Exploring resonance theory and uncontrollability during co-creative art making: A qualitative study among cancer patients.

PURPOSE: Co-creation, characterised by artists and patients creating a joint work of art, may support patients with the integration of life events, such as living with cancer, into their life story. In the process of co-creation, resonance relationships between patients, artists and material may evolve that support such integration. Using the framework of resonance theory, we aim to investigate if and how patients move through the three phases of resonance during a process of co-creation and explore the role of uncontrollability in this process. METHODS: Ten patients who received cancer treatment with palliative intent completed co-creation processes, which were audio recorded. These recordings were imported in Atlas-Ti and analysed by applying content analysis. We searched for the three phases of resonance, Being affected, touched and moved; Self-efficacy and responding; Adaptive transformation. We additionally searched for signs of uncontrollability. RESULTS: Patients used 4-8 sessions (median 5 sessions) with a duration 90-240 min per session (median duration 120 min). We found that patients move through the three phases of resonance during co-creation processes. Uncontrollability both presents a challenge and an invitation to integrate experiences of contingency into one's life narrative. Patients express self-recognition and the experience of contingency in their work of art. CONCLUSIONS: Integration of experiences of contingency into a life narrative can be supported by the process of co-creation of art, which invites patients to relate to their illness, their environment and themselves. The phases of resonance in combination with uncontrollability as a continuously present factor, provide a means to both study and support the integration of experiences of contingency into the life narrative.

Becoming a physician for older patients: exploring the professional identity formation of medical students during a nursing home clerkship. A qualitative study.

BACKGROUND: To prepare medical students for the growing population of older patients, an appropriate professional identity formation is desirable. The community of practice of medical school is primarily hospital-based and disease-oriented which will lead to the development of a physician who is mainly focused on cure. This focus alone however is not always appropriate for older persons' health care. The aim of this study is to explore the influence of participating in a nursing home community of practice on the professional identity formation of medical students. METHODS: A qualitative study based on a constructivist research paradigm was conducted, using individual semi-structured, in-depth interviews and a visual narrative method (drawing) as a prompt. Thematic analysis was applied to structure and interpret the data. The study population consisted of fifth-year medical students participating in a six-week nursing home clerkship. Thirteen participants were purposefully sampled. The clerkship took place in nursing homes in the South-West of the Netherlands. RESULTS: The medical students described the nursing home as the living environment of the patients. Actively participating in the patients' care and experiencing the daily life of the patients was meaningful for the physician the students want to become in five ways: (1) a physician with a complete picture; (2) a physician who is close; (3) a physician who is in dialogue; (4) a physician who is able to let go and (5) a physican who collaborates. CONCLUSIONS: Caring for older patients in the nursing home influences the professional identity formation of medical students. Patient-centeredness, personal, holistic and tailored care, approachability and collaboration are important characteristics in becoming a physician for older persons' health care. The context of this care provides relevant learning experiences for this development and the becoming of a physician in general.

The expression of ultimate life goals in co-creative art processes with palliative cancer patients.

BACKGROUND: Co-creation, characterized by artists and patients creating a joint work of art, may support patients with the integration of disruptive life events into their life story, such as living with cancer. Focusing on experiences of contingency and life goals could support this process. The research questions are: (1) 'how are patient's ultimate life goals and experiences of contingency expressed in the work of art as created in a process of co-creation?'; (2) 'how do the four phases of integration of experiences of contingency unfold during co-creation?' METHODS: Ten patients who were in a palliative stage of cancer treatment completed co-creation processes. Audio recordings of these co-creation processes were imported in Atlas-Ti and analysed by applying directed content analysis. We searched for life goals and experiences of contingency in the four phases of co-creation; Art communications, Element compilation, Consolidation, Reflection. RESULTS: Patients used 4-8 sessions (median 5 sessions) with a duration of 90-240 min each (median duration 120 min). All patients expressed their experience of contingency and their ultimate life goals within the four phases of co-creation and in their work of art. A case description is presented illustrating the co-creation process. CONCLUSIONS: During co-creation, patients move through four phases in which experiences of contingency and ultimate life goals can be made explicit through art making and can be expressed in the work of art, supporting integration of experiences of contingency into one's life narrative.

Co-creative art processes with cancer patients from the artists' perspective: a qualitative study exploring resonance theory.

PURPOSE: Co-creation, characterised by artists and patients creating a joint work of art, may support patients with the integration of life events into their life story, such as living with cancer. In the process of co-creation, resonance relationships between patients, artists and material may evolve that support integration. We aim to investigate if and if so, how resonance relationships occur from the perspective of the artist. METHODS: We used the first 10 audio recordings of supervision sessions between eight artists and their two supervisors on ongoing co-creation processes with cancer patients. By conducting a qualitative template analysis in AtlasTi, we searched for the presence of resonance, as defined by its four main characteristics, Being affected, touched and moved; Self-efficacy and responding; Moments of uncontrollability; and Adaptive transformation. In addition, two case descriptions are presented. RESULTS: We found resonance relationships to be present in the studied co-creation processes where moments of uncontrollability can lead to a next step in the process of co-creation and as such form an important factor within co-creation. CONCLUSIONS: The current study suggests focus on elements of resonance relationships within co-creation, specifically practising with uncontrollability while working with art, could strengthen interventions targeting integration of life events in advanced cancer patients.

Implementing the pharmacy technician role in existing pharmacy settings: Stakeholders views of barriers and facilitators.

BACKGROUND: The field of pharmacy will benefit from pharmacy technicians, a higher educated mid-level support workforce. They support pharmacists in providing pharmaceutical patient care through delegated roles and responsibilities. Empirical research on pharmacy technicians within pharmacy practice community and hospital pharmacy practices tends to focus on the practical outcomes of this workforce addition. It mostly addresses the 'WHAT' of service delivered by pharmacy technicians. Literature on the 'HOW' of their role development in practice is scarce. Furthermore, it seems difficult for most pharmacy technicians to effectively fulfil this professional role. OBJECTIVE: This qualitative study explored factors influencing role development of pharmacy technicians in community and hospital pharmacies. METHODS: On site, individual and small-group interviews were conducted with pharmacy technicians (n = 10), and two colleagues: pharmacists (n = 7) and pharmacy assistants (n = 6). Interviews were based on a semi-structured interview guide. Participants were asked to describe specific incidents and organisational, relational and pharmaceutical care perspectives, illustrative of the process of developing and implementing the pharmacy technician role. Template analysis was used to develop a list of codes representing themes identified in the data. RESULTS: Five interrelated themes influenced development and implementation of the pharmacy technician role. Two of them were at a more contextual level: (a) experiencing a lack of vision on added value of the new role within the field of pharmacy and (b) learning climate. The other three were related to personal interactions between staff members: (c) role expectations and organisational fit, (d) personal traits of pharmacy technicians and (e) support of pharmacy technicians through task delegation and role enhancement. CONCLUSIONS: The data showed that development and implementation of pharmacy technician roles is a complicated process. A detailed plan for addressing and remediating the five identified themes is important to promote role development of pharmacy technicians.

Co-creative art processes with patients: A theoretical framework and qualitative study among artists.

A cancer diagnosis may be experienced as a contingent life event. Co-creation-in which artists together with patients create a work of art reflecting on aspects of the patients' life story-may be used to support patients to integrate such a contingent life event into their life story. We conducted a qualitative study in which we interviewed 10 professional artists to explore if co-creative art processes could facilitate integration of experiences of contingency in patients. Template analyses were performed in AtlasTi. We identified co-creation as a specific form of support to the process of integration of experiences of contingency. In the formation of a new life narrative, patients transcend the boundaries of their previous life narrative by changing their perspective. Self-transcendence forms a pivotal point in co-creation, which may be helpful for patients to integrate experiences of contingency into their life narratives.

This is what life with cancer looks like: exploring experiences of adolescent and young adults with cancer using two visual approaches.

INTRODUCTION: Talking about illness experience can be challenging for adolescents and young adults (AYAs) with cancer. Visual tools, in addition to spoken language, might make this easier, such as rich pictures and photovoice. We aimed to obtain a comprehensive view of the cancer experience of AYAs by using rich pictures and photovoice. METHODS: AYAs (18-35 years old) who had any type of cancer, or were in remission from cancer, were eligible. AYAs drew rich pictures about their experience of living with cancer and explained these during subsequent interviews. Some of the AYAs also participated in photovoice and spent two days with a photographer to make photos about their illness experience. Rich pictures and photos were first analyzed separately, using open coding, after which the identified themes were compared. RESULTS: Twelve AYAs made rich pictures (RPs), of whom seven also participated in photovoice. The two most predominant themes emerging from the data were struggles related to the future and defining one's identity. The AYAs expressed concerns for the future related to relationships, education, and employment. Relating to defining one's identity, many AYAs expressed that the cancer had a negative impact on their body- and self-image. The main themes were visible in the RPs as well as in the photovoice; however, subtle differences in sub-themes were found. CONCLUSIONS: We found that cancer has an effect on many aspects of AYAs' lives. Further research on how the identified themes play a role in the lives of AYAs with cancer is needed.

Repeated use of rich pictures to explore changes in subjective experiences over time of patients with advanced cancer.

BACKGROUND: The combination of verbal and visual tools may help unravel the experiences of advanced cancer patients. However, most previous studies have focused on a specific symptom, at only one moment in time. We recently found that a specific visual tool, originating from systems thinking, that is, rich pictures (RPs), could provide a more comprehensive view of the experiences of patients with advanced cancer. AIMS: To examine whether the repeated use of RPs can make changes in subjective experiences of patients living with advanced cancer visible over time. METHODS AND RESULTS: We performed a prospective study with a generic qualitative approach that was mostly informed by the process of grounded theory. We invited patients to make an RP twice, at the start of the study, and again after 2 months. Both RP drawing sessions were directly followed by a semi-structured interview. Patients with all types of solid tumors, above the age of 18, and with a diagnosis of advanced, incurable cancer, were eligible. Eighteen patients participated and 15 patients were able to draw an RP twice. In eight RP-sets, considerable differences between the first and second RP were noticeable. Two patterns were distinguished: (1) a change (decline or improvement) in physical health (five patients), and/or (2) a change in the way patients related to cancer (three patients). CONCLUSION: RPs are a valuable qualitative research method that can be used to explore the experiences of patients with advanced cancer, not only at a single point in time but also over time.

Narrative recognition and identification: a qualitative pilot study into reading literary texts with advanced cancer patients.

PURPOSE: Patients with advanced cancer can experience their disease as a contingent life event. The sudden interruption of their life stories can obscure life goals and disrupt meaning making. In the context of the research project "In search of stories," we aim to investigate the reading and discussion of selected stories which present ways of dealing with a contingent life event. In addition, we examine the use of a newly developed guide for reading these exemplary texts together with advanced cancer patients. METHODS: This qualitative study describes the experiences of five patients with advanced cancer who participated in a guided reading and discussion about selected literary texts. The intervention consisted of reading a selected story, after which each patient was interviewed, using the reading guide as a conversation template. The interviews were then thematically analyzed for their conceptual content using a template analysis. RESULTS: All five conversations showed some form of recognition in reaction to the chosen text, which led to personal identification of experiences of contingency, such as loss of life goals, impending death, or feelings of uncertainty. Besides the important role of identification, revealed by the responses to the questions in the reading guide, the discussion of the text helped them articulate their own experience and sources of meaning. Diverse worldviews came to the fore and concepts of meaning such as fate, life goals, quality of life, and death. CONCLUSIONS: First experiences with our newly developed reading guide designed to support a structured reading of stories containing experiences of contingency suggest that it may help patients to express their own experiences of contingency and to reflect on these experiences. IMPLICATIONS FOR CANCER SURVIVORS: The intervention tested in this study may contribute to supportive care for survivors with advanced cancer, but further research is needed to evaluate its effect on quality of life.

Symptom- and Prevention-Based Testing of COVID-19 in Nursing Home Residents: A Retrospective Cohort Study.

Nursing homes (NH) residents with COVID-19 can either be tested because of presence of core symptoms (S-based) or because of transmission prevention (TP-based). The investigated study sample included all NH residents who underwent SARS-CoV-2 RT-PCR testing between March 16, 2020 and May 31, 2020 (n = 380). Clinical symptoms, temperature, and oxygen saturation were extracted from medical records, 7 days before to 14 days after testing. COVID-19 was confirmed in 81 (21%) residents; 36 (44%) S-based and 45 (56%) TP-based: 45. Cycle threshold (CT) values did not differ between the groups. In the 7 days prior to the test falling (32%), somnolence (25%) and fatigue (21%) occurred in both groups. Two days before the test, we observed a stronger decrease in oxygen saturation and an increase in temperature for the S-based group compared to the T-based group that remained up to 10 days after testing. Residents within the S-based group were 2.5 times more likely to increased mortality within 30 days than residents in the TP-based group (HR, 2.56; 95% 1.3-5.2). Although, 73% of the T-based group did eventually develop core symptoms. Thus, attention to falling and daily measures of temperature and oxygen saturation can contribute to earlier detection.

Educators' experiences with governance in curriculum change processes; a qualitative study using rich pictures.

In the midst of continuous health professions curriculum reforms, critical questions arise about the extent to which conceptual ideas are actually put into practice. Curricula are often not implemented as intended. An under-explored aspect that might play a role is governance. In light of major curriculum changes, we explored educators' perspectives of the role of governance in the process of translating curriculum goals and concepts into institutionalized curriculum change at micro-level (teacher-student). In three Dutch medical schools, 19 educators with a dual role (teacher and coordinator) were interviewed between March and May 2018, using the rich pictures method. We employed qualitative content analysis with inductive coding. Data collection occurred concurrently with data analysis. Different governance processes were mentioned, each with its own effects on the curriculum and organizational responses. In Institute 1, participants described an unclear governance structure, resulting in implementation chaos in which an abstract educational concept could not be fully realized. In Institute 2, participants described a top-down and strict governance structure contributing to relatively successful implementation of the educational concept. However it also led to demotivation of educators, who started rebelling to recover their perceived loss of freedom. In Institute 3, participants described a relatively fragmentized process granting a lot of freedom, which contributed to contentment and motivation but did not fully produce the intended changes. Our paper empirically illustrates the importance of governance in curriculum change. To advance curriculum change processes and improve their desired outcomes it seems important to define and explicate both hard and soft governance processes.

'I found myself a despicable being!': Medical students face disturbing moral dilemmas.

CONTEXT: The psychological realm of medical students' moral experiences is explored tangentially in medical education literature, often in the context of ethics or professionalism education. This study deepens our understanding by (a) investigating the nature of moral dilemmas experienced at the onset of clinical practice, (b) exploring students' emotional response to these dilemmas, and (c) examining how students perceive the influence of these dilemmas on their professional development. METHODS: This is a cross-sectional qualitative study carried out in 2017 that applied thematic template analysis to individual interviews performed with last-year medical students. The interviews followed the drawing of a Rich Picture representing moral dilemmas experienced by medical students at the onset of clinical practice. RESULTS: Moral dilemmas have four intertwined dimensions. The first relates to students' struggle to prioritise, balance and apply conflicting moral values; the second comprises the clash between students' inner motivation and the external constraints that limit the moral action; the third refers to the conflict between students' current attitudes with the desired/idealised attitudes of the doctor they intend to become; and the fourth corresponds to weighting conflicting ethical principles during the moral decision. Students' emotional responses are intense and long-lasting, and with a remarkable residue effect, particularly when the moral decision does not align with their moral beliefs. Moral dilemmas are impactful experiences that affect the professional development of medical students and can culminate in both detachment and growth in moral courage. CONCLUSION: Moral dilemmas are memorable, complex and emotionally intense experiences that impact the professional development of medical students. Understanding students' moral dilemmas can help educators to devise pedagogical activities to anticipate and reflect on these experiences. These activities should happen under the guidance of a non-judgemental facilitator, capable of listening and legitimating students' thoughts and feelings while providing insights to nurture their professional development.

Medical Education Empowered by Theater (MEET).

The medical education community acknowledges the importance of including the humanities in general, and the liberal arts in particular, in the education of health professionals. Among the liberal arts, theater is especially helpful for educators wanting to bring experiences that are both real and challenging to the learning encounter in an interactive, engaging, and reflective way. In this Perspective, the authors share what they have learned after working together with a company of actors for 8 years (2012-2019) in different obligatory and elective curricular activities. Influenced by Freire's Pedagogy of the Oppressed and the ideas of Boal's Theatre of the Oppressed, Medical Education Empowered by Theater (MEET) embraces social accountability and applies the concept of sensible cognition to empower medical students as the protagonists of their learning and professional development to become agents of change-both in patients' lives and in health care systems. The MEET theoretical framework builds on the concepts of liberation, emancipatory education, critical pedagogy, and participatory theater to offer medical students and teachers an opportunity to problematize, criticize, and hopefully reform the hierarchical and often oppressive structures of medical education and practice. MEET sessions include activating previous knowledge and experiences, warm-up exercises, different improvisational exercises, debriefing, and synthesis. Vital to the praxis of MEET is applying theater-teaching traditions to develop capacities important in medicine: presence, empathy, improvisation, communication (verbal and nonverbal), and scenic intelligence (i.e., the capacity to self-assess one's performance while performing). The authors believe that theater offers a venue to integrate both the personal and professional development of students into a process of reflection and action, targeting the transformation of the medical culture toward social justice.

Trainee-environment interactions that stimulate motivation: A rich pictures study.

CONTEXT: Staying motivated when working and learning in complex workplaces can be challenging. When complex environments exceed trainees' aptitude, this may reduce feelings of competence, which can hamper motivation. Motivation theories explain how intrapersonal and interpersonal aspects influence motivation. Clinical environments include additional aspects that may not fit into these theories. We used a systems approach to explore how the clinical environment influences trainees' motivation and how they are intertwined. METHODS: We employed the rich pictures drawing method as a visual tool to capture the complexities of the clinical environment. A total of 15 trainees drew a rich picture representing a motivating situation in the workplace and were interviewed afterwards. Data collection and analysis were performed iteratively, following a constructivist grounded theory approach, using open, focused and selective coding strategies as well as memo writing. Both drawings and the interviews were used to reach our results. RESULTS: Trainees drew situations pertaining to tasks they enjoyed doing and that mattered for their learning or patient care. Four dimensions of the environment were identified that supported trainees' motivation. First, social interactions, including interpersonal relationships, supported motivation through close collaboration between health care professionals and trainees. Second, organisational features, including processes and procedures, supported motivation when learning opportunities were provided or trainees were able to influence their work schedule. Third, technical possibilities, including tools and artefacts, supported motivation when tools were used to provide trainees with feedback or trainees used specific instruments in their training. Finally, physical space supported motivation when the actual setting improved the atmosphere or trainees were able to modify the environment to help them focus. CONCLUSIONS: Different clinical environment dimensions can support motivation and be modified to create optimal motivating situations. To understand motivational dynamics and support trainees to navigate through postgraduate medical education, we need to take all clinical environment dimensions into account.

Medical student views of and responses to expectations of professionalism.

CONTEXT: To earn society's trust, medical students must develop professional values and behaviours via a transformative process, from lay person to doctor. Yet students are expected to epitomise the values and behaviours of a doctor from the outset of medical school, leading them to feel 'judged all the time' (in terms of their professionalism). Our aim, therefore, is to extend knowledge exploring the expectations communicated to and perceived by medical students and to provide a conceptually framed understanding of students' associated emotional tensions. METHODS: We used a qualitative exploratory case study methodology within a constructivist paradigm to explore the messages communicated about professionalism and students' perceived expectations of professionalism in one medical school. Data were collected in the form of: (i) regulatory and medical school documents, and (ii) focus groups with 23 participants in their first 2 years at medical school. We used thematic analysis for data interpretation and two theoretical lenses, Amalberti et al.'s framework of system migration for health care and Sinclair's adaptation of Goffman's dramaturgical theory, to critically analyse the results. RESULTS: We found messages and perceived expectations of knowledge and competence, and the need to ensure trust. We also identified that the expectations of patients, doctors, society, family and friends are just as, if not more, influential than policy and regulatory expectations for early years' medical students. Moreover, we found tensions, with students feeling that the expectations of them from others were unrealistic for their level of training. With this came a sense of pressure to meet expectations that participants responded to by acting as if already competent. CONCLUSIONS: Our findings suggest that external forces (expectations) drive early years' students to act as if competent. Although this is part of student identity formation it could also have implications for patient safety and therefore necessitates recognition and support from educators.

Living with advanced cancer: Rich Pictures as a means for health care providers to explore the experiences of advanced cancer patients.

BACKGROUND: To provide holistic care to patients with advanced cancer, health care professionals need to gain insight in patients' experiences across the different domains of health. However, describing such complex experiences verbally may be difficult for patients. The use of a visual tool, such as Rich Pictures (RPs) could be helpful. We explore the use of RPs to gain insight in the experiences of patients with advanced cancer. METHODS: Eighteen patients with advanced cancer were asked to draw a RP expressing how they experienced living with cancer, followed by a semi-structured interview. Qualitative content analysis, including the examination of all elements in the drawings and their interrelationships, was used to analyze the RPs, which was further informed by the interviews. RESULTS: The RPs clearly showed what was most important to an individual patient and made relations between elements visible at a glance. Themes identified included: medical aspects, the experience of loss, feelings related to loss, support from others and meaningful activities, and integration of cancer in one's life. The added value of RPs lies in the ability to represent these themes in one single snapshot. CONCLUSIONS: RPs allow for a complementary view on the experiences of advanced cancer patients, as they show and relate different aspects of patients' lives. A RP can provide health care professionals a visual summary of the experiences of a patient. For patients, telling their story to health care professionals might be facilitated when using RPs.

Social Interactions of Clerks: The Role of Engagement, Imagination, and Alignment as Sources for Professional Identity Formation.

PURPOSE: Participating in clinical practice shapes students' identities, but it is unclear how students build meaningful relationships while "dipping into" various social contexts. This study explored with whom students interacted, which social relationships they built, and how these relationships contributed to the formation of a professional identity. METHOD: In this longitudinal study at University Medical Center Groningen, University of Groningen, the Netherlands, 9 undergraduate medical students recorded experiences of thinking about themselves as future professionals (September 2015 to March 2017). The authors conducted template analysis using both open coding and a priori themes derived from Wenger's modes of belonging to communities of practice: engagement, imagination, and alignment. RESULTS: The authors received 205 recorded experiences. While rotating, students used engagement, imagination, and alignment to give meaning to clinical workplace social interactions. Participants considered relationships with doctors, patients, and peers as preconditions for engaging in meaningful experiences. Although imagination and alignment were less represented, discussing imagination with peers and physicians stimulated a deeper understanding of what it means to become a physician. Explicitly being invited "to the table" and awareness of the benefits of being a clerk were instances of alignment that stimulated the development of identities as future doctors. CONCLUSIONS: To understand the nature of professional identity formation, Wenger's modes of belonging must be considered. Where engagement is very prevalent, imagination and alignment are less spontaneously mentioned and therefore more difficult to foster. Looking for ways to support imagination and alignment is important for students' sensemaking process of becoming a doctor.

"My right-hand man" versus "We barely make use of them": change leaders talking about educational scientists in curriculum change processes-a Membership Categorization Analysis.

Health professions education scholarship units (HPESUs) are increasingly becoming a standard for medical schools worldwide without having much information about their value and role in actual educational practices, particularly of those who work in these units, the educational scientists. We conducted a linguistic analysis, called Membership Categorization Analysis, of interviews with leaders of recent curriculum changes to explore how they talk about educational scientists in relation to these processes. The analysis was conducted on previously collected interview data with nine change leaders of major undergraduate medical curriculum change processes in the Netherlands. We analyzed how change leaders categorize HPESUs and educational scientists (use of category terms) and what they say about them (predicates). We noticed two ways of categorizing educational scientists, with observable different predicates. Educational scientists categorized by their first name were suggested to be closer to the change process, more involved in decisional practices and positively described, whereas those described in more generic terms were represented in terms of relatively passive and unspecified activities, were less explicit referenced for their knowledge and expertise and were predominantly factually or negatively described. This study shows an ambiguous portrayal of educational scientists by leaders of major curriculum change processes. Medical schools are challenged to establish medical curricula in consultation with a large, diverse and interdisciplinary stakeholder group. We suggest that it is important to invest in interpersonal relationships to strengthen the internal collaborations and make sure people are aware of each other's existence and roles in the process of curriculum development.

Rich pictures: a companion method for qualitative research in medical education.

CONTEXT: Within the social sciences, researchers increasingly build on visual methods to explore complex phenomena and understand how people experience and give meaning to this complexity. Amongst the variety of visual methods available, rich pictures are beginning to gain traction in health professions education (HPE) research. APPROACH: A rich picture is a pictorial representation of a particular situation, including what happened, who was involved, how people felt, how people acted, how people behaved, and what external pressures they acted upon. Rich pictures expand our perspective; they may highlight connections, illuminate the big picture and reveal unexpected emotions. Although new methods bring excitement to the field, it is our responsibility to also be cautious and insightful about their limitations. Rich pictures are a method in evolution in HPE research, with many unknowns about what is possible and what is optimal. PURPOSE: In the current paper, we aim to map out the background, describe the process and share some reflective insights of using rich pictures as a data collection method.