“Timelining” Treatment Trajectories During Interviews About Shared Decision Making With Ethnic Minorities in Oncology: A Methodological Reflection

Abstract

The use of timelines is well-established in qualitative research and has been employed across a range of studies. However, the development of timelines (timelining) during interviews on shared decision making (SDM) remains relatively uncommon. This article reflects on our experiences with integrating timelining into semi-structured interviews with ethnic minority patients and their relatives on SDM in oncology. During the interviews, the interviewer collaborated with participants to develop visual timelines on paper representing their oncological treatment trajectories. In this methodological reflection, we describe how timelining functioned throughout the interview process, structured chronologically across three phases: (1) the start of the interview, (2) the evolving timeline during the interview, and (3) the completed timeline. During multiple interview encounters the timeline functioned as active agent within the conversation. For participants, it supported recall, facilitated the articulation of their experiences, and helped them to focus on decisional moments. For the interviewer, the timeline aided the clarification of participants’ verbal accounts, supported familiarization with each participants’ particular treatment trajectory, and prompted both narrative-specific and overarching questions. Timelining supported several interviews on SDM by rendering decision making more tangible for both participants and the interviewer. It also facilitated attention to multiple treatment decisions relevant to SDM, and supported an understanding of SDM as a process unfolding across the treatment trajectory. Our reflections suggest that timelining may serve as a valuable methodological aid for exploring SDM in longitudinal and complex treatment trajectories.

Introduction

“You can take my story with you”, a participant responded when RO, the first author and interviewer, asked her whether she wanted to take a picture of the timeline RO had drawn during the interview or keep it herself. The participant had been interviewed for our study on shared decision making (SDM) with ethnic minority patients undergoing cancer treatment. In this article we describe and reflect on how we combined semi-structured interviews with timelining, defined as the process of developing a visual timeline (Sheridan et al., 2011).

The use of timelines is well-established in qualitative research and has been employed across a range of studies, for example with vulnerable populations, or to investigate sensitive topics (Guenette & Marshall, 2009; Kolar et al., 2015; McGrath & Lhussier, 2025; Pell et al., 2020; Sheridan et al., 2011). Timelining during interviews on SDM remains relatively uncommon. Previously, timelines have been employed to structure interviews on a decision-making pathway in maternity care (Murugesu et al., 2021), in co-creation sessions to identify key decisional moments for patients with breast cancer (van Strien-Knippenberg et al., 2022), and to visualize reproductive decision-making journeys of women with chronic kidney disease (Phillips et al., 2021), and cystic fibrosis (Williams et al., 2023). However, detailed descriptions and methodological reflections on the application of timelining in SDM research remain scarce, while it is a promising method to include multiple decisional moments over time and make decision making more tangible. This article offers a methodological reflection on integrating timelining into semi-structured interviews on SDM, providing insights to guide researchers in both the preparation and the conduct of such interviews.

Study Background: SDM With Ethnic Minorities in Oncology

SDM in healthcare is defined as “a collaboration between individuals that blends science, clinical experience, and people’s preferences when comparing options or plans to determine decisions” (Elwyn et al., 2025, Table 1, p. 3892). This process involves (1) creating choice awareness among patients, (2) explaining available options, including their respective benefits and harms, (3) discussing patients’ preferences and supporting them in deliberation, and (4) determining whether patients wish to make the decision themselves, make it jointly, or defer it (Stiggelbout et al., 2015).

SDM is particularly relevant for oncology because multiple treatment options may exist, each with distinct benefits and harms that patients need to weigh (Elwyn et al., 2009; Kane et al., 2014), and because treatments may have a significant impact on patients’ lives, or demand long-term adherence (van der Horst et al., 2023). Moreover, treatment decision making in oncology is complex, often requiring patients to make multiple decisions throughout the treatment trajectory, involving several healthcare professionals (HCPs) (Griffioen et al., 2021; Kane et al., 2014).

Limited research has explored the experiences of ethnic minority patients with SDM in oncology, at a time when their engagement with oncological care is increasing, due to rising cancer incidence associated with the adaptation of a Western lifestyle (Arnold et al., 2010; Lamminmäki et al., 2023). To address this gap, our research investigates the need to adjust SDM to meet the needs of ethnic minority patients in oncology, and explores possible adjustments (Oueslati et al., 2022). In the empirical component of our study, we examined the decision-making experiences of ethnic minority patients of Moroccan, Turkish, and Surinamese Hindustani descent, as well as those of their relatives (Oueslati et al., 2026). These are the largest ethnic minority groups in The Hague (Municipality of The Hague, 2024; Oudhof et al., 2011), which served as the main setting of this study.

We conducted semi-structured interviews with 22 patients, employing timelining for 21 of them. Each patient participated in a single interview and had made diagnostic or treatment decisions within the past three years for various types of cancer, including breast, gynecological, colorectal, hematological, or prostate cancer. We also interviewed 11 relatives, some separately and others together with the patient. In a few of these joint interviews, relatives assisted in interpretation for the patients and interviewer. Three interviews were conducted in patients’ native language by other interviewers. Interviews were held at locations preferred by the participants (e.g., at home, in a hospital, library, or online). One interview was conducted online, during which a timeline was created using a virtual whiteboard. The reflections and experiences presented below are based on the interviews conducted by RO.

Rationale for Using Timelining

Data collection through interviewing occupies a prominent place in qualitative research (Bagnoli, 2009). This method primarily relies on participants’ verbal expressions and memories of or thoughts on a topic. Combining interviewing with drawing would next to verbally also visually capture participants’ experienced decisional moments throughout their oncological treatment trajectories (Adriansen, 2012). We decided to use timelining for several reasons.

First, patients in oncology often undergo multiple treatments over extended periods and may therefore not recall all decisional moments or be aware of their occurrence at all. Timelining thus functions as a graphic elicitation technique that facilitates the identification of a decisional moment for both the participant and researcher (Kolar et al., 2015; Sheridan et al., 2011). Secondly, reflection on decision making requires participants to engage with an abstract concept. A visual representation of a moment of decision making has the potential to support participants to focus and reflect on these specific moments (Copeland & Agosto, 2012; Marshall, 2019; Pain, 2012). Thirdly, SDM research has been criticized for being too narrowly focused on one-off decision encounters, while ignoring processes that take place outside the consultation room, e.g. patients’ deliberation with others, and searching for information (Clayman et al., 2017; Griffioen et al., 2021). We intended the use of timelining to capture the distributed character of decision making, based on the assumption that treatment decisions may evolve across multiple encounters involving various people (Rapley, 2008). Lastly, we expected timelining would enable us to improve our understanding of decision making in the course of patients’ entire treatment trajectory, despite only interviewing the participants once.

Below we will describe our employment of timelining during the interviews, illustrated by RO’s experiences and excerpts from interviews in which either the interviewer or participant referred to the timeline. These segments were coded by RO in the interview transcripts using the software program ATLAS.ti. 23. The segments were identified during the coding process when participants or the interviewer used language referring to the timeline, e.g., the word “here” in relation to the context in which it was uttered, or more explicit phrases such as “Interviewer: And if you look at the trajectory […], are there points on the timeline where you think [..]?” (Interview with Relative 1). Subsequently, RO coded what the timeline both facilitated and elicited during the interview, how it was utilized and what effects it produced.

We present how timelining functioned throughout the interview process, structured chronologically across three phases mirroring the evolving nature of both the interview process and the development of the drawing (Cain, 2010): (1) the start of the interview, (2) the evolving timeline during the interview, and (3) the completed timeline. Along the way, we integrate these experiences with relevant studies and theoretical insights.

The Start of the Interview

Opening Question

Before the interview began, RO informed participants about the interview procedures including that the participant and/or she could draw parts of the oncological treatment trajectory. RO sat close to the participant(s) ensuring the drawing paper was visible to both herself and the participant(s).

Talking about cancer can be a relief for patients (McIlfatrick et al., 2006), but it can also be distressing (Holland & Alici, 2010). Especially among ethnic minorities cancer can be surrounded by stigma and taboo and provoke fear and fatalism (de Kruif et al., 2020; Licqurish et al., 2017; Vrinten et al., 2016). Therefore, it was essential for the interviewer to remain sensitive and responsive to participants’ emotional states. RO did so by starting the interview with a broad question:

“Interviewer: You were told some time ago that you were ill. Could you tell me something about that, when it happened and how it happened?” Interview with Patient 10

This broad question enabled participants to talk about their disease in their own chosen words and to gently enter their reflective frame of mind (Guenette & Marshall, 2009). The participants’ responses enabled RO to talk about their or their relatives’ disease within the frames of their own narrative, while gaining awareness of issues requiring sensitivity.

Initial Drawing and Notes

In other studies the participants were often the ones who drew the timeline, sometimes with the help of the researcher (Bagnoli, 2009; Kolar et al., 2015; Sheridan et al., 2011). In our study however, recalling the beginning of the treatment trajectory frequently evoked strong emotions among the participants. RO observed they were preoccupied with telling their story which would make it difficult for them to combine telling with drawing. Therefore, it naturally came about that RO was the one who drew:

“Interviewer: Shall we draw it out, that…

Participant: Yeah, so first the GP. Yeah.

Interviewer: I’ll just put the diagnosis here.

Participant: Yeah.

Interviewer: And then? I don’t know if you want to draw it yourself or if I should… You can also draw if you want.

Patient: Yeah, that’s fine. Well, the diagnosis was at the oncologist […].” Interview with Patient 2

While the participants were talking, RO decided to make notes on the paper in front of them. During this initial part of the interview, RO already distilled several treatment decisions from their stories, e.g., about chemotherapy, radiotherapy and surgery, that she immediately wrote down in order to zoom in on these decisional moments later in the interview. In this way, the initial drawings and writings helped the interviewer to define the focus points for the remainder of the interview (Figure 1).

Figure 1.

Completed timeline. This is a fictional timeline created by RO, the first author and interviewer, to illustrate what a timeline looks like. It is based on elements from multiple participants’ timelines to protect individual privacy. The original timelines were in Dutch.

The Evolving Timeline During the Interview

Zooming in on Decisions

After participants had told their initial story, RO asked what treatment they received after their cancer diagnosis. Subsequently, RO focused on specific decisional moments:

“Interviewer: Okay, I have drawn along a bit here.

Patient 8: Yes.

Interviewer: I would now like to zoom in on a few [decisional] moments that you mentioned.

Patient 8: Yes.” Interview with Patient 8

Per decisional moment she drew a circle depicting the treatment decision and stick figures representing the people present in the consultation room (Figure 1). To capture the deliberation space extending beyond the consultation with the HCP (Bomhof-Roordink et al., 2019; Elwyn et al., 2012), RO subsequently asked participants what happened after a treatment had been discussed with the HCP, whether they reflected on the decision or discussed it with others:

“Interviewer: […] you mentioned the surgery, after that conversation, when you went home, did you discuss it with other people?” Interview with Patient 3

After we focused on a treatment decision and the context in which it was discussed, RO drew a line on the paper and moved to the next “station” or “stop” in the treatment trajectory, as two participants called the decisional moments on the timeline (Figure 1).

Timeline as Agent

As the interview progressed, the timeline evolved, and RO and sometimes the participant began to use it actively. The timeline influenced the conversation, functioning as an agent in the interaction.

The circle depicting the treatment decision and stick figures representing the people present in the consultation room, and sometimes a reference to the people with whom they discussed the treatment, helped to activate participants’ memory and facilitated their reflection on this particular treatment decision:

“I also noticed, [that] things gradually came back to my mind […] And then you start asking additional questions and then more details emerge.” Patient 8

Furthermore, the visualization of their treatment trajectory aided a few participants in the transmission their verbal story:

“[…] I really found this part [pointing at the timeline] the most difficult, truly, this was the hardest part for me.” Patient 2

The timeline also aided RO as interviewer during the conversation as she used it to determine when a certain event occurred, where patients were in their treatment trajectory, and who was present at the consultation:

“Interviewer: And was that after the surgery, or was it already here [pointing at the timeline] at the beginning?” Interview with Patient 3

Such questions enhance the credibility (Lincoln & Guba, 1985) of the study by checking with participants whether the interviewer has accurately understood the participant’s accounts. In this way, the timeline facilitated in situ member checking by enabling immediate verification and clarification during the interview (Roller & Lavrakas, 2015).

Other researchers noticed that the focus shifts from the participant to the timeline during interviews (Kolar et al., 2015; Sheridan et al., 2011). The above mentioned examples from our study similarly demonstrate that at times, the participants’ focus, and often RO’s, alternated between RO/them and the timeline. In this way, the timeline constructed collaboratively – the participant by telling and RO by asking questions and drawing – in multiple instances started to function as a shared narrative, which both the participant and interviewer used as a reference point. This increased both their understanding as they saw the same representation of the participant’s story.

Defamiliarization Elicits Tacit Knowledge

Mannay (2010) describes how the use of visual methods during data collection, i.e., drawings by her participants, helped her to defamiliarize herself from experiences she was familiar with, as she conducted research within her own social environment (Mannay, 2010). We hypothesized that many participants, particularly those with longer treatment histories, may have become accustomed to repeated encounters with HCPs and routinized decision-making practices. Therefore, we used timelining as a means of defamiliarization, inviting participants to step back from their everyday treatment experiences and to reconsider their treatment trajectory through a decision-making lens. Consequently, timelining may have facilitated the elicitation of forms of tacit knowledge, understood as knowledge that individuals possess but may find difficult to articulate verbally (Polanyi, 1966). Tacit knowledge refers to skills, experiences, intuitions, ideas, feelings, and values (Nonaka & Takeuchi, 1995). With one participant, RO used a circle on the timeline to illustrate the relationships between the patient, relatives, and HCPs, highlighting their distance and proximity to the patient. This enhanced the participant’s reflection on these relationships:

“Interviewer: Where would you place the doctor[s], so to speak? Where would they be in that circle?

Participant: [...] Yes, I think they might be somewhere between the [patient’s] partner and the parents or something. In a way, they have the same distance. In some aspects they are closer to the patient, and in others, they are further away again […].” Interview with Relative 4

Another participant was enabled to explicitly indicate when his hope began to fade:

“Here [pointing at the timeline] I still had hope and here [pointing at the timeline], that hope started to fade a little.” Patient 23

Both examples illustrate forms of knowledge that would have been more difficult to articulate in a purely verbal interview. Timelining therefore facilitated the elicitation of tacit knowledge that might otherwise have remained implicit (Pain, 2012).

The Completed Timeline

Decision Making Across the Treatment Trajectory

The visualization of participants’ entire decision-making trajectory enabled the elicitation of additional insights into their treatment decisions within the context of the full trajectory. At this stage, RO asked some participants overarching questions about their treatment trajectories:

“Interviewer: Are you satisfied with this process, with all the decisions that were made? Or do you think, when you see it like this, […] ‘I might have done it a little differently here or there’, or…?

Participant: Yes, of course I would have liked some things to have gone a little more smoothly, or that the choices hadn’t been so difficult.

Interviewer: Which ones does that apply to?

Participant: Yes, especially with the radiation and hormone therapy, actually.” Interview with Relative 1

Additionally, interviewing patients and relatives about an entire oncological treatment trajectory, and visualizing it, revealed that decisional roles could vary across individual treatment trajectories. This is illustrated by a participant who expressed a firm stance against undergoing a stoma procedure:

“They would rather say: if it’s borderline, just do a stoma right away. But I said no, I want to go to the very limit. And even if I can’t manage anymore, then still no stoma, you understand? So I was very firm about that.” Patient 4

Yet later in the trajectory, the same participant was more accommodating when decisions regarding chemotherapy were made:

“All the decisions about chemo, when she [the HCP] says, ‘I’m going to change this […], I don’t know anything about that, so I leave all of that entirely up to her. […] She also tried to make my life more comfortable, because my fingers became so bent and black that I couldn’t do anything. She said, ‘I’ll remove part of the chemo. In terms of cure it might only make a 2 percent difference, but it won’t harm you, it can only help.’ I always went along with that, but it is something I’m allowed to decide myself, you know? Until she says, ‘No, I’m telling you, you need to do this,’ you know? Okay, if it’s for my own good, then I leave those decisions entirely to her.” Patient 4

Another participant reported having become more experienced and knowledgeable over the course of his treatment trajectory, which influenced involvement in decision making:

“Interviewer: Do you feel that your role has changed in the decision [making]? Because you said: ‘here [pointing at the timeline] I actually did not look for that much information’ and here [pointing at the timeline] you actually know almost more about the different treatments than the doctors.

Participant: […] that trust in the doctors, that is in the initial phase. Really. I let the surgery and radiation all happen and later I thought: let me see if there are more options, but no more options were offered. It was in the second opinion that there was an eye opener.” Interview with Patient 23

Another participant was offered chemotherapy and expressed hesitation, seeking two second opinions—one in the Netherlands and one abroad. For this treatment decision, multiple circles were drawn on the timeline, indicating that the decision unfolded over several moments and involved multiple hospitals and HCPs.

These examples illustrate that timelining enabled the interviewer to ask overarching questions, capture multiple treatment decisions—including those unfolding over several moments—and reveal the dynamic nature of role-taking and shifts in patients’ engagement.

Emotional Responses

Viewing the completed timeline could provoke emotional responses from participants. Integrating timelining into interviews resulted in richer and more detailed accounts compared to interviews conducted without this visual method. As participants revisited and visually traced their cancer treatment trajectories, they not only recounted their experiences but also ‘saw’ them unfold. This process brought a range of emotions to the surface. One participant recalled feelings of uncertainty and fear as she reflected on all the decisional moments:

“Interviewer: How do you feel about seeing this drawing?

Participant: Yes, [I] got a bit emotional and a bit anxious again.” Interview with Patient 5

In contrast, another participant noted that by seeing the timeline she realized how much she had gone through, and that this made her proud of herself, having held her own ground:

“And if I see this […] Yes, so much has happened […]. Sometimes you can just, you know, compliment yourself too.” Patient 6

When asked how they experienced seeing their entire treatment trajectory visualized, several participants reflected on their perception of time, describing it as having passed quickly, as prolonged, or, conversely, as short yet eventful.

Closing the Interview

The ownership of the timeline is not straightforward (Glegg, 2019). It represents the participant’s story drawn by the researcher. Therefore, RO often concluded the interview by asking whether the participant wished to keep the timeline, allow RO to take a picture, or the reverse. Only a few chose to take a picture themselves, others indicated that they were already familiar with their treatment trajectory or did not want to be further reminded of this chapter in their lives, allowing RO to retain the timeline.

Given the sensitive nature of the interviews, RO asked at the end of the interview how it felt to share their experiences. Many participants reported that although reflecting on their treatment trajectory was emotional, they felt relieved to have shared their story. RO never left immediately after an interview – unless this was necessary for the participant – and took the time afterwards to talk about less sensitive topics.

Discussion

The aim of this article was to share our experiences and reflections on the use of timelines during interviews on SDM with patients with cancer and their relatives. These indicate that the timeline acted in various interview encounters. As the timeline evolved, it was used by several participants and the interviewer. For participants, the timeline supported recall, facilitated the articulation of their experiences, and helped them to focus on decisional moments. For the interviewer, it served to clarify verbal accounts, familiarize herself with each participants’ particular treatment trajectory, and to prompt both narrative-specific and more overarching questions. Below we contextualize our experiences and reflections within the existing literature.

Agency in Objects

The timeline’s active role altered the dynamic between interviewer and participant. This has previously been described as a “trialogue” when participants’ drawings were used in interviews, distinguishing the drawings as the third actor next to the interviewer and the participant (Bergbom & Lepp, 2022). Similarly, timelines have been described as an “integral reflexive part of the interview” (McGrath & Lhussier, 2025). Timelines were also shown to function as agents in telephone interviews, where participants drew timelines and used them to organize and structure their thoughts (Park, 2024; Pell et al., 2020) and exert greater control over the topics they chose to address (Pell et al., 2020).

That objects ‘act’ is elaborated in Actor Network Theory (ANT), which acknowledges both human and non-human entities as capable of exerting influence within networks (Latour, 2005):

“After all, there is hardly any doubt that kettles ‘boil’ water, knifes ‘cut’ meat, baskets ‘hold’ provisions, hammers ‘hit’ nails on the head, rails ‘keep’ kids from falling, locks ‘close’ rooms against uninvited visitors, soap ‘takes’ the dirt away, schedules ‘list’ class sessions, prize tags ‘help’ people calculating and so on. Are those verbs not designating actions?” (Latour, 2005, p. 71)

Accordingly, within ANT anything that makes a difference in a state of affairs is considered an actor. Thus, both human and non-human entities may function as actors (Latour, 2005). In our study, the evolving timeline functioned as an actor by influencing and transforming the interview.

Art and agency theory also conceptualizes art objects as operating within networks of social relations. Within these networks, social actors may exert influence through the object or, conversely, be influenced by it (Gell, 1998). This notion has been adopted within the field of visual methods, encouraging researchers to critically reflect on their contribution to the agency of the images used in their research (Newbury, 2020).

Through the lens of this theory, the timelines in our study materialize participants’ agency, as they were constructed from their narrated experiences. The interviewer’s agency is likewise embedded in the timelines through the selective drawing of elements she considered analytically relevant. Consequently, our timelines exemplify Gell’s (1998) notion of the distributed mind (Gell, 1998), in which cognition is not confined to an individual but distributed across persons and objects. As the timeline evolved, participants’ narrated experiences and the interviewer’s interpretive selections became intertwined, gradually influencing both interviewer and participant, positioning each alternately as ‘artist’ and ‘recipient’.

Several researchers describe a hesitancy among participants to draw (Ademolu, 2025; Brailas, 2020), or note that participants require additional time to do so (Bremner, 2020). In our study the interviewer naturally assumed the drawing role. Consequently, the timelines evolved into co-constructed drawings that were more objective than subjective. They primarily represented participants’ decisional events rather than their personal or emotional interpretations (Lyon, 2020). Nevertheless, although the interviewer in this study drew, the timeline also contained the participants’ agency.

The Impact of Timelining on Our View on SDM

Timelining enabled us to identify multiple treatment decisions in participants’ treatment trajectories, with different decisional characteristics. Sometimes, participants indicated they were presented multiple reasonable options with different types of benefits and risks that they had to weigh, e.g., in case of certain hormone- or chemotherapy treatment decisions, the so-called preference sensitive decisions (Stiggelbout et al., 2015). Also, many participants had to make high-impact decisions that affected their health and quality of life, e.g., surgery or chemotherapy. Furthermore, during their treatment trajectory a few participants encountered decisions for which their long-term adherence was needed, e.g., committing to hormone therapy for many years. These all fit within the spectrum of decisions for which SDM is regarded as appropriate (Elwyn et al., 2022; Hargraves et al., 2019; van der Horst et al., 2023).

SDM is increasingly recognized as a longitudinal process (Clayman et al., 2017; Stiggelbout et al., 2023). Timelining helped us to conceptualize treatment decision making as a process, as we occasionally observed patients adopting different decisional roles within their trajectories, and noted that some decisions took time to be made.

Recommendations When Using Timelining

Several considerations warrant attention when timelining to construct decisional moments within treatment trajectories.

First, timelining may evoke emotional responses, as it invites participants to revisit and visualize detailed aspects of their treatment trajectory. Interviewers should therefore remain attentive to participants’ emotional responses, allow space for reflection, and conclude interviews with less sensitive topics when appropriate.

Second, when interviewers take on the drawing role, they may actively invite participants to engage with the timeline by ensuring its visibility, verbalizing what is being drawn, and by asking questions while referring to the timeline. In our study, timelines were typically co-constructed during face-to-face interviews. In one online interview a virtual whiteboard, visible to both interviewer and participant, was used to construct the timeline.

The involvement of our participants in the use of the timeline varied, particularly in joint interviews with relatives, where relatives occasionally acted as interpreters. Additionally, some timelines were relatively brief when participants were at an early stage of their treatment trajectory. Nevertheless, even when participants were less engaged with the timeline or the timeline was short, timelining supported the interviewer in structuring the interview, posing trajectory-specific questions, and verifying her understanding of participants’ experiences. This underscores its value as a methodological instrument.

Concluding Remarks

This article described our use of timelining in semi-structured interviews on SDM. Timelining supported the interview process by rendering decision making more tangible for both participants and the interviewer. It also facilitated attention to multiple treatment decisions relevant to SDM. In addition, timelining supported an understanding of decision making as a process unfolding across the treatment trajectory. Taken together, these reflections suggest that timelining may serve as a valuable methodological aid for exploring decision making in longitudinal and complex treatment trajectories.