The transferability triad: Exploring possibilities for applicability, resonance and theoretical engagement in health professions education scholarship

This paper concludes the three-part series on transferability in qualitative research. Many find transferability perplexing, unsure of what it means and how to address it when writing up a study or project. As authors ourselves, we empathise and eagerly engaged in this series as an opportunity to bring some clarity to the concept. In the first 'How to …' paper,1 we (Renee, Megan, Bridget) shared a bit about the origins of transferability, its various meanings and its complex relationship with generalizability. We proposed three dimensions of transferability (applicability, resonance and theoretical engagement) to consider when designing, conducting and writing up a study, with examples of the kinds of questions to ask throughout the writing process. Many find transferability perplexing, unsure of what it means and how to address it. In the second part of the series, our goal was to demonstrate how transferability can be used in education scholarship. We (RS, MB, BO) shared the 'How to …' paper with Miriam and colleagues whose innovation paper used a layered analysis method to describe the design and implementation of a socially-accountable educational programme in a new medical school,2 and with Satid, Dorene and colleagues who wrote up their qualitative study of paediatric residents' workplace learning in a critical care setting in Thailand.3 These two papers may seem highly specific to their own contexts. Yet, both carry messages with broader relevance, which makes them ideal candidates to demonstrate how the three dimensions of transferability can be leveraged to share empirical work that can inspire health professions education (HPE) professionals and researchers worldwide. Additionally, because the two papers have different purposes (dissemination of an innovation and dissemination of qualitative research), they offer insights into different ways authors can employ the concepts of applicability, resonance and theoretical engagement to enhance the transferability of their work. In this final paper, a collection of the authors from all three papers1-3 engage in a conversation to unpack the thought processes and practices involved in working with the three dimensions of transferability. These insights can open up broader conversations about the possibilities for future use of the transferability triad in HPE scholarship. We (RS, MB, BO) pose questions to the authors of the empirical papers who respond with their reflections and insights. We conclude with a collaborative synthesis of what we learned and what possibilities we envision for future scholarship. Miriam: When thinking about applicability, one must consider the specifics of their locale and programme so that the future reader can fully understand their work and consider how/what to build from. Two aspects of our work seemed particularly important to share. First, in the layered analysis method,4 context-specific techniques are grounded in foundational philosophies and principles. We included information about our school, its location and critical socio-demographic aspects of our region so readers could understand how they informed the guiding philosophy and principles, as well as our specific techniques. Second, we recognised the importance of contextualising our charge to medical educators to be responsive to societal problems. In the first part of our foundational philosophy, we shared information about current challenges in the United States so readers from other countries could decide which were relevant to their circumstances. The rest of the philosophy, namely, that society-specific problems should drive content and structure, responsible use of resources, and so forth, can be applied in any society. Ultimately, our intent was to provide readers with the information they needed to find applicability at the micro/meso levels (US-specific problems) and at the macro/structural level (how to use social responsibility to drive programme development and evaluation). This approach mirrors the process our team used as we built the school. We used local, regional and national data (e.g., health outcomes and epidemiology). It was important that contextually relevant information informed and drove our development decisions. Satid and Dorene: Our international team of authors gave us an opportunity to explore the applicability of findings about workplace learning across cultures and contexts. With medical training, cultural affiliations and HPE scholarship experience in Thailand and the United States, one team member (ST) played a pivotal role in our understanding of unique, nuanced findings related to both the Pediatric Intensive Care Unit (PICU) context and the larger Thai culture. Through an intentional process of 'sense-making',5 ST made connections among the data, the theory that serves as our analytical lens, and his own lived experience. To that end, he was in dialogue with the US team about how the data resonated (or not) with related studies in other contexts and with workplace participatory practices (WPP).6, 7 He also conversed regularly with the Thai team to share his early understandings and posed probing questions to prompt reflection and clarify his interpretation. Taken together, our team leveraged diverse cultural perspectives, different domains of expertise, careful data interpretation and collaborative dialogue to construct our findings. We believe our findings will resonate well with our colleagues in Thailand and have wider potential applicability given its WPP framing. Miriam: Our approach to resonance mirrored how we built engagement as we developed and launched the school. When planning and launching any innovation, thinking about ideas and concepts that resonate with those involved is important as you recruit participants and build engagement. It can increase motivation and buy-in, two critical elements of success for a new or different programme. We expect that most health professionals and medical educators are driven by their desire to help those around them. Clearly articulating the significant challenges that we currently face in health and igniting that motivation to help can be a powerful force. We thought about an audience of educators, curriculum developers and administrators when writing this paper, hoping that our experience would motivate and help them in their work. Satid and Dorene: In the early stages of this study, we pivoted from a focus on resident engagement to a broader exploration of workplace learning to enhance resonance and applicability. We believe this consideration is especially critical in cross-cultural studies. Because metaphors facilitate storytelling, reader engagement and comprehension, we used them to build shared understanding within the team and to enhance the resonance of our cross-cultural research. Our choice was prompted by KT's use of pictures to present preliminary themes. In the end, we used metaphors that were both inter-related and made sense to all team members. Miriam: We selected the layered analysis method as a structured way to present our work to enable transfer to other contexts. We approached the development of our school with a systematic and mission-driven approach. The layered analysis provides an excellent framework that mirrors the approach we took during the development of the school. It makes clear the 'why' behind each decision and provides the links between high-level vision and on-the-ground application. Specifically, as you move from philosophies to principles to techniques,2 you answer the question, 'how do you do that?'. Whereas, when moving from specific examples of techniques to principles and then philosophies, you answer the question, 'why did they do that?'. While this layered analysis covers the overall school, it demonstrates the component parts thereby enabling readers to focus on selected aspects of the innovation, supporting the transferability of the aspects most relevant to the reader. Satid and Dorene: We did not plan to use WPP6, 7 from the start of our research. Prior to this study in Thailand, two of our team members conducted a similar study in the United States8 using a more learner-centric framework compared with WPP. We considered other theories as well (e.g., self-directed learning and team psychological safety) but they did not sufficiently capture the salient features of workplace learning in Thailand, a theoretical transfer of the findings within a unique context, as they are primarily learner-centric. DB and ST were familiar with WPP and proposed it to team members, who agreed that it would facilitate a theoretical transfer of learnings from a Thai context to a Western context. Specifically, WPP helped us appreciate the power of psychological safety within a hierarchy and the capacity of primary care career intentions to influence affordances for learning in intensive care. Bridget, Megan, Renee: We read many innovation reports and qualitative research studies in HPE that engage with transferability either superficially or not at all. We believe this reflects misconceptions about what transferability is and a lack of guidance on how to engage with it in HPE scholarship. In writing the How To paper,1 part of our learning involved appreciating the murkiness of conceptual boundaries and the application of concepts within a field that welcomes many types of scholarship and methodological approaches. We spent considerable time discussing the conceptual complexities, which resulted in the dimensions of applicability, resonance and theoretical engagement. The authors of the empirical papers helped us appreciate that there is no 'one-size-fits-all' approach when it comes to heightening transferability as Table 1 indicates. Below, the empirical author teams offer thoughts on the importance of transferability within HPE scholarship, reflecting on their own experiences throughout this project to offer take-home messages. The authors of the empirical papers helped us appreciate that there is no 'one-size-fits-all' approach to transferability. Miriam: Any person developing or describing an innovation or phenomenon likely hopes that their work will resonate and have an impact widely. This can be challenging in HPE scholarship given the social complexity of the innovations and phenomena we study. Many in health professions education come from biomedical post-positivist backgrounds, making the shift from generalizability (with the goal of identifying replicable findings through control of all variables) to interpretivist or realist notions of transferability (with the goal of describing contextual differences that add nuance to decisions, findings and outcomes) challenging. Transferability can be a useful way to conceptualise the goal of making specific work broadly applicable. It pushes the researcher to think about the idea and role of context, which is a critical component of any educational phenomenon. Integrating transferability early into the process of qualitative work can push the researcher to share their work in a way that enables the future reader to relate to the work and find ways to draw from and apply it in the reader's own context. Transferability can be a useful way to conceptualise the goal of making context-specific work broadly applicable. Satid and Dorene: Health professions education scholarship must keep pace with an increasingly globalised economy, society and environment.9 Attending to the transferability of findings of any one study, albeit a small step, plays an integral role in making information constructed with one group available to—and capable of affecting the understanding of—those in another group. We underscore the significance of Thailand's collectivist culture in shaping workplace learning by inviting participation and setting the stage for psychological safety. Given that learning environments and psychological safety are key areas of interest in HPE scholarship, it is imperative to consider valuable lessons that can be learned from outside of one's own culture. Therefore, the concept of transferability serves not only as a conduit for sharing knowledge but also as an invitation to consider diverse cultural perspectives and their impact on education. Transferability serves not only as a conduit for sharing knowledge but also as an invitation to consider diverse cultural perspectives and their impact on education. Engaging with this series has been an educational journey for all involved in these papers. We have had the privilege of developing our own understanding and practice as education researchers throughout this process and through discussions within and between author teams. We hope the three dimensions of transferability described in this series will provide guidance for researchers throughout the duration of a scholarly project—from design to dissemination—and enable them to communicate the relevance and impact of their work more clearly. We also hope researchers will choose elements of these dimensions that suit their project at different times and will not feel obligated to address all three or be limited to only these three. We may not have captured all that is important to transferability in your context. This conceptualisation is not a map, but a compass. It cannot tell you exactly what to do, and what decisions to make to enhance the transferability of your work, but it can guide you to think reflectively and critically about your approach. Bridget C. O'Brien: Conceptualization; writing—original draft; writing—review and editing; project administration. Renée E. Stalmeijer: Conceptualization; writing—review and editing; writing—original draft. Miriam Hoffman: Conceptualization; writing—original draft; writing—review and editing. Satid Thammasitboon: Conceptualization; writing—original draft; writing—review and editing. Dorene F. Balmer: Conceptualization; writing—original draft; writing—review and editing. Megan E.L. Brown: Conceptualization; writing—original draft; writing—review and editing. The authors have no acknowledgement to disclose. The authors have no conflict of interest to disclose. The authors have no ethical statement to declare. Our paper does not use data.