BACKGROUND: An array of evidence shows how the presence of implicit bias in clinical encounters can negatively impact provider-patient communication, quality of care and ultimately contribute to health inequities. Reflexive practice has been explored as an approach to identify and address implicit bias in healthcare providers, including medical students. At the Lausanne School of Medicine, a clinically integrated module was introduced in 2019 to raise students\' awareness of gender bias in medical practice using a reflexivity and positionality approach. The purpose of this study is to describe the gender bias that were identified by medical students, analysing their types, places and modes of emergence during a clinical encounter. It further explores how positionality supported students\' reflection on the way in which social position modulates their relationship to patients.
METHODS: As part of the teaching activity, medical students individually reflected on gender bias in a specific clinical encounter by answering questions in their electronic portfolio. The questionnaire included a section on positionality. We qualitatively analysed the students\' assignments (n=76), applying a thematic analysis framework.
RESULTS: Medical students identified and described gender biases occurring at different moments of the clinical encounter (anamnesis (i.e. patient history), physical exam, differential diagnosis, final management). They causally associated these biases with wider social phenomena such as the gendered division of labour or stereotypes around sexuality and gender. Analysing students\' reflections on how their position influenced their relationship with patients, we found that the suggested exercise revealed a major contradiction in the process of medical enculturation: the injunction to be neutral and objective erases the social and cultural context of patients and impedes an understanding of gender bias.
CONCLUSIONS: Gender biases are present in the different steps of a clinical consultation and are rooted in broader gendered social representations. We further conclude that the tension between a quest for objectivity and the reality of social encounters should be made explicit to students, because it is constitutive of medical practice.

BACKGROUND: Lived experience researchers draw on their lived and living experiences to either lead on or inform research. Their personal experiences are relevant to the research topic and so they must manage the interplay of their health and healthcare experiences with the research, population, and data they work with, as well as the more general challenges of being a researcher. Lived experience researchers must navigate these dilemmas in addition to queries over their competency, due to issues relating to intersectionality and epistemic injustice. This justifies a motivation to better understand the experiences of lived experience researchers and develop appropriate and personalised supervision based on their preferences and needs.
METHODS: Q methodology was used to identify a collection of identity-related issues that impact lived experience researchers during PhD research in the context of the UK. These issues were presented in the form of 54 statements to 18 lived experience researchers to prioritise as topics to explore in supervision.
RESULTS: It was found that lived experiences researchers could be grouped into three distinct factors following an inverted factor analysis: Factor 1: Strengthening my identity, skills, growth, and empowerment; Factor 2: Exploring the emotional and relational link I have with the research and Factor 3: Navigating my lived and professional experiences practically and emotionally. The findings suggest that there may be three types of lived experience researchers, each with different needs from supervision, suggesting the population is heterogeneous.
CONCLUSIONS: The research identified a deeper understanding of the needs of lived experience researchers and highlights the importance of personalised supervision according to the individual needs of the researcher and their preferences for supervision. The findings reinforce the importance of integrating a clinical dimension into supervision to support the needs of all lived experience researchers.

This article highlights the importance of pausing and reflecting on one\'s motivation, capacity, and positionality when engaging in health equity research and encourages researchers to engage in critical self-reflection and contribute to the ongoing dialogue on the ethical conduct of health equity-focused cancer research. In response to the urgent need to address health disparities and improve health equity in cancer survivorship care, the Cancer Prevention and Control Research Network (CPCRN) Survivorship workgroup discussed developing a study focused on understanding how racism impacts patient engagement in cancer survivorship care. However, during the study\'s development, the workgroup recognized limitations in research team composition and infrastructure. The workgroup engaged in critical self-reflections, individually and collectively, leading to the halting of the research study. Consequently, they redirected their efforts towards strengthening the necessary infrastructure for conducting such research, including diverse investigator representation and equitable partnerships with cancer survivors. The description of this process, along with suggestions for reflection, may be helpful and informative to other researchers and research networks seeking to center marginalized voices and work in partnership to address healthcare and health equity.

Clinical reasoning is the cornerstone to healthcare practice and teaching it appropriately is of utmost importance. Yet there is little formal training for clinical supervisors in supervising this reasoning process. Distance education provides interesting opportunities for continuous professional development of healthcare professionals. This mixed methods study aimed at gaining in-depth understanding about whether and how clinical teachers can develop complex pedagogical competencies through participation in a Massive Open Online Course on the supervision of clinical reasoning (MOOC SCR). Participants self-assed their clinical supervision skills before and after partaking in the MOOC SCR through the Maastricht Clinical Teachers Questionnaire. Item scores and the distribution of response proportions before and after participation were compared using paired t-tests and McNemar\'s tests respectively. In parallel, the evolution of a subset of MOOC participants\' pedagogical practice and posture was explored via semi-structured interviews throughout and beyond their MOOC participation using simulated and personal situational recalls. The verbatim were analysed with standard thematic analysis. Quantitative and qualitative findings converged and their integration demonstrated that partaking in the MOOC SCR promoted the development of complex pedagogical competencies and reflexivity with the participants. This was quantitatively evidenced by significantly higher self-assessed supervision skills and corresponding attitudes after completing the MOOC. The qualitative data provided rich descriptions of how this progression in pedagogical practice and posture occurred in the field and how it was shaped by participants\' interaction with the MOOC\'s content and their motivations to progress. Our findings provide evidence for the development of pedagogical skills and corresponding attitudes for the supervision of clinical reasoning through participation in the MOOC SCR and contribute to the literature body on the opportunities that distance learning provides for the development of pedagogical competencies. The extent to which the pedagogical underpinnings of the MOOC contributed to these developments remains to be determined.

OBJECTIVE: To critically evaluate the concepts of harm and re-traumatization in the research process and to explore the ethical implications of conducting research on distressing topics using our research on the experiences of nurses working during the COVID-19 pandemic as an exemplar.
METHODS: Longitudinal qualitative interview study.
METHODS: Using qualitative narrative interviews, we explored the impacts of the COVID-19 pandemic on nurses\' psychological well-being in the UK.
RESULTS: To reduce the potential for harm to both research participants and researchers, the members of the research team were keen to establish ways to reduce the power differential between the researcher and participants. We found that our collaborative and team-based approach, with participant autonomy and researcher reflexivity embedded into the research framework, enabled the sensitive generation of data.
CONCLUSIONS: Reduction of potential harm for both participants and researchers in the generation of at times highly distressing data with a traumatized population was achieved through a respectful, honest and empathetic approach within a team that met frequently for reflection.
CONCLUSIONS: The research participants were not harmed by our research, instead they expressed gratitude at being given space and time to tell their stories in a supportive environment. Our work advances nursing knowledge through accentuating the value of giving autonomy to research participants to control their stories whilst working within a supportive research team with emphasis placed on reflexivity and debriefing.
UNASSIGNED: Nurses working clinically during COVID-19 were involved in the development of this study. Nurse participants were given autonomy over how and when they participated in the research process.

Gender bias interferes with medical care for both men and women, leading to health inequalities. Reflexivity is used in medical education to improve health provision. This study aims to understand if a reflective approach integrated in medical practice enables raising awareness of gender bias during medical school teaching.
We conducted this study in general ambulatory medicine in Lausanne Hospital, Switzerland with 160 Master\'s students. Through group discussions and reflection questionnaires, students were asked to discuss clinical cases they encountered focusing on potential gender bias. We analyzed the data using a thematic analysis approach.
The reflection on the clinical reasoning steps from a real case identified gender bias at each stage of the clinical case management. The analysis revealed two factors that facilitated gender reflexivity: guidance from a gender expert and peer-to-peer exchange.
Our study shows that a reflective approach integrated in medical practice enables raising awareness of gender bias during medical teaching. It provides students with a systematic method they can apply in their future clinical work, thus improving care processes and experiences towards more equitable care.
All gender and medicine curricula should include teaching such as this linking theory and practice through reflexivity.

Researchers in Human-Computer Interaction (HCI) have long developed technologies for older adults. Recently, researchers are engaging in critical reflections of these approaches. IoT for aging in place is one area around which these conflicting discourses have converged, likely in part driven by government and industry interest. This article introduces diffractive analysis as an approach that examines difference to yield new empirical understandings about our methods and the topics we study. We constructed three analyses of a dataset collected at an IoT design workshop and then conducted a diffractive analysis. We present themes from this analysis regarding the ways that participants are inscribed in our research, considerations related to transferability and novelty between work centered on older adults and other work, and insights about methodologies. Our discussion contributes implications for researchers to form teams and account for their roles in research, as well as recommendations how diffractive analysis can support other research agendas.

Young people transitioning from out-of-home care frequently have a history of maltreatment and multiple psychosocial challenges. \'Survivalist self-reliance\' - thought to involve social disconnection from others, and reluctance to seek support - provides one coping strategy. However, little is known about the self-reliant young person\'s own reflexive interpretations of social relationships and support during transition. This qualitative study addresses the question: In the context of transitioning from out-of-home care, what reflexive meanings do \'avowedly\' self-reliant individuals attribute to current social support and social relationships? Participants were four avowedly self-reliant young adults in transition from care, each with a history of maltreatment and multiple adversities. In this secondary analysis, data were from semi-structured interviews utilizing Margaret Archer\'s internal conversations interview framework. Data were analyzed using Interpretative Phenomenological Analysis (IPA). Three thematic contexts were identified in which social support was salient: (a) current thoughts and active memories of both the birth family and foster families; (b) the importance of socializing; and (c) perceptions of formal services. There was evidence of cognitive reappraisal (a known amenable resilience factor) and selective engagement with social support, despite the strong overall stance of self-reliance. The findings suggest a more nuanced approach to our understanding of \'survivalist self-reliance\'.

Visual timeline methods have been used as part of face-to-face qualitative interviewing with vulnerable populations to uncover the intricacies of lived experiences, but little is known about whether visual timelines can be effectively used in telephone interviews. In this article, we reflect on the process of using visual timelines in 16 telephone interviews with women as part of the \"STarting a family when you have an Autoimmune Rheumatic disease\" study (STAR Family Study). The visual timeline method was used to empower women to organize and share their narratives about the sensitive and complex topic of starting a family. We conducted a thematic analysis of the audio-recorded interview data, using researchers\' field notes and reflections to provide context for our understanding of the benefits of using timelines and to understand the process of using visual timelines during telephone interviews. Resource packs were sent to women before study participation; 11 of the 16 women completed a version of the timeline activity. Six themes were identified in the methodological data analysis: (1) use and adaptation of the timeline tool, (2) timeline exchange, (3) framing the interview: emphasizing that women are in control, (4) jumping straight in, (5) taking a lead, and (6) disclosing personal and sensitive experiences. The use of visual timelines facilitated interviewee control and elicited rich narratives of participants\' experiences in telephone interviews. Women created their visual timelines autonomously and retained ownership of their timeline data; these features of the data generation process need to be considered when using visual timelines in telephone rather than face-to-face interviews. Use of visual methods within telephone interviews is feasible, can generate rich data, and should be further explored in a wider range of settings.

Though the knowledge base on implementation strategies is growing, much remains unknown about how to most effectively operationalize these strategies in diverse contexts. For example, while evidence shows that champions can effectively support implementation efforts in some circumstances, little has been reported on how to operationalize this role optimally in different settings, or on the specific pathways through which champions enact change.
This is a secondary analysis of data from a pragmatic trial comparing implementation strategies supporting the adoption of guideline-concordant cardioprotective prescribing in community health centers in the USA. Quantitative data came from the community health centers\' shared electronic health record; qualitative data sources included community health center staff interviews over 3 years. Using a convergent mixed-methods design, data were collected concurrently and merged for interpretation to identify factors associated with improved outcomes. Qualitative analysis was guided by the constant comparative method. As results from the quantitative and initial qualitative analyses indicated the essential role that champions played in promoting guideline-concordant prescribing, we conducted multiple immersion-crystallization cycles to better understand this finding.
Five community health centers demonstrated statistically significant increases in guideline-concordant cardioprotective prescribing. A combination of factors appeared key to their successful practice change: (1) A clinician champion who demonstrated a sustained commitment to implementation activities and exhibited engagement, influence, credibility, and capacity; and (2) organizational support for the intervention. In contrast, the seven community health centers that did not show improved outcomes lacked a champion with the necessary characteristics, and/or organizational support. Case studies illustrate the diverse, context-specific pathways that enabled or prevented study implementers from advancing practice change.
This analysis confirms the important role of champions in implementation efforts and offers insight into the context-specific mechanisms through which champions enact practice change. The results also highlight the potential impact of misaligned implementation support and key modifiable barriers and facilitators on implementation outcomes. Here, unexamined assumptions and a lack of evidence-based guidance on how best to identify and prepare effective champions led to implementation support that failed to address important barriers to intervention success.
ClinicalTrials.gov , NCT02325531 . Registered 15 December 2014.