Timeline Mapping as a Methodological Approach to Study Transitions in Health Professions Education

Abstract

The aim of this paper is to highlight timeline mapping exercise as a research tool and the benefits and challenges of incorporating this method into research. Timeline mapping offers a novel methodological approach toward gathering and accessing rich and meaningful data in the study of life transitions for instance from secondary education to higher education or from education to employment. This paper especially focuses on how it can be incorporated into research studies specific to HPE (Health Professions Education). It also offers researchers step-by-step instructions on how to conduct timeline mapping exercises and how to go about analysing the findings and gathering insights from the findings.

Introduction

Timeline mapping method is used for exploring life trajectories across life stages and can be beneficial for Health Professions Education (HPE) research as it can highlight the significance of events such as transition from secondary school to medical school or from resident to attending physician (Rees, 2018; Westerman et al., 2010). Despite a move toward novel qualitative research methods in HPE, timeline mapping is yet to be incorporated as a tool in the existing repertoire of tools and methodologies. Although visuals and drawings, in general, are increasingly being incorporated into HPE research (Rees, 2018), there is still much to explore when it comes to using timeline mapping method. The aims of the current paper are to argue for the use of timeline mapping in HPE research by: (a) explaining how timeline mapping can be conducted in the research area of interest, (b) how timeline mapping can be analysed in order to gain an in-depth understanding of patterns or changes in an individual’s life, and (c) describing how the use of this method could be beneficial when researching HPE trajectories.

The paper has been organised into four sections: an introduction to timeline mapping, description of case studies where timeline mapping has been used, value for adopting timeline mapping in HPE, methodological aspect of using timeline mapping in research design, analysis of the timeline data, and a reflection on the benefits and challenges of the method.

Introduction to Timeline Mapping

The timeline mapping method became popular post-1960 as a standard method of data collection in life-course interviews (Adriansen, 2012; Chen, 2018). Timeline mapping exercises can be diverse — both non-artistic and artistic — and can be conducted in different styles, as shown in Figures 1-3. It provides opportunities for sharing experiences and chronological events over the course of single or multiple interviews, in which narratives are the object and method of analysis (Rees, 2018; Roberts, 2020).

Figure 1.

Sample horizontal timeline mapping of education to work transition.

Figure 2.

Sample list-like timeline mapping of education to work transition.

Figure 3.

Sample timeline mapping of psychological developmental transitions (Gramling & Carr, 2004); reproduced with permission from Copyright Clearance Centre.

Personal narratives, or stories (often used interchangeably), are central to making sense of the subjective experiences of the participants or storytellers. Timeline mapping exercises help the participants to organise their narratives in a chronological way and reflect on their past, negotiate the present, and plan for the future (Bagnoli, 2009; Berends, 2011). Timeline mapping exercises are particularly useful to unravel and understand the richness of the journey of an individual, their transitions from one life event to another, and similar patterns in different life stories in relation to the wider socio-economic, cultural, and political contexts (Adriansen, 2012; Basnet et al., 2020).

Timeline mapping method can be used to facilitate and ease the participants into expressing themselves, voicing their opinions, or sharing problems without the fear of judgment. Therefore, the use of timeline mapping exercises has an added value in investigating sensitive topics. Timeline mapping exercises have served as an important research tool to gather information and insights on lived experiences and memories. They have proven to be especially useful when interviewing potentially vulnerable individuals (see for example, Kolar et al., 2015). The relatively non-invasive nature allows individuals who might have traumatic experiences to share their life stories in a comfortable setting. For instance, it has been used to interview groups such as survivors of violence or abuse, immigrant groups, and persons with disabilities. Such vulnerabilities in participants could prove to be barriers (minors and survivors as well) to adequately communicate with the researcher verbally (Bagnoli, 2009; Westerman et al., 2010). Therefore, timeline mapping exercises can be a novel methodological approach where the power relations are altered, adopting a more person-centered approach (Basnet et al., 2020; Kolar et al., 2015). Instead of the researchers, participants are at the steering wheel and control the direction of the story.

Interviews conducted using timeline mapping exercises have a profound impact on the richness of the data collected. Worth’s (20) research on exploring transition to adulthood with visually impaired young people in the north of England is one such example. Worth uses life mapping method to analyse the time and spaces inhabited by young people in their transition to adulthood. Worth argues that life maps support the complex oral narratives by allowing researchers to see all the experiences at once in the visual form and adds rigour to the analysis. Not only that, by applying arts-based methods such as a timeline mapping in the research interview as a supplementary method can allow researchers to gather information of an individual on a deeper level (Bagnoli, 2009; Monico et al., 2020; Sheridan et al., 2011).

Often, when participants narrate their stories, the narratives are linear. But individual lives and experiences are much more complex. Timeline mapping exercises help us to view these complex stories in a visual/drawing form.

Value for Adopting Timeline Mapping Exercises for Research in HPE

Although good numbers of transitions research has been carried out in professional identity development of medical students (Wilson et al., 2013), preparing medical students for clinical practice (Teagle et al., 2017), and medical student clerkship to career selection (Day et al., 2016), extensively in HPE — use of timeline mapping exercises are limited. For example, the scoping review of transitions within medical school by Atherley et al. (2019) shows that out of 45 identified studies of transitions within medical school from United States, Europe, Canada and Australia, 27% of the researchers employed typical qualitative research methodologies. These methodologies ranged from narrative analysis, focus group discussions and interviews. Notably, in their review of the methodologies used in health professional education, Mann et al. (2009) found that next to qualitative methodologies, 24% of the researchers have employed cross-sectional studies, 18% of the researchers have used descriptive case studies, 7% have employed longitudinal studies, and the remaining have either employed a descriptive comparative studies, have reviewed the papers or have written a concept paper. Recently, few studies such as Cristancho and Helmich (2019) and Molinaro et al. (2021) have suggested on using rich pictures or visual methods in HPE to explore various emotions. However, the multifaceted nature of transitions requires not only exploration of the emotions but also the patterns of transitions, barriers and enablers, perceptions, and other various aspects of individuals that influences their trajectories. In such a situation, timeline mapping exercises would be beneficial because it could provide insights into how trajectories of health professions students and professionals unfold and the various events guiding their decision-making. Timeline mapping in medical education trajectories could both be used for data triangulation to increase internal validity and also to understand the nuances in the experiences of students and health professionals. Furthermore, it could also be used as a supplementary method to add rigour to traditional qualitative interviews.

Recent studies demonstrate that the transitions from medical education to clerkship (Day et al., 2016) and becoming a doctor (Westerman et al., 2010; Teagle et al., 2017) is a challenging processes. Medical students go through diverse forms of transitions like any other individual, for instance, transitions from (a) high school student to becoming a medical undergraduate; (b) medical undergraduate student to becoming a practicing doctor, (c) an undergraduate student to becoming a resident; and (d) an undergraduate student/resident to becoming a doctoral student/medical specialist. There are other aspects of their lives that can also be studied through timeline mapping method such as their trajectories from medical education to setting up a family, and the role of family support during medical education and residency.

For HPE transition, it is not enough to entirely describe moves and choices; we need more in-depth discussions of events that inform those choices, moments of decision-making, and the patterns in their transitions including their choices in order to extract the meaning of their transition process. For instance, understanding the transition of medical students to residency training and then becoming an attending in a university or in a hospital (Westerman et al., 2010). Residency training lasts for three to 6 years depending on the research location and it is an arduous process. Moreover, residency (for specialization) is also the time when many students start or plan to start their families. These personal circumstances are important factors informing these transitions.

In addition, factors such as gender, identity and ethnicity also play a key role in influencing the transitions process of medical students to becoming doctors (Wouters et al., 2017; Mulder et al., 2022), or transitions of individuals in general (Basnet et al., 2020; 2022). It is also worth highlighting the potential use of timeline mapping method in medical education research as a tool to further understand the role of sense of belongingness and professional identity development in the transition to becoming a successful doctor. Belongingness and professional identity development are important in medical education research because they are relevant to patient care (Sheridan et al., 2011; Wilson et al., 2013). Understanding and exploring belongingness during the transitions, especially in underrepresented groups, who can experience a lack of a sense of belonging in medical education trajectories (Isik et al., 2021), could potentially demonstrate their lived experiences and decision making process (Wouters, 2020). The key characteristic of timeline mapping which is chronological arrangement of the events helps us to understand the significance and deeper meaning attached to the events highlighted in the trajectory of a physician to becoming an attending.

Methodological Aspect of Timeline Mapping Exercise Research Design

A general process of research design involves planning, gathering, assessing, reasoning, and reporting the data in the form of results (Saldaña, 2014). In a visual method study, literature indicates, there are different ways to conduct research with visual exercises. Scholars in the health professional education have so far used photography, collage, rich pictures, images, charts and drawings (Rees, 2018). Research studies which have used these visual exercises have combined it with quantitative research or with interviews (Mann et al., 2009). The decision for adopting any research method or technique should be based on research aims, objectives, researcher’s experiences, philosophical assumptions, personal understanding and belief on the use of the methods (Saldaña, 2014). Similarly, research questions, data collection and data analysis in research which uses timeline mapping exercises also depends on each of these components. To further elucidate this technique to researchers, we describe it in the following steps:

Step 1: Explain the research aims, objectives and intentions of the interview to the participant(s).

Step 2: Explain what the timeline mapping exercise is and how it is conducted. Sample timeline mapping exercises could be used to explain to the participants how their interviews will be conducted. The participant(s) must be made aware that they are in no way restricted to the drawing styles shown in the examples and have the freedom to do it their way, unless the research objectives and techniques are designed with a set criterion for drawing timeline maps. In addition, the information on the timeline mapping could be either drawings, illustrations, symbols or a short text of events (as shown in Figures 1 and 2).

Step 3: Confirm with the participant(s) that they have understood the objectives of the exercise and are clear about their role in it. If the participant(s) feel hesitant or confused try to explain again and answer their questions until the participants feel comfortable.

Step 4: Provide the participant(s) with the drawing materials. Ask the participant(s) to sketch their life stories from the time in question (e.g. their birth or after joining higher education etc.) to the present moment. Explain again that they will be using drawings as a way to display their chronological lives while they narrate their stories to the researcher. The timelines could be horizontal, vertical, or unstructured or could be of any shape. The participants do not need to possess good drawing skills.

Step 5: The instructions to the participants should be minimal and very general so that the researcher does not influence how and what events the participants recall from their past. The purpose of doing so is to allow the participant(s)to be in-charge of their own stories, and allow them to choose events that have influenced their life trajectories the most (Bagnoli, 2009; Kolar et al., 2015). The participants’ conversation with the researcher while they draw the timeline should be recorded.

Step 6: Once the interview and mapping exercise is over, switch-off the recording device and ask the participant(s) if there are any events or information that they feel is missing in the timeline. If at a later date they feel they have forgotten to mention anything, they should be encouraged to share it via email or text. This step is necessary to allow participant(s) to express themselves when they are not under observation or being recorded.

The display of the stories in the examples (see box 1, 2, and 3) consists of timelines with dates. The information about participants’ school life, college or university life and employment was recorded in order to explain their transition from education to work, the opportunities and barriers they encountered, their perceptions of their job and the life events that influenced their decision making.

It should be noted that in timeline mapping exercises the participants frequently insert dates, age, school details, high-school details, events such as separations (either from the parents or of their parents), relationships with their siblings, parents, partners, or with their teachers. Some participants can be more artistic than others, which can give life to the timeline mapping exercise and make the interview process even more enjoyable. In some cases, the participants might find it difficult to work with timelines, in which case, the researcher may share his/her story using their personal timelines and sharing turning points in his/her life.

Analyses of Timeline Data

While timeline mapping has been used by scholars in their research, it can prove difficult to include such data in their analysis because of the lack of clear guidelines (Patterson et al., 2012; Westerman et al., 2010). Here, we provide a brief overview of six steps in timeline mapping data analyses:

Step 1: Reading and familiarizing oneself with the timeline information

The researchers need to familiarize themselves with the data, i.e., the timeline maps that have been created by the research participants. It is also important to understand how the trajectories have unfolded and what types of stages and turning points could be identified for each life stories.

Step 2: Identifying themes and patterns chronologically (in line with the research literature)

The researcher then needs to explore the various themes that can be identified in the timelines, for instance, transitions from high school to university, or from university to employment, barriers and enablers during the transition etc. These themes are developed in line with the research topic at hand and the questions that the research team is addressing. The topic could range from health issues, education transitions, employment transitions, coping strategies, stress management, mental health transitions, access to schools, successfully becoming employed and many more.

Step 3: Compare and contrast themes between different timelines

Once the researcher identifies the various themes that emerge, they need to identify the similarities or differences across various identifiers such as gender, age, socio-economic backgrounds in relation to the research area at hand. This process will help to get a comprehensive overview of the cross-cutting nature of the common themes and how they intersect.

Step 4: Identify life events, critical moments or significant moments

After the comparisons of the different timelines, the researcher should discuss and identify the various life events, critical moments or significant moments in each timeline as indicated by the participants and explore how these events or significant moments have shaped their trajectories.

Step 5: Reviewing and finalising

It is important to re-evaluate the themes developed, the questions at hand, and the findings. The researcher should check and evaluate the data analysis process and results and it would be advisable to share the findings with a team or an external evaluator to ensure that the entire process and the findings meet the required standards.

Step 6: Present the story of trajectories

The last step is to show the actual timelines that have emerged from the analysis of the timeline maps and explain those trajectories and the influencing factors.

Benefits and Challenges in Timeline Mapping

The timeline mapping method acts as a tool for participants to organise and express their stories and experiences in a way that allows them to put complex occurrences in a coherent way. It gives the participants an opportunity to be in charge of their stories. Through timeline mapping, participants also get an opportunity to reflect on their own trajectories and describe the experiences in detail (Day et al., 2016; Worth, 2011). The method could be used to gather insight on retrospective events as well as events in real-time. Moreover, using such a method to collect rich data also facilitates the development of trust between the researcher and the participant and helps create non-hierarchical relationships by minimizing the role of researchers, and their potential biases (Basnet et al., 2020; Monico et al., 2020). In addition, researchers could also integrate the timeline mapping exercises as a supplementary method, for example, in intervention-based research, diary-based research, or impact measurement research. Timeline mapping exercise is not only limited to collecting events based data or information of individuals, it could also act as an intervention in itself in many cases. For instance, when working with/in groups, it will allow the participants to learn from each other, share experiences, and come up with a possible solutions to the problem at hand.

Timeline mapping exercise, however, also comes with challenges when used during interviews (Basnet et al., 2020; Gramling & Carr, 2004). The aim of timeline mapping is to help identify chronology of events and its significance on an individuals’ life by connecting to those events on a deeper level. Such conversations, at times (depending on the topic at hand) can trigger negative emotions, pain, and a feeling of loss among the participants. In such instances, the researcher needs to be able to deal with the situation tactfully and listen to the participants’ experiences empathetically (Basnet et al., 2020). Finally, individual life experiences are complex and therefore demand time from the participant as well as the researcher(s) involved. This might result in dropout of participants, shortening of the narratives, and gaps in information. To avoid these issues, researcher(s) should provide adequate information about the nature of the research to the participants beforehand and show flexibility. For example, instead of conducting the exercises in one go, the researcher(s) could plan to collect the data over the course of multiple meetings.

Conclusion

This paper suggests that timeline mapping can be a relevant and useful method in HPE research as well as health research for studying people’s life trajectories as well as health trajectories, especially the transitions. It can provide nuanced insights into professional identity formation and career and specialization choices of HPE students.