising NAPLAN testing and applying wicked problem theory to the issue, this article asserts that many of the challenges can be managed and indeed may empower and liberate stakeholders.

Summary In health professions education, we are often interested in researching change over time, for example the development of professional identity or the adoption of new practices. Taking a longitudinal qualitative approach to such research can provide valuable insights. In this article, we present some longitudinal qualitative methods to support researchers interested in getting started with this type of research. We discuss what longitudinal qualitative approaches offer, consider the challenges and suggest how to go about it. We also highlight some specific ethical considerations that may arise in longitudinal studies.

Johnston, JL in 2015, 'Issues of professionalism and teachers: critical observations from research and the literature ', Australian Educational Researcher, vol. 42, no. 3, AbstractThe concept of 'professionalism' has become more evident in discourse about teacher quality in recent years. In fact, in some contexts 'professionalism' is used as a euphemism for quality and reform. This critical essay applies a critical theory perspective and discusses notions of educational professionalism from the academic literature. It draws on research findings about teachers' understandings of the diverse ways the term 'professionalism' is used in discussions of teacher quality, and highlights three key assumptions that appear to underpin contemporary 'professionalism' discourses. It suggests that the reification of 'professionalism' may have had a number of regrettable consequences for teachers, and challenges the apparent lack of evidence that links 'professionalism', however it might be defined, with quality educational outcomes. The essay concludes by arguing that the emergence of 'professionalism' as a signifier of quality has served to obscure and confuse many other important issues concerning the quality of teaching. Topic words: professionalism, teachers, professional development, professional learning, professionalisation, standards AbstractThe concept of 'professionalism' has become more evident in discourse about teacher quality in recent years. In fact, in some contexts 'professionalism' is used as a euphemism for quality and reform. This critical essay applies a critical theory perspective and discusses notions of educational professionalism from the academic literature. It draws on research findings about teachers' understandings of the diverse ways the term 'professionalism' is used in discussions of teacher quality, and highlights three key assumptions that appear to underpin contemporary 'professionalism' discourses. It suggests that the reification of 'professionalism' may have had a number of regrettable consequences for teachers, and challenges the apparent lack of evidence that links 'professionalism', however it might be defined, with quality educational outcomes. The essay concludes by arguing that the emergence of 'professionalism' as a signifier of quality has served to obscure and confuse many other important issues concerning the quality of teaching.

This paper, on using theory in health professions education research, is the second in a series that aims to support novice researchers within clinical education, particularly those undertaking their first qualitative study. Diving into the world of education theory can be challenging and uncomfortable for clinician-educators. Nonetheless, theory is an essential ingredient in high-quality research, shaping everything from research questions to study design, analysis and, ultimately, the interpretation of findings. We hope that this paper, introducing different levels of theory and examples of how to use theory, will shed light on how theory can be used in research, and that it will help you in getting to grips with using theory in your own work. It will help you in getting to grips with using theory in your own work.