Supplemental digital content for O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards forreporting qualitative research: A synthesis of recommendations. Acad Med.

Supplemental Digital Appendix 1
Full List of 40 Sources Used to Develop the Standards for Reporting Qualitative Research(SRQR)(Note: This Appendix includes the 25 sources listed in Table 2 as well as the additional 15
sources used to develop the SRQR items. Table 2 presents the 25 most complete sources ofrecommendations identified by the authors and shows how the SRQR items map to original
sources.)

1.

Attree P, Milton B. Critically appraising qualitative research for systematic reviews. Evid
Policy. 2006;2:109–126.

2.

Blaxter M. Criteria for the evaluation of qualitative research. Med Sociol News.
1996;22:34–37.

3.

Bordage G, Caelleigh AS. A Tool for Reviewers: Review Criteria for Research
Manuscripts. Acad Med. 2001;76:904–951 and Appendix 1: Checklist of Review
Criteria:958–959.

4.

Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research:developing taxonomy, themes, and theory. Health Services Research. 2007;42:1758–1772.

5.

Britten N, Jones R, Murphy E, Stacy R. Qualitative research methods in general practiceand primary care. Family Practice. 1995;12:104–114.

6.

Burns N. Standards for qualitative research. Nurs Sci Q.1989;2:44–52.

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7.

Cohen, D, Crabtree, B. Guidelines for designing, analyzing, and reporting qualitative
research. Qualitative Research Guidelines Project, Robert Wood Johnson Foundation;
2006. http://qualres.org/HomeGuid-3868.html. Accessed April 8, 2014.

8.

Cohen D, Crabtree B. Evaluative criteria for qualitative research in health care:
controversies and recommendations. The Annals of Family Medicine. 2008;6:331–339.

9.

Côté L, Turgeon J. Appraising qualitative research articles in medicine and medical
education. Med Teach. 2005;27:71–75.

10.

Critical Appraisal Skills Program (CASP). Critical Appraisal Skills Programme (CASP)
Qualitative Research Checklist; 2013. http://www.casp-uk.net/wpcontent/uploads/2011/11/CASP-Qualitative-Research-Checklist-31.05.13.pdf. Accessed
April 8, 2014.

11.

Devers KJ. How will we know “good” qualitative research when we see it? Beginning the
dialogue in health services research. Health Services Research. 1999;34(Pt 2):1153.

12.

Duran RP, Eisenhart MA, Erickson FD, et al. Standards for reporting on empirical social
science research in AERA publications. Educational Researcher. 2006;35:33–40.

13.

Elder, NC, Miller, WL. Reading and evaluating qualitative research studies. The Journalof Family Practice. 1995;41:279–785.

14.

Elliott R, Fischer CT, Rennie DL. Evolving guidelines for publication of qualitative
research studies in psychology and related fields. British Journal of Clinical Psychology.

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Supplemental digital content for O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards forreporting qualitative research: A synthesis of recommendations. Acad Med.

1999;38:215–229.
15.

Fade SA. Communicating and judging the quality of qualitative research: The need for a
new language. Journal of Human Nutrition and Dietetics. 2003;16:139–149.

16.

Fossey E, Harvey C, McDermott F, Davidson L. Understanding and evaluating qualitative
research. Australian and New Zealand Journal of Psychiatry. 2002;36:717–732.

17.

Frambach, JM, van der Vleuten, CPM, Durning, SJ. AM Last Page: Quality criteria inqualitative and quantitative research. Acad Med. 2013; 88:552.

18.

Giacomini M, Cook, DJ. Users’ Guides to the Medical Literature: XXIII. Qualitative
Research in Health Care A. Are the Results of the Study Valid? JAMA. 2000; 284:357–
362.

19.

Giacomini M, Cook, DJ. Users’ Guides to the Medical Literature: XXIII. Qualitative
Research in Health Care B. What Are the Results and How Do They Help Me Care for
My Patients? JAMA. 2000;284:478–482.

20.

Inui, T, Frankel, R. Evaluating the quality of qualitative research: A proposal pro tem.
JGIM. 1991;6:485–486.

21.

Kitto SC, Chesters J, Grbich C. Quality in qualitative research. Med J Aust. 2008;188:243.

22.

Knafl, KA, Howard, MJ. Interpreting and reporting qualitative research. Res Nurs Health.
1984;7:17–24.

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23.

Kuper A, Lingard L, Levinson W. Critically appraising qualitative research. BMJ.
2008;337:687–689.

24.

Law M, Stewart D, Letts L, Pollock N, Bosch J, Westmorland M. Guidelines for thecritical review of qualitative studies. McMaster University Occupational Therapy
Evidence-Based Practice Research Group; 1998.
http://www.usc.edu/hsc/ebnet/res/Guidelines.pdf. Accessed April 20, 2014.

25.

Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet.
2001;358:483–487.

26.

Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative
research. BMJ. 2000;320:50.

27.

Meyrick J. What is good qualitative research? A first step towards a comprehensive
approach to judging rigour/quality. Journal of Health Psychology. 2006;11:799–808.

28.

Morse JM. A review committee’s guide for evaluating qualitative proposals. Qual HealthResearch. 2003;13:833–851.

29.

Newman M, Elbourne D. Improving the usability of educational research: guidelines for
the REPOrting of primary empirical research Studies in Education (The REPOSE
Guidelines). Evaluation & Research in Education. 2004;18:201–212.

30.

Pearson A, Field J, Jordan Z. Appendix 2: Critical Appraisal Tools. Evid.-Based Clin. Pr.
Nurs. Heal. Blackwell Publishing Ltd.; 2009:177–182.

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Supplemental digital content for O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards forreporting qualitative research: A synthesis of recommendations. Acad Med.

http://onlinelibrary.wiley.com/doi/10.1002/9781444316544.app2/summary. Accessed
April 13, 2014.
31.

Popay J, Roger A, Williams G. Rationale and standards for the systematic review ofqualitative literature in health services research. Qual Health Res. 1998;8:341–351.

32.

Rowan M, Huston P. Qualitative research articles: information for authors and peer
reviewers. Can Med Assoc J. 1997;157:1442–1446.

33.

Russell CK, Gregory DM. Evaluation of qualitative research studies. Evidence Based
Nursing. 2003;6:36–40.

34.

Ryan GW. What are standards of rigor for qualitative research; 2005.
http://www.wjh.harvard.edu/nsfqual/Ryan%20Paper.pdf Accessed April 20, 2014.

35.

Sale JEM. How to assess rigour . . . or not in qualitative papers. J Eval Clin Pract
2008;14:912–913.

36.

Sandelowski M, Barroso J. Writing the Proposal for a Qualitative Research Methodology
Project. Qual Health Res. 2003;13:781–820.

37.

Stige B, Malterud K, Midtgarden T. Toward an agenda for evaluation of qualitative
research. Qual Health Res. 2009;19:1504–1516.

38.

Stiles WB. Evaluating qualitative research. Evidence Based Mental Health. 1999;2:99–
101.

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Supplemental digital content for O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards forreporting qualitative research: A synthesis of recommendations. Acad Med.

39.

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research(COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care.
2007;19:349–357.

40.

Webb, C. Editor’s note: Introduction to guidelines on reporting qualitative research.
Journal of Advanced Nursing. 2003;42:544–545.

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Supplemental digital content for O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards forreporting qualitative research: A synthesis of recommendations. Acad Med.

Supplemental Digital Appendix 2
Explanations and Examples of the 21 Items from the Standards for Reporting Qualitative
Research (SRQR) that the Authors Consider Essential for Complete, Transparent
Reporting of Qualitative Research
In this Appendix, we provide explanations to accompany the qualitative reporting standards(SRQR) presented in Table 2. We recognize that authors may not be able to report on all
recommended elements within each item. Correspondingly, we recommend that authors consider
each item and prioritize elements that are most relevant to the given study, findings, context, andreadership. We also acknowledge that some publishing traditions, journal requirements, andpersonal preferences may dictate a different sequence or organization of the information
reported.

We identified recent (2011-2013) examples from journals that frequently publish qualitative
research in medical education (Academic Medicine, Advances in Health Sciences Education,
Medical Education, Medical Teacher) to illustrate each standard.

TITLE AND ABSTRACT

Item 1. Title: Concise description of the nature and topic of the study. Identifying the study as
qualitative or indicating the approach (e.g., ethnography, grounded theory) or data collection
methods (e.g., interview, focus group) is recommended.
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Explanation:
The authors should provide a title that clearly conveys the topic of the study.1,2 We suggest thatthe title indicate that the study is qualitative or include a commonly used term that identifies theapproach (e.g., ethnographic study, grounded theory) or data collection methods (e.g.,interviews, focus groups, observations). 1,2 This allows readers and reviewers to quickly identify
the type of study.

Examples:Residents learning from a narrative experience with dying patients: a qualitative study.3

Medical students' perceptions of the factors influencing their academic performance: an
exploratory interview study with high-achieving and re-sitting medical students.4

Undergraduate rural medical education program development: focus group consultation with
the NRHA Rural Medical Educators Group.5

Item 2. Abstract: Summary of key elements of the study using the abstract format of the intended
publication; typically includes background, purpose, methods, results, and conclusions.

Explanation:
A reader should be able to read the abstract independent of the manuscript and get a sense of the
background, purpose, methods, main results and implications that will be described in greater

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detail in the manuscript. The information presented in the abstract should be consistent with theinformation presented in the full text.2

The abstract's structure typically needs to conform to journal guidelines, but authors shouldattempt to include the following:Background about the problem or phenomenon of interest

Description of the study purpose or research question;



Methods, including the approach or perspective (e.g., general inductive, groundedtheory), context (setting, time period), sample (number and key characteristics ofparticipants, events, documents), data collection strategies (e.g., observation, interview,
focus group) and data analysis techniques

Description of main findings (e.g., themes or inferences) related to the study purpose
and/or research questionStudy implications 1,2

In some cases the journal’s structured abstract format aligns more with positivist paradigms andquantitative approaches than with qualitative traditions, so translation may be necessary. For
example, what might be labeled “findings” in many qualitative research traditions could bereported as “results” in the abstract.6

Example:Purpose: Although academic centers rely on assessments from medical trainees regarding theeffectiveness of their faculty as teachers, little is known about how trainees conceptualize andapproach their role as assessors of their clinical supervisors.
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Method: In 2010, using a constructivist grounded theory approach, five focus group interviews
were conducted with 19 residents from an internal medicine residency program. A constantcomparative analysis of emergent themes was conducted.

Results: Residents viewed clinical teaching assessment (CTA) as a time-consuming task withlittle reward. They reported struggling throughout the academic year to meet their CTA
obligations and described several shortcut strategies they used to reduce their burden. Rather
than conceptualizing their assessments as a conduit for both formative and summative feedback,residents perceived CTA as useful for the surveillance of clinical supervisors at the extremes ofthe spectrum of teaching effectiveness. They put the most effort, including the crafting of writtencomments, into the CTAs of these outliers. Trainees desired greater transparency in the CTA
process and were skeptical regarding the anonymity and perceived validity of their faculty
appraisals.

Conclusions: Individual and system-based factors conspire to influence postgraduate medical
trainees’ motivation for generating high-quality appraisals of clinical teaching. Academic
centers need to address these factors if they want to maximize the usefulness of theseassessments. 7

INTRODUCTION

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Item 3. Problem Formulation: Description and significance of the problem/phenomenon studied;review of relevant theory and empirical work; problem statement.

Explanation:
The problem formulation typically appears in the introduction and describes the theoretical
and/or practical issues or concerns that make the study necessary. It should provide an overview
of what is known about the problem, highlight gaps in current knowledge (the problem
statement), and define the scope of the research problem or phenomena addressed in the study(what will and will not be included).8 It should include a review of theoretical and/or empirical
work directly relevant to the problem or phenomena studied.1,9 The problem formulation should
be described in a way that suggests the need for a qualitative approach (e.g., to elucidate poorly
defined or previously unexplored constructs, to generate theories or to develop causal
explanations connecting processes and outcomes, to understand phenomena as they naturally
occur and the role of context, to explore problems involving high complexity, to gain insight into
participants’ perspectives when such insight is lacking).10–12

Example:Regulatory focus theory may therefore offer insight into the variability in responses to feedback,but how well do these experimental findings translate to real clinical situations in which thereality of responsiveness to feedback seems frustratingly complex? …. In order to betterelaborate a theory to account for this variability in learner response to feedback, the present
study was undertaken. We aimed, in this study, to determine how readily clinical learning events
could be classified as activating a promotion or a prevention focus, and to explore, through a
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careful analysis of doctors’ descriptions of their feedback experiences, the predictive value of
regulatory focus theory in the context of real clinical learning situations.13

Item 4. Purpose or research question: Purpose of the study and specific objectives or questions.

Explanation:
In qualitative research, as in all types of research, the authors should include a statement of study
intent. This statement can be framed as one or more research questions, purposes, goals, orobjectives. Qualitative studies often explore “how” and “why” questions related to a social or
human problems or phenomenon, and they are designed to enhance readers’ understanding of aproblem or phenomenon.8,10,12,14 By clearly stating the purpose of the study, authors set readers’expectations for the methods, findings and discussion sections of the manuscript.11

Example:The purposes of this study were to investigate how medical students recognize, respond to andutilise feedback, and to determine whether there are maturational differences in understandingsof the role of feedback across academic years in medical school.15

METHODS

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Item 5. Qualitative approach and research paradigm: Qualitative approach (e.g., ethnography,
grounded theory, case study, phenomenology, narrative research) and guiding theory if
appropriate; identifying the research paradigm (e.g., post-positivist, constructivist/interpretivist)is also recommended; rationale.

Explanation:
The research paradigm is the set of beliefs and assumptions that guide the research process.
These commonly include positivist, post-positivist, constructivist or interpretivist, and criticaltheory.16 Qualitative research generally draws from a post-positivist or
constructivist/interpretivist paradigm.17,18 We recommend identifying the research paradigm sothat readers understand whether the researcher assumes that there is a single, objective reality(positivist or post-positivist) and has thus designed the study to describe this reality or whether
the researcher assumes multiple, subjective realities and designed the study to describe these
multiple realities, with no attempt to merge or reconcile these realities(constructivist/interpretivist). The paradigm has implications for the study design, approach,methods, and techniques to ensure rigor and trustworthiness.16

Qualitative research includes an array of approaches and methodologies, both general (e.g.,qualitative content analysis,19,20 general inductive approach21) and specific (e.g., ethnography,22,23
grounded theory,24,25 phenomenography26,27). Since the research paradigm does not necessarily
dictate particular approaches or methods,17 the approach should also be clearly defined. Stating
the approach provides readers the opportunity to evaluate the fidelity of the research approach to
the research question(s) and consider the rationale for modifications and deviations from the
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selected approach. Qualitative research also includes an array of methods that can be used acrossparadigms and approaches. (See also Item 10) The researcher should explain why the selected
approach is appropriate for the research question, and provide references to theories or traditions
that guide the use of the approach as needed.1,28

Examples:The study was performed from a constructivist point of view using an interpretative
phenomenological epistemology.[REFs] Based on the notion that social phenomena areconstructed by the communal making of meaning about the underlying phenomena, we aimed toconstruct insightful accounts of lead consultants’ approaches to educational change, rather than
to identify the ‘true’ nature of these approaches. Because the management of change by lead
consultants is an under-researched area, we conducted an exploratory qualitative study…29

Given the relative dearth of explanatory theories about factors affecting medical students’emotional reactions, we chose to develop one by applying methods associated with groundedtheory, specifically constant comparative analysis, [REF] to qualitative data obtained fromlearning logs and interviews. Our approach was constructivist, [REF] deliberately using
researchers’ own experiences and acquired knowledge to enhance theoretical sensitivity andenrich theory development.30

Item 6. Researcher characteristics and reflexivity: Researchers’ characteristics that may influence
the research, including personal attributes, qualifications/experience, relationship with
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participants, assumptions, and/or presuppositions; potential or actual interaction between
researchers’ characteristics and the research questions, approach, methods, results and/ortransferability.

Explanation:
Reflexivity refers to intentional, systematic consideration of the potential or actual effects of theresearcher(s) on all aspects of the study process.31,32 In positivist and post-positivist paradigms,
personal characteristics and perspectives of researchers might be viewed as biases that limit thecredibility of study findings, while in constructivist or interpretivist paradigms the characteristics
and perspectives of the researchers are important contextual factors that are an accepted part ofthe study design, data collection, and data analysis. These characteristics and perspectives may
explain how the researcher(s) obtained access to the site or participants included in the study or
may add valuable insight during data analysis.

To demonstrate reflexivity, authors should describe important personal characteristics andperspectives of members of the research team that may influence design, data collection, anddata analysis. Relevant personal characteristics might include cultural background, occupation,
experience, training, position/ power dynamics, gender, race/ethnicity, and sponsoring
institution. Authors should also describe the perspectives, assumptions, prior knowledge,
preliminary hypotheses, and/or motives (the "stance") of the members of the research team.33

Authors also should describe the researchers’ relationships to participants in the study and what
decisions were made in light of these relationships. 8,10,33,34 For example, were any members of
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the research team part of the sample of potential participants in the study? Do any members of
the team teach, supervise, or have any authority over participants in the study? If so, how dothese characteristics influence choices about their roles in data collection and analysis? For
observational research (e.g., ethnography), it is also important to identify the role of theresearcher along a spectrum from passive observer (no involvement in the activity studied) toparticipant-observer (ranging from some limited involvement in the activity to full
involvement).6,17,33

There is no expectation that the study could be precisely replicated; these characteristics andperspectives of the researcher should not be mentioned in the limitation section.35 (See also Item
14.)

Example:Reflexivity was maintained by the research team through the analysis and writing by recording,
discussing and challenging established assumptions. In addition both EH and SV kept reflexive
diaries.36

The first author conducted all interviews and discussion groups. Her own medical
undergraduate training took place between 1995 and 2000. She was not known to theparticipants of this research prior to undertaking the study and deliberately did not undertakeany clinical or teaching activities locally alongside this research. Whilst it was useful to ‘know’(from her own background) what the students were talking about medically (and in terms ofdetecting items of significance), as a researcher she made conscious efforts not to accept
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potentially common assumptions at face value.37

Item 7. Context: Setting/site and salient contextual factors; rationale.

Explanation:
The authors should describe the setting/site(s) in which the study was conducted, the reason(s)why the setting/site(s) was selected, and the salient cultural, political, historical, economic and/or
other external factors that influence the study. This information helps readers interpret themeaning and significance of the study findings by situating them in social, cultural, temporal andother relevant contexts.6,8,10,33 Additional context may be reported with findings (i.e., the Results
section) to add evidence for interpretations and to enhance discussion of transferability.34,38,39

Example:We conducted the study among hospital-based clinical teachers of students in years 4 to 6 of a
six-year undergraduate medical program at Maastricht University Medical School. Years 4 to 6
are devoted to clerkships in the academic hospital and affiliated regional hospitals. Rotations
differ in duration depending on the type of rotation and the discipline, and the sequence ofrotations differs among students. During rotations, students spend time in the wards, theoutpatient clinics, and the accident and emergency department. Clerkships in years 4 and 5 last
between 4 and 10 weeks (“regular clerkship”), whereas students in year 6 undertake an 18-week“senior clerkship” in a discipline of their choice.40

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Item 8. Sampling strategy: How and why research participants, documents, or events wereselected; criteria for deciding when no further sampling was necessary (e.g., sampling
saturation); rationale.

Explanation:
The authors should describe how and why research participants, documents, and/or events wereselected for inclusion in (and, if appropriate, exclusion from) the study, along with a justification
for this strategy.6,8,28,33,39 We recommend that authors describe the sampling strategy rather thansimply labeling the strategy (e.g., "purposive" or "snowball"), since such labels do not have auniversally accepted definition and, more importantly, since procedures tend to be studyspecific.28,41,42 Several sampling strategies are commonly used in qualitative research, althoughmost fall under the umbrella of purposeful (or purposive) sampling. Purposeful sampling meansthat participants, documents, or events are selected for their relevance to the research question,
based on guiding theory or experiences and assumptions of the researchers.32,33,43 Over thecourse of the research process, researchers may determine that additional or different
participants, documents, or events should be included to address the research question. Other
sampling techniques, such as theoretical sampling (seeking examples of theoretical constructs),
snowball sampling (using study participants to identify additional participants who meet study
criteria), and convenience sampling (including any volunteers with no or minimal criteria forinclusion) may be appropriate depending on the question and approach, so long as the authors
provide explanation and justification.32,43

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Although investigators often do not determine sample size a priori in qualitative research, theyshould nonetheless describe how they established the final sample size. When appropriate (e.g.,when a flexible sampling strategy was used), they should explain the criteria used to decide when
no further sampling was necessary.6,39,41,44 If data collection ends at the point when the
researchers determine that “saturation” has been reached, then the specific criteria used to define
saturation should be described.1,17,33,44

Procedures used to recruit participants should also be described, including who was involved inrecruitment, what their relationship was to participants, how and when recruitment occurred, andwhy these procedures were selected.6,8,28 (See also Item 6)

Examples:As students’ perceptions were previously shown to be related to gender, age, prior experienceand place of attachment,[REF] we purposely selected respondents with different backgrounds. This
sampling strategy led to the diversity of gender, age, prior patient experience and place of
attachment shown in Table 1.45

Purposive sampling was directed towards achieving maximum variation in age and specialty,
using a snowball approach (‘a non-probabilistic form of sampling in which persons initiallychosen for the sample are used as informants to locate other persons having necessary
characteristics making them eligible for the sample’).[REF ] 46

Potential participants were all medical students in Years 1 and 2 at the University of
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Toronto in 2004. Following research ethics board approval, recruitment was conducted via email to class listservs. Participant responses were sent directly to the research assistant, who
was unknown to participants, so that the principal investigators did not know who did or did notparticipate. This process was engaged to protect participants’ anonymity and to avoid any
impression of coercion because the lead researcher (SG) was involved in the administration of
the undergraduate curriculum at the time. Sample size was estimated to be sufficient based on
the principle of theoretical saturation [REF] and our previous experience with this methodology(i.e., with a relatively homogeneous population, we expected to reach saturation withapproximately 15 interviews per group). There were no exclusion criteria and we accepted thefirst 15 students from each class who volunteered.47

Item 9. Ethical issues pertaining to human subjects: Documentation of approval by anappropriate ethics review board and participant consent, or explanation for lack thereof; otherconfidentiality and data security issues.

Explanation:
Qualitative research often involves interaction between researchers and research participants.
Correspondingly, researchers should ensure that participants are fully aware of their participation
in a research study, the risks and benefits associated with the study, the steps and precautions theresearchers will take to minimize risks, such as loss of privacy and confidentiality, and how the
researchers plan to use the data.8,28 Authors should report approval for the study from anappropriate institutional review board for research associated with human subjects.28 They
should describe procedures used to protect participants, including data collection (e.g.,
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recruitment and informed consent),44 analysis (e.g., data security and integrity),44 and reportingof findings (e.g., anonymization of excerpts).48 If researchers provided compensation or offered
incentives to facilitate participation, this should be reported.1

Example:Ethical approval was granted by the University of Otago and student participants were invited toattend each focus group discussion by the university representatives of New Zealand Medical
Students Association (NZMSA). Usually, a key concern when collecting data from students isthat students may feel vulnerable when sharing their experiences with academic staff during a
focus group discussion. However, this potential harm was removed as each group discussion
was facilitated by a fellow student, the discussions were transcribed by a professionaltranscribing service, and only the primary researchers [Names]had access to the raw data.49(See also reference #47 under Item 8.)

Item 10. Data collection methods: Types of data collected; details of data collection procedures
including (as appropriate) start and stop dates of data collection and analysis, iterative process,triangulation of sources/methods, and modification of procedures in response to evolving study
findings; rationale.

Explanation:
Qualitative research encompasses an array of data collection methods appropriate for various
paradigms and approaches, including (but not limited to) interviews, focus groups, observations
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(direct or indirect via video), and review of written text, photographs, and other documents ormaterials. Researchers may choose to use information from multiple sources, contexts, and/ortime points depending on their approach and research question(s).33,38 (See Item 11 fortriangulation.) Given this diversity of methods, authors should describe in detail their datacollection design and method(s) and justify them in relation to the research question(s),paradigm, approach, and other methods.1,28,39 Methods used to decide when to end datacollection should also be described (see Item 8).

Qualitative research often occurs as an iterative process, meaning that researchers begin data
analysis before they complete data collection.1,38 The data collection and analysis process may
occur in phases or stages, and thus authors must clearly describe the iterative process of datacollection and analysis.11,41 As part of an iterative collection-analysis process, researchers willoften alter their data collection methods to explore their preliminary impressions in greater depth
and/or actively pursue confirming and disconfirming perspectives. If such changes occur during
the research process, authors should describe how and why study procedures changed in
response to evolving study findings.1,11,39,48

The study period (start and end dates for data collection and analysis) should be identified so thatreaders can place the study in temporal context and identify factors not mentioned by the authorsthat might affect findings, interpretation, and implications.1,33 (See Item 8 for ending datacollection.)

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Authors should describe important characteristics of the individuals conducting interviews,
observations or focus groups, and methods used to train these individuals.8,44 This information
clarifies the relationship between the individuals involved in data collection and the participantsin the research and also explains what efforts were made to ensure consistency in the datacollection process 8,11 (See Items 6 and 15.)

Example(s):Further, it was decided that group interviews, also known as focus group discussions would be
the best means of data collection. This is a method of data collection that enables groupmembers to feed off each other's ideas and an effective moderator will maintain group focus
whilst at the same time permitting flexibility in the direction those aspects of the discussion might
take. [REF] 49

Adjustments to the interview protocol were made according to early experience and information
participants had provided (i.e. redundant questions were eliminated; questions were reworded to
improve flow and clarity; additional probes were included).50

Faculty staff were then interviewed individually by a trained study investigator in a 15-minute,semi-structured interview. This sequence was repeated with other video encounters. Table 2
presents examples of interview questions. Each faculty member was interviewed by at least threeinterviewers over their various interviews. Interviewers were chosen based on their experience
in interviewing. All were trained during a half-day meeting to interpret and deliver the interview
guide in the same manner in order to elicit information of a consistent type.50
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Item 11. Data collection instruments and technologies: Description of instruments (e.g.,interview guides, questionnaires) and devices (e.g., audio recorders) used for data collection;
if/how the instrument(s) changed over the course of the study.

Explanation:
Data collection for qualitative research draws upon a variety of instruments or tools, including(but not limited to) interview or focus group guides, observational protocols and prompts forfield notes, and data extraction or coding protocols for selection and analysis of documents,
photographs, videos, or other artifacts.33 The authors should describe all such instruments,
guides, and protocols, including their development and cite relevant literatures, theories orconceptual frameworks as appropriate.1 It is often helpful for authors to provide access to thedata collection instrument(s) or a detailed description of them.

The authors should also describe the use of equipment for audio or video recording, reproductionof paper documents or computer files, or other processes in data collection. This is relevant so
readers understand the full context in which data collection occurred and how this context might
have affected data collection (e.g., the influence of recording devices on participants' behaviors;
the nature of inferences drawn from live vs. recorded events).33

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To facilitate the discussion and to maintain consistency over different sets of discussions, key
trigger questions were devised prior to the discussion. The opening trigger question was:‘Thinking back to some of your best clinical learning placements in 4th and 5th year. What wasit about those clinical placements that provided good opportunities for learning?’ 49

Interviews included discussion of the expectations, processes and consequences of AEE[authentic early experiences]. The interview schedule was derived following identification ofquestions that could not be fully answered in a systematic review of previous empirical ortheoretical literature. It comprised a sequence of topic areas including experiences in action,
and areas of frustration in Medical Education such as the learning of content knowledge,
achieving functional knowledge, and transfer of knowledge.[REF]… Interested readers canrequest a copy of the schedules from the corresponding author. Interviews lasted between 20 and
90 min. and discussion groups between 60 and 90 min. All interviews and discussion groups
were conducted in private rooms at the participant’s workplace—the medical school for students
and faculty, and individual places of work for workplace supervisors (except for one who choseto be interviewed at the medical school). All data were audio-recorded, and transcribedverbatim.37

Item 12. Units of study: Number and relevant characteristics of participants, documents, or
events included in the study; level of participation.

Explanation:

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Authors should describe the participants, documents, or events included in the study (the units ofstudy).1,33 The sampling item (Item 8) describes the target or ideal participants, documents, or
events selected for the study. By contrast, Item 12 focuses on description of the actual
participants, documents or events included in the study. Authors should describe how the actual
participants, documents, or events differ from the targeted sample, why these differences may
have occurred, and how this might affect the findings.

Authors should describe characteristics of the participants, documents or events that are relevantto the study purpose and research question(s).1 For participants, this might include age, gender,
profession, institution, year of training, or relationship to the researcher and/or other participantsin the study.33 For documents, this might include the source, intended audience, date, or type of
document. For events, this might include the location, date(s), length, characteristics ofattendees or participants in the event, or mood or emotional climate. If the degree of participation
varied among individuals (e.g., multiple occasions; interviews and observations), the authors
should describe different levels of participation.33,44 For example, if some participants wereobserved and interviewed and others only interviewed, or if some participants completed
multiple interviews and others completed a single interview, these variations should be
explained. Authors should also explain the reasons for these differences (i.e., the researchers’
choice or the participants’ preferences) and how these different levels of participation were taken
into account in the analysis. Authors should also include the dates or timeframe for participation.

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This information about participants could appear in the Methods section as part of the descriptionof the sample, or at the beginning of the Results section to provide context for the findingspresented.

Example:Of the 70 Mindful Communication program participants, 46 met the eligibility requirements toparticipate in the in-depth interviews. We randomly chose and then contacted 22 participants, ofwhom 20 agreed to be interviewed within six months of completing the program: 15 in personand 5 by telephone. Two declined for lack of time. On reaching saturation after 20 interviews, nofurther attempts to contact the remaining 24 participants were made.51

There were 31 nursing handovers covering 137 patients, and 21 resident handovers covering
101 patients included in this study.52

Item 13. Data processing: Methods for processing data prior to and during analysis, includingtranscription, data entry, data management and security, verification of data integrity, datacoding and anonymization / de-identification of excerpts.

Explanation:
Authors should describe the ways in which data are prepared for analysis and managed
throughout the analysis process.28 These activities might include transcription, coding, data
entry, and organization of data. When processing audio or video recordings, relevant details
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might include indication of verbatim transcription of dialogue, additional notes to capture nonverbal information (especially for group interviews or focus groups), and annotations to indicate
vocal inflections and utterances, as appropriate for the analytic approach.1,39 Authors should also
describe procedures used to check transcripts for accuracy.

Authors should describe the processes used to organize, compile, and categorize data (e.g., fieldnotes, transcripts, documents, photographs, artifacts) for analysis.

Authors should describe procedures used to maintain data security and protect the privacy ofparticipants, as specified in the human subjects protocols.48 For example, if data are anonymized,
the authors should explain how and at what point in the process this occurred. Authors may
choose to use anonymous labels or identifiers to represent quotes or excerpts from uniqueparticipants, documents or events, in order to reflect the variety of sources from which such data
were derived.

Examples:Interviews were anonymised and each participant was given a code number.46

The interviewers and another member of the research team (H.B.) reviewed transcripts for
accuracy.51

We collected data throughout the admission process through direct observation, audiorecording, and chart extraction. We audio-recorded, transcribed, and anonymized both the
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overnight and morning case review discussions. We also observed the morning case review
discussions in person and collected field notes. For each case review discussion, we copied theadmission notes from the patient’s record and de-identified all data.53

Item 14. Data analysis: Process by which inferences, themes, etc. were identified and developed,
including the researchers involved in data analysis; usually references a specific paradigm orapproach; rationale.

Explanation:
Techniques used for data analysis will depend on the paradigm, approach, and/or data collection
methods selected by the researchers. Correspondingly, authors should be as transparent as
possible about the analytic process so that readers can follow the logic of inquiry from theresearch question(s) to the analysis and findings. For example, this description may involve
characterizing the processes and decisions made for initial classification or segmentation of data,
pattern identification and description, and/or development of in-depth interpretations.1 If theresearchers used an approach that has a well-defined process for data analysis (e.g., groundedtheory, discourse analysis, phenomenography), the authors should cite the guiding literature anddescribe their processes in sufficient detail so readers can judge the extent to which the processesalign with the guiding approach. If modification to or deviations from the guiding approachoccurred, the authors should explain and justify these modifications.

Authors should specify the unit of analysis.1 In qualitative research, the unit of analysis is notnecessarily the same as the unit of sampling (e.g., individual participants or events). Instead,
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some approaches use specific events as the unit of analysis, such as mentions of a particular topic
or experience, or observations of a particular behavior or phenomenon, while others use groups
rather than individual group participants. This specification has implications for how the data areorganized and analyzed as well as the inferences drawn from the data.39

Authors should explain the rationale underlying different decisions made throughout the data
analysis process to provide as much transparency as possible. In some approaches researchers
use memoing or bracketing to make their reflections, interpretations, and links among passages
explicit and more transparent to others.33,54 In some types of analysis, participants’ perspectives
or observations that contrast or deviate from the concepts or themes identified by the researchers
are an important part of the analysis. In such cases, the authors must describe how these
discrepancies were handled during the analysis.10,28,32,34,55

During the analysis process, researchers may draw upon a theoretical perspective or framework,
which may have been identified early in the conception of the study or may be identified by the
researchers after reviewing some or all of their data.31,54 Either way, the authors should describe
theoretical or other influences on their analysis scheme or categories if they exist.31 Sometimes
these are referred to as “sensitizing concepts” to acknowledge that the approach is inductive, butwith influence from relevant theory, models, or organizational schemes.56,57 Alternatively,
themes may be developed from the data with no external influences.58

Authors should describe which members of the research team are involved in data analysis andwhat perspective(s) they bring to the analysis. Authors should also indicate if any software was
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used to assist with data analysis and how it was used (e.g., used to apply codes after the final
coding scheme was developed; to extract coded passages for further synthesis and identificationof themes; or to identify passages with key words).6,33 Simply stating that software was used isinsufficient.31,39,54

Example:…we brought sensitizing concepts to the analysis while we conducted an open, inductive
analysis.[REF]In this case the sensitizing concepts arose, a priori to analysis, from a framework
derived from the literature [REF] (as described above), in which participants’ motivations to act
are based on principles of professionalism, internal affect, or potential implications of theiractions. [REF] 59

Through an iterative process of listening, discussing, and relistening, the team identified andconsensually validated emerging themes[REF] and appended segments of dialogue supporting the
proposed themes. Recruitment stopped when saturation was reached (no new themes wereidentified). The team systematically reviewed the themes and sorted them into content domains.
The team used an analytic matrix to identify patterns and connections amongst the domains. Twoof us not involved in the qualitative coding process (R.E., M.K.) audited the analytic matrix,
choice of quotes, and thematic analysis.51

The analysis started after the first interview. All data were analyzed with the aid of the audiocoding facility of the NVivo 8: QSR International Pty Ltd, Doncaster, Vic, Australia programme.
First, [name] and [name] coded independently from one another, making sure to stay
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semantically close to the participants’ wording. Then we discussed these open codes and defined
axial codes.[REF] New insights about the impact of CST were written down in memos.60

Videotapes were analysed using immersion/crystallisation methods of qualitative data
analysis.[REF] With no pre-existing framework developed in advance for analysis, an inductive
approach was used to discover patterns of NVB in the data. A team of six researchers met weeklyfor 18 months to view videos together. Using a consensus-building approach based on a
combination of field notes, ‘opportunistic’ interviews with the participants, and repeated viewingof the same material, sometimes many months apart, we eventually achieved consensus on
verbal, non-verbal, and physical themes and patterns observed in the data. Finally, as a test of‘goodness-of-fit,’ we carefully reviewed the videotapes for any ‘deviant’ cases that did not fit thecategories we had developed.52

All transcripts were coded thematically by four of the five authors, who met regularly to identify
areas of convergence until full agreement was reached. One of the interviewers (P.M.)
maintained an audit trail to track the team’s developing thinking. A process of dialecticalempiricism[REF] was used to categorise the emergent themes into more abstract concepts...46

Item 15. Techniques to enhance trustworthiness: Techniques to enhance trustworthiness andcredibility of data analysis,(e.g., member checking, triangulation, audit trail); rationale.

Explanation:

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Authors should describe methods used to ensure trustworthiness and credibility throughout thedata collection and analysis process. Such methods will depend on the paradigm, approach,
and/or methods used. Correspondingly, the authors should explain their choice of techniques andwhy these are appropriate for the particular study.31,61,62

Commonly used techniques to enhance trustworthiness include: member checking; triangulationof data sources, methods, and/or researchers; creation of an explicit audit trail; and immersion in
the site of data collection for an extended period of time (especially for research in which anobserver's presence is likely to disrupt the phenomenon under investigation).10,28,32,43,63 Member
checking involves sharing findings, such as descriptions of key phenomena, themes, or an
explanatory model, with participants and asking them to verify the accuracy or resonance with
their perspectives.6,8,33 Triangulation involves using more than one data source, method, or
researcher to add diverse perspectives on the findings of the study and, in some approaches, totest the transferability or generalizability of a model.6,28,39 An audit trail involves careful
documentation of all decisions made throughout the study, from initial conceptualization to study
design, sampling, analysis, and reporting, to provide transparency and to enable an external
researcher to review all the steps involved in the study.32,34,43

Examples:Member checking
Member checks [REF] with an external TBL expert (R.L.) supported the validity of theseanalyses.64

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Triangulation of data types and data sources
The interview data were triangulated with the data of 11 student and supervisor focus groups ofa previous study, and more specifically, with those data that concern in particular the influenceof CST [Communication Skills Training] on the development of patient-centredness.…
Triangulation with the focus group data allowed us to broaden the in-depth information from theinterviews in the analysis and to ‘share and compare’ this with information from students anddoctors with varying levels of CST (no, limited, full programme) and from two universities(Universities of Antwerp and Ghent). Moreover, this enabled us to better explore the evolution
over time, given that the focus groups included participants at different stages of their study:
before clerkships (year 4, undergraduate), during clerkships (year 6, undergraduate), after
clerkships (year 7, undergraduate) and postgraduate (general practice trainees, and supervising
specialists and GPs; Table 1).60

Finally, as a test of ‘goodness-of-fit’, we carefully reviewed the videotapes for any ‘deviant’cases that did not fit the categories we had developed.52

Triangulation of Researchers + Audit trail
To ensure rigor and increase authenticity in our methodology, we used two kinds oftriangulation—investigator triangulation and data triangulation.[REF] We sought analytical rigor
using an audit trail and multiple coders; our coding team included an experienced clinician(M.G.) as well as a nonclinician with expertise in medical communication and team dynamics(L.L.).53

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RESULTS / FINDINGS

Item 16. Synthesis and interpretation: Main findings (e.g., interpretations, inferences, andthemes); might include development of a theory or model, or integration with prior research ortheory.

Explanation:
In qualitative research the distinction between results and discussion tends to blur because
analysis often involves interpretation, inference, and synthesis.11,39,54 Although most journals
require separate sections for Results and Discussion, many elements of Items 16-19 could
reasonably be reported in either section. As such, we defer to authors and editors to determine
where to report these essential elements.

Authors should identify the main analytic findings (e.g., interpretations, inferences, narratives,
themes, models).1,6,8 The nature of these findings and how they are reported will depend on theapproach and methodology selected and thus should be in alignment with the approach andmethods.11

In most cases, the authors should report a synthesis of their data along with specific quotes,
examples, or illustrations derived from their data.11 Authors might also report frequency, variety,representativeness, counter-examples, concrete details, contextualization, conditions, andqualifications related to their findings. Frequency counts (e.g., the frequency of specific themes

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or codes) play a limited role in qualitative research, and need not be reported unless they play ameaningful role in interpretation of the data.31,65

Findings might also include integration with prior literature or theory and/or the development ofa theory, model or meta-narrative.11,54,66 Judicious use of tables and figures can help
communicate such findings.

Example:We identified four patterns of NVB (non-verbal behavior) that relate to handover quality andhave dubbed them: (1) joint focus of attention; (2) ‘the poker hand’; (3) parallel play; and (4)kerbside consultation. Each pattern constitutes a ‘transfix,’ or systematic way of participating
non-verbally in the care transfer process. And, although there are variations in each pattern, we
have been able to code virtually every handover we have observed in nursing, medicine andsurgery into one of these four categories.52

Because our participants came from similar educational backgrounds, had studied medicine as
their tertiary course, were embedded in the culture of medicine, and were associated inmeaningful ways with a single medical school, we approached their transcripts with theassumption that they belonged to a loosely formed discourse community. Although theirgraduation dates ranged over a period of 50 years and their collective sphere of practiceincluded 10 different specialty areas, there were many similarities in their experiences of
enculturation during and after medical school.

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Their three major (often overlapping) areas of concern were epistemic (acquiring knowledge
and skill), interpersonal (relating to patients, families, colleagues and administrators) andpersonal (achieving work–life balance). In each of these areas, medical enculturation wasachieved by two overlapping processes, ‘absorption’ and ‘assimilation’, each of which may havedistinct implications for postgraduate medical education.46

Item 17. Links to empirical data: Evidence (e.g., quotes, field notes, text excerpts, photographs)
to substantiate analytic findings.

Explanation:
The authors should provide evidence (e.g., quotes, field notes, text excerpts, photographs) to
substantiate the more general and abstract concepts or inferences they present asfindings.1,8,11,63,67 Such evidence is typically de-identified to protect the privacy of study
participants, settings, and/or institutions. The evidence may be presented in a variety of ways
such as in a table or figure, incorporated into a narrative description of findings, as a stand-alone
narrative, or in text blocks embedded in the manuscript text. If word limits or media limitations(e.g.. video) limit the authors’ ability to provide sufficient representation of supporting data, an
appendix, supplemental material, or web-based repository could be used to provide access toadditional data.34
Examples:See Frankel et al.52 for an excellent example of how to use photographs (or snapshots fromvideo) to illustrate and provide supporting evidence for patterns of behavior identified in theanalysis. http://qualitysafety.bmj.com/content/21/Suppl_1/i121.
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We identified five interruption types: (1) probing for further data, (2) prompting for expectedsequence, (3) teaching around the case, (4) thinking out loud, and (5) providing direction (seeTable 1). Several interruption types served both goals of the case review discussions—teachingand patient care. For example, when thinking out loud, supervisors reasoned through problems
and taught the team: “So that’s the big question, did she have a mechanical fall, or did she havea medicine-related fall?” (Case 2). Supervisors prompted for expected sequence, preventing
presenters from skipping over information while simultaneously allowing the supervisor to
instruct the team on presentation style: “So now you can tell me what the rest of his test results
are because I haven’t heard those” (Case 16).53

DISCUSSION

Item 18. Integration with prior work, implications, transferability, and contribution(s) to thefield: Short summary of main findings, explanation of how findings and conclusions connect to,support, elaborate on, or challenge conclusions of earlier scholarship; discussion of scope of
application/generalizability; identification of unique contribution(s) to scholarship in a disciplineor field.

Explanation:

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The authors should begin the Discussion with a short summary of the main findings. The shortsummary reminds readers of the main findings and may help them assess whether the subsequentinterpretation and implications formulated by the authors are supported by the findings.6,39,68

The authors’ description of their findings or results should include some interpretation of the datain the context of previous findings, experiences, theory, or a guiding paradigm or approach. The
discussion provides authors an opportunity to elaborate on their findings in relation to theirresearch question(s) and study purpose(s); connect their findings to prior empirical work,
theories, and/or frameworks; and discuss implications.11,41 The authors should explicitly describe
how their findings contribute to or advance the field. Implications may include transferability, or
specifying the appropriate scope for generalization of the findings beyond the study (e.g., toother settings, populations, time periods, circumstances).1,41,69

Examples:This study contributes to the understanding and discussion of the complexity of involving
patients in healthcare education. It shows that integrating patient-led teaching into initiatives
that are partly faculty-led influences the way in which students perceive learning from and with
PIs. What is not known, however, is whether perceptions are also affected by type of healthprofession and the students’ different orientation towards logics of care and science, and issuesof authority and power relations.70

For complete examples of Discussions, see:Henriksen & Ringsted, 2013; http://www.ncbi.nlm.nih.gov/pubmed/23591973. 70
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Westerman et al., 2013; http://www.ncbi.nlm.nih.gov/pubmed/23488760. 71

Item 19. Limitations: Trustworthiness and limitations of findings

Explanation:
Authors should describe techniques used to ensure trustworthiness in the Methods section of themanuscript. In the Discussion, authors should identify problems or gaps in their efforts to ensure
trustworthiness and the potential implications. For example, if researchers intended to interview
individuals with certain characteristics, or who might offer different perspectives, but were
unsuccessful in recruiting any willing participants, they should explain this issue and describe
possible consequences for transferability.6,31,69 (See also Item 18.)

All research paradigms and approaches have strengths and weaknesses, and authors should
explicitly discuss how the paradigm, approach, and methods they used will influence thesituations to which their findings may reasonably apply. (See also Item 18.) In addition, theyshould explain how specific decisions or events in the conduct of the study strengthen or weaken
the rigor of their findings.

Example:The study has several limitations. One is that the focus group interview method reveals students’
perceptions rather than their actual behaviors. Observations of the patient-led teachingencounter may have illuminated an understanding of the relationship between patient instructors
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and medical students. Another limitation is that the PI-led teaching is optional rather thanmandatory, which may have influenced students’ attitudes in a positive direction. Moreover,students who are eager to take on extra-curricular activities may not be representative of thewhole population. That only 23 out of 39 students signed up for this study might also haveinfluenced results if the missing group of students represented other perceptions than thosepresent in the focus groups. However the received data from the focus groups were rich ininformation and diverse perceptions were present. Another limitation is the overrepresentationof women over men in our sample. Even though women are also overrepresented in medical
school this might potentially have influenced results, but gender differences in perceptions were
nevertheless not identified in the data.70

OTHER

Item 20. Conflicts of interest: Potential sources of influence or perceived influence on study
conduct and conclusions; how these were managed.

Explanation:
Authors should identify any real or potential conflicts of interest that might have influenced or
could appear to have influenced the research. Authors should also explain how these conflicts
were managed in the conduct of the study, and describe the potential impact on study findings
and/or conclusions.1,72 Some aspects may be mentioned as part of reflexivity (see Item 6).

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Item 21. Funding: Sources of funding and other support; role of funders in data collection,interpretation, and reporting.

Explanation:
The authors should describe any sources of funding and other support for the study and the roleof funders in data collection, data analysis, and reporting if applicable.1

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References
The numbering of the references in this Appendix does not match that of the references in thereport, nor are all the references here the same ones as in the report. The superscripts used in thisAppendix refer to the references in this Appendix only.

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