Researcher Positionality, Reflexivity and Relationship Building

Introduction

Qualitative health research is not conducted from a position outside the social world. Researchers enter clinical settings, communities, hospitals, homes and digital spaces carrying biographies, professional identities, institutional authority, assumptions and expectations. These characteristics influence what is noticed, what participants disclose, how data are generated, and how accounts are interpreted.

This does not mean that qualitative inquiry is merely subjective or that rigour is impossible. Rather, it means that knowledge is produced through relationships and situated practices. A reflexive researcher makes these conditions visible, examines their effects and takes responsibility for the ethical consequences of research decisions.

Positionality, reflexivity and relationship building are therefore central methodological concerns rather than optional personal reflections. They are particularly important in health care, where researchers may hold professional authority, participants may be ill or dependent on services, and research findings can affect access, treatment, reputation and resource allocation.

This chapter examines how identity, power, assumptions and professional roles influence inquiry. It presents practical approaches including reflexive journaling, bracketing, cultural humility, relational ethics, community engagement and patient involvement. It also considers the challenges of applying these approaches in organisational and digitally mediated research.

Learning objectives

By the end of this chapter, you should be able to:

1. Define positionality, reflexivity, bracketing, cultural humility and relational ethics.
2. Analyse how identity, power and professional role influence qualitative research.
3. Distinguish reflexivity from simple self-disclosure or personal opinion.
4. Design and use a reflexive journal and a structured bracketing process.
5. Apply culturally humble and relationally ethical approaches to health research.
6. Plan meaningful patient, public and community engagement.
7. Evaluate the methodological and governance implications of researcher–participant relationships.

1. Positionality: the researcher as situated instrument

1.1 Meaning and dimensions

Positionality refers to the social, cultural, professional and institutional location from which a researcher approaches inquiry. It includes characteristics such as gender, age, ethnicity, class, nationality, language, religion, disability, sexuality and migration history. It also includes professional discipline, seniority, employment status, research experience, political commitments and relationship to the topic.

Positionality is not a fixed list of demographic attributes. It is relational and contextual. A nurse researcher may be an insider in relation to clinical practice but an outsider in relation to a particular ethnic community. A junior researcher may share participants’ age and language while lacking their experience of poverty or chronic illness. A hospital manager studying frontline staff may be an organisational insider but also represent surveillance, appraisal or managerial control.

A useful distinction is between ascribed position and achieved position. Ascribed position concerns identities socially assigned or inherited; achieved position concerns roles acquired through education, employment or experience. Both affect access and interpretation, but neither automatically determines how a researcher will be perceived.

1.2 Insider, outsider and multiple positioning

An insider shares one or more meaningful characteristics with participants. An outsider does not share those characteristics or is associated with a different social group. These categories are fluid rather than absolute. Researchers may occupy an in-between or border position, moving between insider and outsider status during fieldwork.

Insider status may support trust, linguistic fluency and contextual understanding. However, it can also produce assumptions, over-familiarity and unexamined agreement. Outsider status may make difference more visible and encourage clarification, but it can limit access or create misunderstanding. Neither position is inherently superior. The important task is to examine what each position makes possible and what it obscures.

1.3 Professional identity and role conflict

Health-care professionals often conduct research in settings where they also provide care, supervise staff or make decisions. This creates potential role conflict. A patient may interpret a clinician-researcher’s invitation as a treatment requirement. A staff member may fear that criticism will affect employment. A manager may unintentionally frame organisational priorities as research questions.

Researchers should explicitly distinguish roles, explain that participation is voluntary and clarify who will see the data. Where role conflict is substantial, an independent interviewer or researcher may be preferable. Ethical consent is not secured merely by obtaining a signature; it requires realistic freedom to decline or withdraw.

2. Power, knowledge and representation

2.1 Power in the research relationship

Power is the capacity to influence decisions, opportunities, interpretations or outcomes. It may arise from professional authority, control of resources, clinical expertise, institutional affiliation, language, age, social status or ownership of data. Power is often uneven even when researchers are respectful and well intentioned.

Power operates at several stages:

Power is also productive: it shapes what can be said, who is recognised as knowledgeable and which explanations appear legitimate. A patient’s experiential knowledge may be treated as anecdotal, while a clinician’s interpretation is treated as evidence. Reflexive inquiry challenges this hierarchy without assuming that all claims are identical or equally supported.

2.2 Epistemic injustice

Epistemic injustice occurs when people are unfairly disadvantaged in their capacity to contribute to or receive knowledge. Testimonial injustice arises when a speaker’s account is given less credibility because of prejudice—for example, when a person with a mental health diagnosis is presumed unreliable. Hermeneutical injustice arises when people lack the shared concepts or recognised language needed to express an experience, such as coercive care or racialised pain assessment.

Qualitative health researchers should ask whose accounts are absent, which categories were imposed, whose language was edited out and whether findings reinforce stereotypes. This is both an ethical and methodological responsibility.

2.3 Representation and voice

“Giving voice” can be misleading because participants already possess voices; researchers control the conditions under which those voices become visible. Representation involves selection, translation, editing, interpretation and publication. Direct quotations do not automatically provide authentic access to a participant’s reality. A quotation may be removed from context, expose identity or be used to support a conclusion the participant would reject.

Good practice includes preserving context, checking potentially identifying quotations, explaining analytic decisions and avoiding deficit-only representations of communities.

3. Reflexivity as methodological practice

3.1 Definition

Reflexivity is the systematic examination of how the researcher and research process influence one another. It includes reflection on assumptions, emotional responses, relationships, decisions, omissions and consequences. Reflexivity is more than introspection and more than a paragraph stating the researcher’s background. It must connect personal and institutional positioning to concrete methodological effects.

Reflexivity has at least four dimensions:

• Personal reflexivity: examining values, experiences, emotions and expectations.
• Interpersonal reflexivity: examining how relationships with participants and colleagues shape data.
• Methodological reflexivity: questioning sampling, interview design, coding and interpretation.
• Structural reflexivity: examining institutional, political, economic and historical conditions.

Reflexivity can be prospective, occurring before fieldwork; concurrent, occurring during data generation; and retrospective, occurring during analysis and dissemination.

3.2 Reflexivity and validity

Some researchers worry that reflexivity weakens objectivity. In qualitative inquiry, the alternative to reflexivity is not neutrality but unexamined influence. A transparent account of the researcher’s position allows readers to assess the plausibility and boundaries of interpretations.

Reflexivity does not mean that every interpretation is equally valid. Claims remain accountable to the data, theoretical framework, analytic procedure, ethical standards and engagement with alternative explanations. Reflexivity should therefore strengthen, not replace, methodological rigour.

3.3 The reflexive journal

A reflexive journal is a structured record of experiences and decisions made throughout a study. It should be maintained alongside, but separately from, the descriptive fieldwork record. The fieldwork record documents what happened; the reflexive journal documents how the researcher participated in and interpreted what happened.

Useful journal entries may address:

1. What did I expect before the encounter?
2. What did I notice, and what might I have overlooked?
3. How did my role affect participation or disclosure?
4. What emotions did I experience, and how could they influence analysis?
5. Which assumptions were confirmed, challenged or left unresolved?
6. What alternative interpretations are plausible?
7. What ethical concerns emerged?
8. What action will I take as a result?

Entries should be dated and linked to interviews, observations, analytic meetings or decisions. They should distinguish description from interpretation and avoid unnecessary identifying details. A journal is not a diary of private feelings alone; it is an auditable methodological resource.

3.4 Reflexive team practice

In team research, reflexivity should be collective. Teams can maintain an assumption log, conduct positionality discussions, compare independent interpretations and examine disagreements. Disagreement is not necessarily a problem to eliminate; it can reveal how disciplinary training and social position shape analysis.

A team should document who performed recruitment, interviewing, translation, coding and interpretation. If a participant’s account was translated, the team should consider how meaning, emotion and culturally specific concepts may have changed.

4. Bracketing and the management of assumptions

4.1 Meaning and limits

Bracketing is the deliberate identification and management of preconceptions. It is associated particularly with phenomenological research, where researchers seek to attend closely to participants’ lived experience. The term is sometimes interpreted as complete removal of prior knowledge. That standard is generally unrealistic: researchers cannot erase language, history or theoretical understanding.

A more practical interpretation is disciplined reflexive bracketing. Researchers make assumptions explicit, suspend premature judgement where possible, return to participants’ descriptions and test interpretations against disconfirming evidence. Bracketing is therefore an ongoing discipline, not a one-time declaration of neutrality.

4.2 A bracketing protocol

Before data collection, the researcher can:

• write a positionality statement;
• list expectations about the phenomenon and population;
• identify concepts likely to be taken for granted;
• record professional interests and possible conflicts;
• formulate open-ended questions that do not presuppose a problem;
• discuss assumptions with supervisors or community advisers.

During analysis, the researcher can:

• code descriptive material before applying abstract concepts;
• preserve contradictory and negative cases;
• record changes to the codebook;
• ask what evidence would challenge the emerging explanation;
• compare interpretations across participants and settings;
• invite participant or stakeholder comment when appropriate.

Bracketing does not require rejecting theory. It requires making the relationship between theory and data visible.

5. Cultural humility and culturally responsive inquiry

5.1 From competence to humility

Cultural competence is often presented as a body of knowledge about groups. Such knowledge can be useful, but it may encourage stereotyping if cultures are treated as uniform and static. Cultural humility is a lifelong commitment to self-critique, recognition of power imbalance, institutional accountability and learning from people whose experiences differ from one’s own.

Cultural humility does not mean claiming ignorance or avoiding cultural questions. It means asking respectfully, avoiding assumptions and recognising that participants are experts in their own lives. Researchers should not expect individuals to educate them without compensation or shouldering the burden of correcting institutional practices.

5.2 Culturally responsive procedures

Culturally responsive research may require:

• consultation with community representatives during question development;
• appropriate language access and trained interpreters;
• attention to gender, privacy, family and authority structures;
• flexible interview locations and times;
• recognition of collective as well as individual decision-making;
• culturally appropriate compensation;
• review of dissemination materials for harmful or stigmatising language.

Cultural responsiveness must not be reduced to food, clothing or ceremonial gestures. It concerns decision-making power, access, communication and the legitimacy of different forms of knowledge.

6. Relational ethics

6.1 Beyond procedural ethics

Research ethics committees commonly assess consent, confidentiality, risk and data management before a study begins. These are essential, but ethical responsibility continues throughout the relationship. Relational ethics focuses on responsiveness, mutual respect, dignity, vulnerability and the consequences of particular interactions.

A formally valid consent process may still be ethically weak if participants feel unable to refuse, do not understand how data will be used or are treated as sources of information rather than people. Relational ethics asks what the situation requires here and now, including when formal protocols do not provide a complete answer.

6.2 Consent as an ongoing process

Consent should be revisited when circumstances change, interviews become emotionally difficult, new data uses are proposed or participants’ capacity fluctuates. Researchers should monitor verbal and non-verbal signs of distress, fatigue or reluctance. Participants should know how to pause or stop an interview without penalty.

In studies involving patients, capacity, dependency and therapeutic misconception require particular attention. Therapeutic misconception occurs when participants incorrectly believe that research is designed primarily to provide individual treatment. Researchers must explain the difference between research and care in accessible language.

6.3 Reciprocity and boundaries

Participants may reasonably ask what research will change. Researchers should not promise benefits they cannot deliver, but they should explain how findings will be used and return results in accessible forms where feasible. Reciprocity may involve payment, feedback, training, service improvement or public dissemination; it should not create coercion or imply that participants owe personal disclosure.

Boundaries are equally important. Researchers should avoid becoming informal clinicians, counsellors or advocates unless those roles are explicitly authorised and supported. A distress protocol should identify when to pause, what referral options exist and who is responsible for follow-up.

7. Patient, public and community engagement

7.1 Engagement as partnership

Patient and public involvement (PPI) means involving people with relevant lived experience in shaping research rather than merely studying them. Community-based participatory approaches go further by sharing decision-making, building local capacity and addressing community-defined priorities.

Engagement may occur at several levels:

No level is automatically appropriate for every project. Researchers should state honestly the degree of influence available.

7.2 Designing meaningful engagement

Meaningful engagement begins before the protocol is fixed. Researchers should identify who is affected, including people who are often excluded: unpaid carers, people with disabilities, migrants, people experiencing homelessness, children and those with limited digital access.

A practical engagement plan should specify:

• purpose and decision points;
• recruitment and accessibility arrangements;
• payment and recognition;
• training and support;
• confidentiality expectations;
• conflict-resolution procedures;
• how feedback changed the research;
• how results will be returned.

Tokenism occurs when participants are present but lack influence, are invited only after major decisions have been made or are selected because they are unlikely to challenge researchers. Engagement should be evaluated by influence and accountability, not by attendance alone.

8. A practical framework for reflexive inquiry

The following five-phase framework can be applied to qualitative health projects.

Phase 1: Locate

Describe the researcher’s identities, professional role, institutional interests, relationship to the topic and relevant lived experience. Avoid presenting identity as a complete explanation of behaviour.

Phase 2: Anticipate

List assumptions, risks, power differences and possible misunderstandings. Identify who may be silenced and what resources or safeguards are required.

Phase 3: Relate

Build trust through clarity, consistency, cultural humility and appropriate boundaries. Negotiate access with participants and communities rather than treating access as extraction.

Phase 4: Examine

Use journals, team dialogue, negative-case analysis, peer debriefing and participant feedback to examine how data and interpretations were shaped.

Phase 5: Account

Report positionality, ethical decisions, changes in approach, limitations and the intended and unintended consequences of dissemination. Accountability extends beyond publication.

Figure: Reflexivity as a continuous cycle linking researcher position, relationships, analysis and accountability.

9. Applied case: researching missed outpatient appointments

This is an illustrative case. A university–hospital team plans to study missed appointments among patients with diabetes. The initial proposal describes missed appointments as a problem of patient non-compliance. The lead investigator is a senior physician and the project is funded by a hospital quality-improvement unit.

Background and problem

Community advisers report that patients miss appointments because of transport costs, insecure work, language barriers, caregiving responsibilities and previous experiences of disrespect. The original framing risks blaming patients and may lead to an intervention based on reminders alone.

Reflexive analysis

The team maps its positionality. The physician has clinical authority and institutional status. The qualitative researcher has no diabetes diagnosis but has experience of economic insecurity. Community advisers include patients and carers who have missed appointments. The team recognises that recruitment through clinics may discourage criticism and that patients may believe participation affects care.

The team revises recruitment so that an independent researcher approaches potential participants. Information sheets explain that participation will not affect treatment. Interviews are offered in preferred languages, interpreters are trained in confidentiality, and participants receive appropriate compensation. The team keeps a reflexive journal documenting moments when “non-adherence” appears in discussion and records how that label is challenged.

Approach and analysis

Interviews explore how appointments are organised, experienced and negotiated. The team uses descriptive coding before developing interpretive categories. Negative cases are actively sought, including patients who attend reliably despite similar barriers. Patient advisers review emerging themes, not to determine whether every quotation is “true,” but to identify missing context, stigmatising language and impractical recommendations.

Outcome

The final analysis identifies missed appointments as an interaction between scheduling systems, transport, employment, communication and clinical relationships. The resulting recommendations include flexible scheduling, transport support, reminder options selected by patients and staff training in respectful communication. The report avoids presenting attendance as a simple measure of motivation.

Learning points

1. Positionality can change the research question, not only the writing style.
2. A professional role may affect both recruitment and disclosure.
3. Community engagement is strongest when it influences interpretation and action.
4. Reflexivity can reveal institutional contributions to an apparently individual problem.
5. Ethical dissemination avoids converting structural disadvantage into personal deficit.

10. Digital, technological and AI-mediated research

Digital interviews, online communities, electronic records and social media create new positionality questions. Researchers may be more distant from participants, but distance does not remove power. Platform ownership, algorithmic visibility, digital exclusion and data permanence affect who can participate and how privacy is understood.

In AI-assisted research, tools may support transcription, translation, coding or summarisation. They can also reproduce racial, linguistic and disability-related bias; flatten ambiguity; misrecognise speech; or expose sensitive data to unauthorised systems. Researchers remain responsible for checking outputs rather than treating automated classifications as neutral findings.

Before using an AI system, the team should assess data governance, contractual ownership, storage location, access controls, consent compatibility, accuracy and the possibility of re-identification. Participants should be informed when automated processing materially affects their data. AI-generated themes should be treated as provisional analytic prompts, not as independent interpretations. Reflexive records should document the tool, version, purpose, human checks and decisions to accept or reject outputs.

11. Challenges and limitations

Reflexivity has several risks. It can become performative self-disclosure, in which researchers list privilege without changing practice. It can recentre the researcher’s biography and displace participants’ accounts. It may also create excessive individual responsibility for structural inequalities that require institutional action.

Bracketing can be misunderstood as complete neutrality. Cultural humility can become endless self-doubt or avoidance of meaningful cultural discussion. Community engagement can consume unpaid labour, reproduce consultation fatigue or create conflicts between academic timelines and community priorities. Participant feedback may be inappropriate in some interpretive traditions or may expose participants to pressure to approve findings.

These limitations do not justify abandoning reflexive and relational approaches. They require proportionality, transparency and critical evaluation. Researchers should state what they did, what they could not do, whose interests were served and what remains uncertain.

12. Best-practice checklist

Before fieldwork, researchers should:

• prepare a positionality statement and assumption log;
• map power relationships and role conflicts;
• involve patients or communities in question and protocol development;
• establish accessible consent and distress procedures;
• agree payment, confidentiality and data-governance arrangements;
• plan interpreter, translation and accessibility support.

During fieldwork, researchers should:

• clarify roles repeatedly where confusion is possible;
• maintain a dated reflexive journal;
• monitor consent, distress and withdrawal signals;
• record changes in sampling, questions and relationships;
• discuss emerging concerns with supervisors or community partners.

During analysis and dissemination, researchers should:

• examine negative and contradictory cases;
• compare disciplinary and community interpretations;
• protect contextual and quotation-based confidentiality;
• report positionality and methodological changes;
• return findings in accessible formats;
• assess possible harms, including stigma and misuse.

Chapter Summary

Qualitative health research is situated within relationships, institutions and histories. Researcher positionality describes the social and professional location from which inquiry is conducted; it affects access, communication, interpretation and representation. Power operates through recruitment, clinical authority, language, analysis and dissemination, and can produce epistemic injustice when some forms of knowledge are discounted.

Reflexivity is an ongoing methodological practice that examines personal, interpersonal, methodological and structural influences. Reflexive journals, team discussion, assumption logs, bracketing and negative-case analysis help make those influences visible. Bracketing does not erase prior knowledge; it disciplines assumptions and tests interpretations.

Cultural humility requires lifelong self-critique, attention to power and institutional accountability. Relational ethics extends beyond procedural approval by treating consent, boundaries, reciprocity and care as continuing responsibilities. Patient, public and community engagement is meaningful when people influence decisions rather than merely provide information. Across all stages, researchers must connect reflection to action and remain accountable for how knowledge is produced and used.

Key Terms

Positionality: The social, cultural, professional and institutional location from which a researcher approaches inquiry.

Reflexivity: Systematic examination of how the researcher and research process influence one another.

Insider: A researcher who shares relevant social, cultural or experiential characteristics with participants.

Outsider: A researcher positioned as different from the participant group in a meaningful context.

Power: The capacity to influence decisions, opportunities, interpretations or outcomes.

Epistemic injustice: Unfair disadvantage in producing, communicating or being recognised as a knower.

Testimonial injustice: Discounting a speaker’s credibility because of prejudice.

Hermeneutical injustice: Lack of shared concepts or language needed to express an experience.

Bracketing: Deliberate identification and management of researchers’ preconceptions.

Reflexive journal: A dated record of assumptions, reactions, decisions and methodological consequences.

Cultural humility: Ongoing self-critique, recognition of power imbalance and accountable learning across cultural difference.

Relational ethics: Ethical practice grounded in responsiveness, dignity, mutuality and relationships.

Therapeutic misconception: Confusing research participation with receipt of individual clinical treatment.

Reciprocity: Appropriate exchange of value, recognition or benefit between researchers and participants.

Patient and public involvement: Involving people with relevant lived experience in shaping research.

Co-production: Shared authority among researchers, practitioners, patients or communities in developing knowledge or action.

Tokenism: Symbolic inclusion without meaningful influence over decisions.

Negative case: Evidence that challenges or complicates an emerging explanation.

Researcher role conflict: Tension arising when a researcher simultaneously holds clinical, managerial or evaluative responsibilities.

Review Questions

Short Answer Questions

1. Define researcher positionality and explain why it is contextual rather than fixed.
2. What is the difference between reflexivity and simple self-disclosure?
3. Explain the purpose of a reflexive journal.
4. What does cultural humility add to the idea of cultural competence?
5. Define therapeutic misconception and state one way to reduce it.

Long Answer Questions

1. Discuss how professional authority can affect recruitment, consent and disclosure in qualitative health research.
2. Compare insider and outsider positions, including the methodological advantages and risks of each.
3. Explain how power and epistemic injustice may influence the representation of patient knowledge.
4. Describe a structured process for bracketing assumptions before and during qualitative analysis.
5. Evaluate the role of relational ethics alongside formal research ethics review.

Analytical / Application Questions

1. You are a hospital manager interviewing staff about unsafe staffing levels. Identify the major power and role-conflict risks and design safeguards for recruitment, interviewing and reporting.
2. A community advisory group says a study’s interview guide describes people who miss appointments as “non-compliant.” Analyse the problem and propose a culturally humble, community-engaged revision.
3. Your team uses an AI tool to translate and code interviews with migrants. Develop a reflexive and governance plan addressing consent, privacy, translation accuracy, bias and human accountability.

Multiple Choice Questions with Answers

Question 1

Which statement best defines researcher positionality?

A. The researcher’s fixed level of objectivity

B. The social, professional and institutional location from which inquiry is conducted

C. The demographic profile of participants

D. The statistical representativeness of a sample

Correct Answer: B. The social, professional and institutional location from which inquiry is conducted

Question 2

What is the primary purpose of a reflexive journal?

A. To replace the study’s field notes

B. To record only participants’ direct quotations

C. To document how the researcher’s assumptions and actions may shape the study

D. To provide a personal diary unrelated to methodology

Correct Answer: C. To document how the researcher’s assumptions and actions may shape the study

Question 3

Which practice best illustrates disciplined bracketing?

A. Attempting to erase all prior knowledge permanently

B. Making assumptions explicit and testing interpretations against alternative evidence

C. Using only theories selected before data collection

D. Accepting the first interpretation that fits most interviews

Correct Answer: B. Making assumptions explicit and testing interpretations against alternative evidence

Question 4

Cultural humility primarily involves:

A. Memorising characteristics of every cultural group

B. Avoiding all discussion of culture

C. Ongoing self-critique, attention to power and accountable learning

D. Allowing researchers to define cultural meanings for participants

Correct Answer: C. Ongoing self-critique, attention to power and accountable learning

Question 5

A patient believes joining a study guarantees improved individual treatment. This is an example of:

A. Negative-case analysis

B. Therapeutic misconception

C. Testimonial injustice

D. Tokenism

Correct Answer: B. Therapeutic misconception

Question 6

Which engagement level gives participants the greatest formal influence?

A. Inform

B. Consult

C. Collaborate

D. Community-led

Correct Answer: D. Community-led

Question 7

Why can insider status create methodological risk?

A. Insiders are never trusted by participants

B. Shared experience may encourage assumptions and over-familiarity

C. Insiders cannot understand local language

D. Insiders are prohibited from conducting interviews

Correct Answer: B. Shared experience may encourage assumptions and over-familiarity

Question 8

Which example best represents testimonial injustice?

A. A participant lacks transport to an interview

B. A patient’s account is discounted because of prejudice about their diagnosis

C. A study uses an encrypted database

D. A researcher changes an interview time

Correct Answer: B. A patient’s account is discounted because of prejudice about their diagnosis

Question 9

When AI is used to code qualitative interviews, researchers should:

A. Treat automated themes as final findings

B. Assume the tool is culturally neutral

C. Document its use and critically check outputs for error and bias

D. Omit the tool from the methods report

Correct Answer: C. Document its use and critically check outputs for error and bias

Question 10

Which action most directly supports relational ethics?

A. Obtaining one signature and never revisiting consent

B. Treating participants solely as data sources

C. Monitoring consent, distress and boundaries throughout the relationship

D. Avoiding any discussion of research benefits or risks

Correct Answer: C. Monitoring consent, distress and boundaries throughout the relationship