thematic analysis in qualitative research nursing

Varieties of Qualitative Research Methods pp 463–468 Cite as

Thematic Analysis

• Vicki Squires 4  
• First Online: 02 January 2023

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Part of the book series: Springer Texts in Education ((SPTE))

Thematic analysis is a method of qualitative data analysis that was first described in the 1970s (Joffe, Harper and Thompson (eds), Qualitative Research Methods in Mental Health and Psychotherapy: A Guide for Students and Practitioners, Wiley-Blackwell, 2012) but became more prominent at the end of the 1990s with researchers such as Boyatzis ( 1998 ) and Hayes ( 1997 ) (as cited in Braun, V., & Clarke, V. (2012). Thematic analysis. In H. Cooper (Ed.), APA Handbook of Research Methods in Psychology (vol.2) (pp. 57–71). American Psychological Association.). As qualitfvecome more accepted across social science disciplines and now across health professions education, the need for systematic methods to analyze qualitative sets is more accentuated (Castleberry and Nolen, Currents in Pharmacy Teaching and Learning 10:807–815, 2018). ( Braun, V., & Clarke, V. (2012). Thematic analysis. In H. Cooper (Ed.), APA Handbook of Research Methods in Psychology (vol.2) (pp. 57–71). American Psychological Association.) highlighted that thematic analysis is “an accessible, flexible, and increasingly popular method of qualitative data analysis” (p. 57). Although thematic analysis shares similarities with other methodologies that have systematic processes for analyzing data such as Interpretative Phenomenological Analysis or grounded theory, it does not “require the detailed theoretical and technological knowledge” of these approaches (Braun and Clarke, Qualitative Research in Psychology 3:77–101, 2006). However, (Braun and Clarke, Qualitative Research in Psychology 3:77–101, 2006) emphasized that the theoretical position of the study needs to be made explicit, as there are inherent assumptions regarding the nature of the data that has been analyzed.

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Braun, V., & Clarke, V. (2012). Thematic analysis. In H. Cooper (Ed.), APA handbook of research methods in psychology (vol.2) (pp. 57–71). American Psychological Association.

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Hayes, N. (1997). Theory-led thematic analysis: Social identification in small companies. In N. Hayes (Ed.), Doing qualitative analysis in psychology (pp. 93–114). Psychology Press.

Joffe, H. (2012). Thematic analysis. In D. Harper & A. Thompson (Eds.), Qualitative research methods in mental health and psychotherapy: A guide for students and practitioners (pp. 203–223). Wiley-Blackwell.

Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic analysis: Striving to meet the trustworthiness criteria. International Journal of Qualitative Methods, 16 , 1–13. https://doi.org/10.1177/1609406917733847

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Additional Resources

Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11 (4), 589–597. https://doi.org/10.1080/2159676X.2019.1628806

Maguire, M., & Delahunt, B. (2017). Doing a thematic analysis: A practical, step-by-step guide for learning and teaching scholars. All Ireland Journal of Higher Education , 9 (3), 3351–3364. http://ojs.aishe.org/index.php/aishe-j/article/view/335

Thematic analysis:-7:23

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Thematic analysis (the ‘Braun & Clarke’ way): an introduction-1:02:19

https://www.youtube.com/watch?v=5zFcC10vOVY

Understanding Thematic Analysis: 6 steps to perform Thematic Analysis- 6:26

https://www.youtube.com/watch?v=WodStS6nQSk

Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing & Health Sciences, 15 (3), 398–405. https://doi.org/10.1111/nhs.12048

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Vicki Squires

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Keith D. Walker

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Squires, V. (2023). Thematic Analysis. In: Okoko, J.M., Tunison, S., Walker, K.D. (eds) Varieties of Qualitative Research Methods. Springer Texts in Education. Springer, Cham. https://doi.org/10.1007/978-3-031-04394-9_72

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Qualitative thematic analysis based on descriptive phenomenology

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• 1 Faculty of Caring Science, Work Life and Social Welfare University of Borås Borås Sweden.
• PMID: 31367394
• PMCID: PMC6650661
• DOI: 10.1002/nop2.275

Aim: The aim of this paper was to discuss how to understand and undertake thematic analysis based on descriptive phenomenology. Methodological principles to guide the process of analysis are offered grounded on phenomenological philosophy. This is further discussed in relation to how scientific rigour and validity can be achieved.

Design: This is a discursive article on thematic analysis based on descriptive phenomenology.

Results: This paper takes thematic analysis based on a descriptive phenomenological tradition forward and provides a useful description on how to undertake the analysis. Ontological and epistemological foundations of descriptive phenomenology are outlined. Methodological principles are explained to guide the process of analysis, as well as help to understand validity and rigour. Researchers and students in nursing and midwifery conducting qualitative research need comprehensible and valid methods to analyse the meaning of lived experiences and organize data in meaningful ways.

Keywords: healthcare research; lifeworld; lived experiences; meanings; midwifery; nursing; phenomenology; qualitative; thematic analysis.

• Open access
• Published: 16 April 2024

‘Enough is enough’: a mixed methods study on the key factors driving UK NHS nurses’ decision to strike

• Daniel Sanfey 1  

BMC Nursing volume  23 , Article number:  247 ( 2024 ) Cite this article

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The UK National Health Service (NHS) is one of the largest employers in the world and employs around 360,000 registered nurses. Following a protracted pay dispute in December 2022 NHS nurses engaged in industrial action resulting in the largest nurse strikes in the 74-year history of the NHS. Initially it appeared these strikes were a direct consequence of pay disputes but evidence suggests that the situation was more complex. This study aimed to explore what the key factors were in driving UK NHS nurses’ decision to strike.

A convergent parallel mixed methods design was used. The study was conducted throughout the UK and involved participants who were nurses working for the NHS who voted in favour of strike action. Data collection involved the use of an online survey completed by 468 nurses and 13 semi-structured interviews. Descriptive and inferential statistics were used for quantitative data analysis and a process of inductive thematic analysis for the qualitative data. The quantitative and qualitative data were analysed separately and then integrated to generate mixed methods inferences.

The quantitative findings showed that patient safety, followed by staff shortages, pay, and unmanageable work demands were the most important factors encouraging nurses’ decision to strike. The qualitative findings served to further the understanding of these factors particularly in relation to participants’ perception of the NHS and the consequences of inadequate pay and staff shortages. Three overarching and overlapping themes represented the qualitative findings: Save our NHS, Money talks, and It’s untenable. Integration of the findings showed a high level of concordance between the two data sets and suggest that the factors involved are interconnected and inextricably linked.

Conclusions

The UK NHS is a challenging and demanding work environment in which the well-being of its patients is dependent on the well-being of those who care for them. Concerns relating to patient welfare, the nursing profession and the NHS played a large part in driving UK NHS nurses’ decision to strike. In order to address these concerns a focus on recruitment and retention of nurses in the NHS is needed.

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The United Kingdom National Health Service (NHS) is the seventh largest employer in the world [ 1 ] providing public health services for a population of around 67 million people [ 2 ]. Of the 1.4 million staff working for the NHS approximately a quarter of these are registered nurses [ 3 ]. Nurses are the backbone of the NHS providing hospital and community services and are often patients’ first and last point of contact when accessing care.

Nurses working for the NHS are paid according to a pre agreed pay and grading system decided upon by the UK Government with recommendations from an independent NHS pay review body. Research has shown that when taking inflation into account the average pay of NHS nurses has fallen in real terms by 8% between 2010/11 and 2021/22 [ 4 ], with the figure estimated at closer to 20% for more experienced nurses [ 5 ].

The Royal College of Nurses (RCN) is the largest nursing union in the world and represents around 405,000 registered nurses working in the UK [ 6 ]. Following a protracted pay dispute with the UK government, in October 2022 the RCN balloted its members working for the NHS on whether to take industrial action in the form of strikes. Despite the high threshold for success, with all ballots needing to be conducted by post and a 50% turnout and 40% vote in favour, the ballot was conclusive. NHS nurses voted in favour of strike action in the majority of NHS Trusts throughout the UK. Footnote 1 In December 2022, for the first time in the RCN’s 106-year history their members engaged in strike action. The largest nursing strike in the 74-year history of the NHS.

On the surface it appears clear. NHS nurses were striking to secure better pay. This is supported by the most recent NHS staff survey [ 7 ] which found that only 25.6% of staff were satisfied with their level of pay. However, the staff survey also highlighted a number of other factors that indicate a high level of discontent, portraying the NHS as a stressful, demanding and unsatisfactory work environment. Furthermore, increasing numbers of nurses are leaving the profession due to health reasons, burnout and exhaustion [ 8 ], with additional nurses voicing their intent to leave because of high workload pressures and feeling undervalued [ 9 ]. This leads to the question: what are the key factors that have driven UK NHS nurses’ decision to strike?

Answering this research question is particularly pertinent at this time as the UK NHS is currently experiencing some of the greatest pressures in its history [ 10 ]. Waiting times are at an all-time high and record numbers of patients are waiting for treatment [ 11 ]. Not only are nurses engaging in strike action but also a plethora of other professions within the NHS including doctors, radiologists and physiotherapists; all of which only serves to exacerbate what is widely considered as an NHS in crisis [ 12 ]. At a time of widespread industrial action throughout the UK in which 2022 saw the highest number of working days lost to strikes for more than 30 years [ 13 ], determining the key factors driving UK NHS nurses’ decision to strike may serve to inform those concerned with prolonged and future industrial action, not just within the nursing profession and the NHS, but also the wider UK workforce.

Literature review

A strike has been defined as ‘A temporary stoppage of work by a group of employees in order to express a grievance or enforce a demand’ (p.3) [ 14 ], Hyman [ 15 ] highlights that it is predominantly a calculated act and that the complete stoppage of work and its temporary and collective nature distinguish it from other forms of work-based protest.

Nursing strikes are a global phenomenon with incidences occurring in a diverse range of countries including America, Japan, Kenya, India, Australia and throughout Europe. In the UK nurses have a rich history of protest, but the incidences of strikes within the profession are few and far between. A limited number of empirical studies exist identifying factors that have driven nurses to go on strike. These include quantitative [ 16 , 17 , 18 ], qualitative [ 19 , 20 , 21 ], and mixed methods designs [ 22 , 23 ]. Within these, issues relating to pay and working conditions predominate, but other factors such as intimidation from unions, failures of healthcare systems and addressing public perceptions of nurses were also found. What is notable is that none of these studies focus solely on factors driving nurses’ decision to strike, instead collecting data on a broad range of topics. This diverse approach may explain to some extent why they fail to facilitate a thorough understanding of the key factors driving nurses’ decision to strike. At present, it appears that there are no existing empirical studies focusing on nurse strikes within the UK, signifying a gap in the literature.

In addition to existing empirical studies there is a wide body of literature in the form of retrospective accounts that document and provide theoretical interpretations of individual and country specific nurse strikes [ 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. By depicting the nurse strike within a historical, political, and professional context these accounts help to further illuminate the phenomenon and facilitate a much richer and deeper understanding. With this, we begin to appreciate the nurse strike as distinct from those within industrialised settings and as much a form of advocacy as that of self-preservation.

For any strike there are consequences. Whether they be for employers, workers, service users, the government, or for society at large. Within the healthcare environment there are concerns that a strike may have the additional consequence of compromising patient care. This has led some to denounce strikes by nurses citing them as immoral, unjustifiable [ 31 ] and wholly inappropriate [ 32 ]. Yet, it has been argued that such a stance fails to see the bigger picture and puts too much emphasis on the nurse/patient relationship [ 33 ].

Healthcare provision is a collective endeavour and whilst nurses have a professional responsibility to prioritise patient care and put the safety and wellbeing of those requiring care at the forefront of all they do [ 34 , 35 ]; governments, employers and health policy makers also have a responsibility to facilitate an environment conducive to such an approach [ 36 ]. In situations where this does not happen it can be argued that to not stand up and take appropriate action would in itself be unethical [ 37 ] and antithetical to the standards required. It has therefore been posited that concerns around patient safety and standards of care can now be seen as one of the key driving factors for nurse strikes [ 26 ].

The aim of this study is to explore what the key factors are driving UK NHS nurses’ decision to strike. The findings of this study can be used to inform government, employers, unions and health policy makers concerned with prolonged and future industrial action and stimulate a wider discussion around the demands of contemporary nursing and the challenges of working for the UK NHS.

Study design

A convergent parallel mixed methods design was used for the study to facilitate a detailed inquiry into the research question and enhance the validity of any inferences made. Quantitative and qualitative data were collected concurrently but separately, with equal importance given to each. The two data sets were then analysed independently, after which the results were merged and interpreted [ 38 ]. This approach helped to better understand the statistical trends associated with the nurse strikes whilst gaining a contextual understanding of the motivation and experiences that lay behind them. A summary of the study design can be seen in Fig.  1 . The study is deemed exploratory in nature due to the lack of previous research on the topic within the UK and also to allow a certain amount of creativity and flexibility within the research methods used [ 39 ].

Convergent parallel mixed methods design used for study

Study setting and sampling

The study took place within the United Kingdom across all four nations of England, Wales, Scotland and Northern Ireland. The eligibility criteria included registered nurses working for the UK NHS who were also members of the RCN and voted in favour of strike action in the ballots conducted in October/November 2022 and/or May June 2023.

Participants were recruited for the quantitative methods through a combination of voluntary and convenience sampling. Nurses were notified of the study and invited to participate via the use of online nursing forums related to the RCN, social media sites (including Facebook, Twitter and LinkedIn), networking, and word of mouth. In addition, following approval from the local research and development (R&D) boards the study was advertised within two large NHS trusts in the south of England. This was achieved by distributing flyers and posters amongst the hospital wards. An email notification was also sent by the R&D department in one of the trusts. Further sampling was achieved on the picket lines outside two hospitals in Wales during the strikes in June 2023 with nurses informed of the study in person and provided with a QR code to access a survey.

Over 300,000 nurses were balloted in the first ballot on strike action in October/November 2022 [ 40 ]. The number of ballots completed and the proportion of nurses who voted in favour of strike action were not released and were not provided on request. However, with UK law [ 41 ] requiring a 50% response rate and a minimum of 40% voting ‘yes’ for strike action to happen we can assume that the actual population of nurses voting for strike action was at the very least 60,000 Footnote 2 nurses. A sample size of 384 participants was therefore deemed necessary in order for the sample to be representative. This was calculated using a basic prevalence sample size calculator with a confidence level of 95% and a margin of error at 5% [ 42 ].

Purposive and voluntary sampling was used for the qualitative methods. Potential participants were identified by scanning social media platforms for posts by nurses that implied they were in favour of and passionate about the strikes. Those nurses were then contacted, informed of the study and invited to participate ( n 8). In addition, on hearing of the study a number of nurses came forward and volunteered their participation ( n 5).

Quantitative data collection and analysis

An online cross-sectional survey was designed and administered for the study (Additional file  1 ) and was made available via the digital survey platform Lamapoll [ 43 ]. Data was collected between the 21st April and 1st July 2023 and was analysed using IBM SPSS Statistics software v.29. Prior to data collection the survey was piloted and reviewed by 8 nurses who provided feedback. This resulted in minor adjustments in the wording for a single question and the subsequent removal of a sub-scale which was deemed unclear and lacking relevance.

The survey asked participants to select which factors they felt encouraged their decision to vote for strike action from a predetermined list. The list included seven factors which were compiled to reflect the most relevant points from the literature review, the stance of the RCN, and the current political climate within the UK. Descriptive statistics were used to depict how frequently each of the factors were chosen. In addition, participants were asked to rank those factors in order of importance. Means were calculated and compared. A one-way repeated measures ANOVA test was performed to determine whether the difference between the ranked levels of importance between factors was significant.

A number of the factors (staff shortages, pay and unmanageable work demands) were singled out for further exploration. This was done to try and gain an insight into the motivation lying behind each of those factors; that is, were those nurses more concerned with self-preservation and their own individual well-being ( self-motivation ), or were they more concerned with the well-being of the profession and the patients it cares for ( professional motivation ).

To determine the weighting towards the two constructs of self-motivation and professional motivation a series of Likert items were designed using a 5-point bipolar scale, ranging from strongly disagree to strongly agree . The items were divided into three subscales relating to each of the chosen factors. The three sub-scales combined had good reliability [ 44 , 45 ] for both the Professional motivation construct (Cronbach’s α = .88; 6 items) and the Self-motivation construct (Cronbach’s α = .86; 6 items). Measures of internal consistency for the individual sub-scales can be found in Table  1 . The order of questions within each sub-scale were varied to minimise acquiescent response bias [ 46 ]. The scales were numerically coded into interval data and grouped under their corresponding constructs. Paired t-tests were performed to determine whether the difference between the two constructs was statistically significant for each sub-scale.

Demographic data was obtained to inform what type of nurses participated in the survey and presented in tabular form using descriptive statistics.

Qualitative data collection and analysis

Semi-structured interviews were conducted using an interview guide consisting of a range of questions and probes designed to elicit rich and insightful responses (Additional file  2 ). An additional set of probes were used for responses that complimented the factors listed within the survey so as to facilitate congruence between the data sets (Additional file  3 ). To allow the inclusion of participants from a broad geographical range interviews took place online via the video conferencing platform Zoom. They were conducted between the 23rd May and the 23rd June 2023. Interviews were conducted until it was felt that saturation of data was achieved; meaning, new data appeared to be repeating what was previously collected and thus, it was felt that further data collection was unlikely to add to the findings. The mean length of the interviews was exactly 50 minutes.

Thematic analysis of the data was conducted using the methods outlined by Braun and Clarke [ 47 ] with the help of MAXQDA 2022 data analysis software. These methods involved a 6-phase process. Phase 1 – familiarisation, began by a single researcher conducting the interviews and transcribing them verbatim. This helped to facilitate familiarity with and immersion of the data. An inductive approach was used for phase 2 - generating initial codes, in which coding of the transcripts was guided by the content of the data rather than any preconceived theoretical or epistemological perspectives. This phase generated over 90 interrelated and often overlapping codes which were sorted and organised using a mind map. Organising the codes in this way helped to see the relations between them and formed the beginnings of phase 3 – searching for themes. Initially this phase took on a rather positivist approach that saw the inception of themes based on the prevalence of codes and their semantic level context. However, a more interactive and organic approach developed in phase 4 – reviewing themes, where the initial set of themes were revised to ensure they really represented the coded extracts, as well as the story being told across the entire data set. It is here that the researcher’s subjective interpretation began to play a more influential role. Themes developed not just based on the data within the codes but on how they were perceived and understood by the researcher. This process gained momentum in phase 5 – defining and naming themes where the essence of each theme, how they related to one another and the story that they told was fully realised. Phase 6 – producing the report saw the outcome of this process in which the qualitative results tell a story that reflects the coming together of the experiences, meaning and reality of participants with that of the understanding, values and skills of the researcher.

Mixed methods analysis

Quantitative and qualitative data were integrated at the interpretation and reporting level. The key findings of the quantitative data were presented alongside qualitative data using a joint display table. This approach helped to merge the data in a more direct way and facilitate a better understanding of the mixed methods meta-inferences [ 48 ].

Ethical considerations

Ethical approval was granted by the University of Freiburg’s ethical research committee (Application no. 23–1126-S2). All surveys were completed anonymously and informed consent gained from all participants. Participants who partook in the interviews were provided with a participant information sheet and asked to sign a consent form prior to being interviewed. The interviews were anonymised during transcription with all identifiable data subsequently deleted. All data was held and stored in accordance with the UK Data Protection Act of 2018. Participation was completely voluntary, and no financial incentives made.

Five hundred forty-four nurses responded to the survey. Those that did not fulfil the eligibility criteria or provided an insufficient amount of data were discarded, resulting in 468 completed surveys included in the analysis. Thirteen participants were recruited for the semi-structured interviews. The demographics and work-based characteristics for the quantitative and qualitative samples are displayed in Tables  2 and Table  3 respectively. Female nurses working in hospital settings with adult patients predominated. There was a broad range of experience across the two data sets with the majority of nurses having trained in the UK. Demographics for RCN membership were not available to draw comparisons with; however, the sample is broadly proportional to that of the UK nursing register with regards to age, gender and type of nursing. It is underrepresented by mental health nurses and those who trained outside of the UK [ 49 ].

Quantitative results

The factors that encouraged nurses’ decision to strike are displayed in Fig.  2 . The mode number of factors chosen was 5, in which Staff shortages and Patient safety were the most frequently cited.

Factors that encouraged participants’ decision to strike. Note .  N  = 468

Nurses indicated that patient safety, followed by staff shortages were the most important factors that encouraged their decision to strike. The ranked means and standard deviations for the level of importance ascribed to each factor are presented in Table  4 . A one-way repeated measures ANOVA found that the difference between the level of importance for the factors was significant at the .05 alpha level. Wilks’ Lambda = .04, F (6, 462) = 2149.69, p  < .001, multivariate partial eta squared = .97. However, post-hoc pairwise comparisons with a Bonferroni adjustment indicate that the difference was not significant between each level of ranking. Those that were significant are highlighted in Table 4 .

Responses to the Likert sub-scales and the level of agreement that nurses had to the individual items are presented in Fig.  3 . The results of the paired t-tests (Table  5 ) indicate that those who cited pay and unmanageable work demands as factors that encouraged their decision to strike were significantly more professionally motivated than self-motivated ( α  = .05). However, it should be noted that the effect size, whilst moderate for pay was small for unmanageable work demands. The difference between the level of professional motivation and self-motivation for those who cited staff shortages as a factor that encouraged their decision to strike was not statistically significant.

Likert sub-scales showing individual items and their relation to the constructs professional motivation and self-motivation. Note . Order of items presented to facilitate easy understanding of how the items relate to the constructs of Professional Motivation and Self-motivation. The order of items within the survey was different

Qualitative results

The process of thematic analysis identified three overarching and overlapping themes which were selected to represent the data. These themes included: Save our NHS, Money talks, and It’s untenable.

Save our NHS

The state of the NHS was reflected upon throughout the interviews. Participants were passionate about the NHS and its ability to provide high standards of safe and effective care, free at the point of need. However, there was a recognition that the NHS was failing as an institution, the injustice of which was palpable and articulated by the following comment:

I don't understand, genuinely don't understand why people aren't rioting because of the state of the NHS. We are going to lose this incredible thing… It's just, I mean, I feel quite emotional. It’s just shocking. It's just shocking that it's happening. Participant 2

Witnessing the decline of the NHS seemed to elicit a sense of loss and foreboding in participants. One nurse explained how this had evolved into a sense of shame at what it has become.

I was very proud going back years ago to put on a uniform, to enter that building and start my shift. And I was proud to tell people that I worked for the NHS. And I'm not anymore. I'm embarrassed by it. I'm embarrassed by the care that we give. I’m embarrassed by the treatment that some of the patients get. It's heart breaking, it really is. Participant 10.

And yet, these feelings seemed to stem, not from an idealistic view of what the NHS should be or how it should be run, but rather from the lived experience of providing frontline care on a day-to-day basis. This results in a visceral understanding that nurses are not just the providers of care but also the recipients of care, along with their families, loved ones, and the nation as a whole. For example, on reflecting on caring for a dying patient participant 6 acknowledged “That could be me one day.” In addition, whilst talking about the poor standards of care she had witnessed, participant 13 expressed “I’m worried about the care my parents are going to receive, I’m worried about the care I’m going to receive in the future!” Participant 5 spoke about living with a congenital heart condition, needing regular specialist review, extensive surgery and a costly hospital stay. He concluded “I’ve really benefited from the NHS, as an end user and also as an employee. I think it’s a great institution and I think it needs to continue.”

Nurses’ decision to strike could therefore be seen as a call to arms in response to the witnessed decline of the NHS and all that it entailed. The value and appreciation that nurses hold for the NHS comes with a real sense that it is worth fighting for. The decision to strike was seen to play an important part in that fight. Participant 12 highlighted this point in saying:

It really is about the health of all people in the UK and the future of what that's going to look like. And it's not looking good, you know, from where we're at just now. If we don't fight, I believe there's a real possibility we could lose the NHS.

Money talks

It was widely felt throughout the interviews that the rate of pay that nurses receive does not reflect their level of expertise, professional development, and the responsibility that comes with the job. The following nurse discussed this in relation to her own professional development.

If I did my nurse prescribing in a couple of years, which is a possibility, it's not going to get me any more pay. And the level of responsibility that comes with that… We're a very responsible profession, you know, breaking bad news, seeing things that the ordinary general public wouldn't even dream to see… And yet, we're not recognised financially, or with the respect as a profession that we deserve. Participant 11

Participants throughout the interviews felt that the nursing profession was undervalued and underappreciated, especially by the government and thus, their decision to strike was an attempt to highlight this. This sentiment was particularly pertinent in relation to the recent COVID pandemic. Participants reflected upon the sacrifices they made during the pandemic and the discrepancy of being hailed as heroes by the government one day, to receiving yet another below inflation pay rise the next. This served to exacerbate the feeling of being undervalued as highlighted in the following excerpts:

My husband had a heart attack during the pandemic, I couldn't visit him. But I was still going to work. I was in this building. But I couldn't go and see him. There are huge, huge sacrifices made by all of us. Four of my colleagues died, and we're not even worth a real time pay increase! Participant 2.

Yes, let's all stand out on our doorsteps and clap and bang our pans for the wonderful people who are doing a wonderful job. But actually, when you want a decent wage, we're not going to give that to you. Participant 5

The level of pay that nurses receive was therefore perceived as a measure of the value and appreciation ascribed to the profession. In addition, better pay was viewed as a vital tool in incentivising people to become nurses and to work in the NHS. This point was made by Participant 4 who explained:

I don't personally care about the pay. For me at least as an individual… But I do care about pay for my colleagues and the wider NHS, is it 47,000 nursing vacancies? They're not going to get filled with shoddy pay. There needs to be an incentive to be a nurse at the moment.

The pursuit of better pay was a key factor driving nurses’ decision to strike because better pay was seen as integral to addressing the ongoing recruitment and retention crisis of nurses within the NHS.

It’s untenable

The recruitment and retention crisis, and it’s resulting staff shortages was frequently cited by participants as being the root of the problem and fundamental to their decision to strike. Staff shortages result in nurses having to take on an additional workload to meet the needs of patients. As participant 7 explains, “It’s not doable. You’re having to work twice as hard… You’re having to do several people’s jobs.” Participants spoke of how staying late after work and working through their breaks to try and keep on top of the workload was an everyday occurrence. The relentless pressure and responsibility of the job is at times overwhelming and the impact on individual nurses seen as untenable. As participant 13 pointed out.

We're not designed to be in flight mode all the time, are we? And if we don't get respite, then we're in trouble and that's what we're seeing on our work force right now in terms of how people feel, burnout, wanting to leave, going off sick….

This was also reflected upon by participant 10 who spoke about her own experiences of being burnt out from work and how this impacted her.

I ended up being off for three months… I was at the point where I didn’t want to be a nurse anymore, I didn’t want to be in my marriage. I wanted to walk out of my home, my children, my…. I just wanted to pick-up and walk out of my life.

With this we see that the morale of nurses working in an environment that is chronically understaffed is persistently under threat. As participant 1 lamented, “it makes you feel inadequate. It makes you feel that you’re not doing your job as well as you should be.” A point further elaborated on by participant 11 who noted: “nurses can’t be the nurses that they want to be. You know, they’re feeling disappointed with themselves, they’re feeling let down, they feel that they have failed.” All of this results in more and more nurses leaving the NHS or the profession completely, which only serves to exacerbate the problem of staff shortages. The decision to strike was effectively a way of nurses saying, “enough is enough, this cannot go on!”

Despite the strains of the job, it is interesting to note however that participants largely considered the real consequences of staff shortages to be suffered by patients. With increasing workloads and high patient to nurse ratios nurses’ ability to provide even the most basic standards of care are compromised. They are often faced with difficult decisions on prioritising and allocating care; things get missed, mistakes happen, and treatments and care are not provided in a timely fashion. This compromises the safety of patients and results in them coming to harm. A point stressed by participant 13.

I have seen, and I have experienced patients having poor health outcomes, or poor experiences as a result of not being able to deliver the care that we know we can deliver. And that's because of circumstances such as short staffing, and people being off long-term sick with stress.

It seems then that nurses’ decision to strike was a cry for help, not just for nurses working within the NHS, but for the very patients it aims to serve.

Integration of quantitative and qualitative results

Integration of the quantitative and qualitative findings show a high level of concordance between the two data sets. Table  6 provides examples of how the qualitative findings not only confirmed the key quantitative findings ( confirmation ) but also served to expand the understanding of them ( expansion ). No incidences were found where the two sets of findings contradicted each other ( disconfirm ).

This mixed methods study offers valuable insights into the key factors driving UK NHS nurses’ decision to strike. The quantitative findings identify that patient safety, followed by staff shortages and pay were the most important factors. The qualitative findings support these findings and further enhance our understanding of them. Mixed methods inferences suggest that the factors driving UK NHS nurses’ decision to strike are complex, interconnected and inextricably linked.

What is notable from the findings was that two factors: perspectives of the RCN and/or my colleagues and other UK services going on strike were deemed the least important factors and cited by less than 10% of participants. In addition, they did not arise within the qualitative data. This suggests that the decision to strike by participants was made with a high level of autonomy and was largely independent of the widespread industrial action taking place within the UK during that time.

In contrast to other empirical studies conducted on nurse strikes outside of the UK [ 16 , 17 , 18 , 21 , 22 , 23 ] this study found that pay was not the most cited factor encouraging nurses’ decision to strike. Due to these studies varying considerably in their aims, context and methodological profiles it is difficult to draw any definitive conclusions as to why this difference occurs; however, it suggests that factors driving nurses’ decision to strike are context specific and reflective of differing cultural and economic environments.

Although pay was not found to be the most important factor, the qualitative findings indicate that it still plays an integral role in encouraging nurses’ decision to strike. In part, this is because it was seen as an indicator of how valued and appreciated the nursing profession is. West et al. [ 50 ] argue that this sense of value is essential for nurses’ well-being and their ability to deliver high-quality care. The finding that nurses perceive pay as a measure of value is supported by Clayton-Hathway et al. [ 51 ] who go on to suggest that the lack of value ascribed to the nursing profession, and its resulting low pay is rooted in the perception of nursing as ‘women’s work’ and indicative of the patriarchal society historically found within the UK. This concept of gender disparities in relation to pay is compelling and challenges the assumption that low pay is simply to do with a lack of funds. It suggests that further research on the qualitative determinants of nurses pay would be valuable.

Within this study it was found that there was a high level of both self and professional motivation behind the factors driving participants’ decision to strike, but it was the latter that predominated. The concept of professional motivation being a driving force in nurses’ decision to strike is supported by accounts of nurse strikes both within the UK [ 25 , 52 ] and outside [ 19 , 24 , 26 , 28 ]. Briskin [ 24 ] referred to it as ‘the politicisation of caring’, a theory closely aligned to Hart’s [ 25 ] ‘clinical militancy’. However, there is a danger in adopting such terminology that we are merely conforming to the stereotypes around industrial action and failing to adequately reflect the nuances of the nurse strike. The findings of this study indicate a softer, more considered approach by nurses that is deeply rooted in a sense of moral justice and duty of care. With this understanding one is compelled to rethink the depiction of the strike as a form of self-gratifying militancy, to that of a legitimate act of compassionate care [ 53 ].

The finding that professional motivation plays a significant role behind the factors driving UK NHS nurses’ decision to strike is important as it can be used to garner public support for future nurse strikes and better inform those in opposition to them. In addition, it can be used by the RCN to reflect upon their communication strategies and ensure they adequately reflect the perceptions of their membership; furthermore, it may serve to challenge those accounts by media outlets that portray the strikes to be driven solely by individual monetary gain. A suggestion for further research could therefore be to conduct a content analysis on the media coverage of the strikes and compare the findings with that of this study. This could provide valuable insights into the validity of the mainstream media’s interpretation of strikes and the role it plays in influencing public opinion.

The mixed methods inferences of this study help us to understand that the factors driving UK NHS nurses’ decision to strike are complex, multifaceted and inextricably linked. Figure  4 provides a conceptual model of these inferences and summarises the interconnected nature of the factors.

Interconnectedness of factors drawn from mixed methods inferences. Note . This model shows how factors encouraging nurses’ decision to strike lead into one another and are centred around staff shortages. The interplay of pay, staff shortages and unmanageable work demands creates a vicious cycle that manifests as a recruitment and retention crisis, resulting in compromised patient safety

Limitations

The findings of this study should be judged within the context of its limitations. First of all, it should be noted that this study was conducted by a single lone researcher who is also a registered nurse working for the UK NHS and a member of the RCN. Whilst every attempt was made to reduce bias and provide a true representation of participants perspectives the lack of investigator triangulation leaves the study susceptible to observer bias. In particular, the validity of the qualitative findings would have been enhanced by a second reviewer confirming the selection of and allocation of codes, and the generation of themes.

A further limitation can be found in the sampling methods used. The use of voluntary sampling means that the findings are likely to be subject to self-selection bias and thus less representative of those nurses who were less forthright about their decision to strike. Furthermore, a large proportion of participants were recruited via social media meaning that the study may not adequately reflect the views of those nurses who do not use social media. Data collection began approximately 5 months after the initial ballot in which nurses first voted to strike. It may have been that by this time there was an element of strike fatigue resulting in an unwillingness to participate and engage with the study. Had the data collection happened sooner it may have helped to minimise response bias and encourage greater participation.

This notion of strike fatigue may also explain to some extent why the RCN failed to secure a further strike mandate following the completion of this study. In focusing on the key factors that drove nurses’ decision to strike this study fails to adequately portray how those decisions, and the volition to strike may change over time.

Although the results of this study are compelling it is important to recognise that an element of social desirability bias may have played a part. Participants may have felt drawn toward emphasising those factors that portrayed them as striking for the greater good so as to uphold the reputation of the profession and justify the act. Although it is not possible to quantify to what extent social desirability bias played a role it should be taken into consideration when interpreting the results.

In keeping with the exploratory nature of this study a novel approach was used in the survey design. Due to the lack of previous research in this area and the absence of a strong theoretical foundation in relation to the constructs used, there is a danger that the survey lacks construct validity. The survey would therefore benefit from greater scrutiny in the form of expert opinion review, further research and refinement with the use of factor analysis.

This mixed methods study has facilitated an exploration into the key factors driving UK NHS nurses’ decision to strike leading up to and during the industrial action of 2022/23. The findings identify that factors relating to patient safety, staff shortages, pay and unmanageable work demands were key, and that there was a strong sense of professional motivation lying behind them; that is, participants concerns around the welfare of patients, the nursing profession and the NHS often came before that of their own.

In adopting a mixed methods design this study helps to highlight that the factors driving UK NHS nurses’ decision to strike do not stand in isolation and therefore, a holistic and multifactorial approach to addressing them is required. Nurses’ concerns around recruitment and retention and the implications of staff shortages need to be taken into consideration. Perhaps more importantly however, this study demonstrates that the NHS is a challenging and demanding work environment, and that the well-being of its patients is dependent on the well-being of those who care for them. If nobody cares for the carers the process of healthcare delivery breaks down. Thus, one can consider these nurse strikes as a movement, a movement toward putting the care back into care .

This study paves the way for future research on nurse strikes and could also be used to inform research into other healthcare related professions engaged in industrial action. Further research looking at the factors driving nurses’ decision to strike is required to confirm the validity of these findings and also to develop the constructs of self and professional motivation in relation to strikes. In addition, research looking into the perspectives of the mainstream media on nurse strikes and the determinants of nurses’ pay would offer valuable insights and increase our understanding of the nurse strike.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

NHS Trusts are organisations that provide healthcare services on behalf of the NHS within a given specialisation or geographical area. The majority of nurses working for the UK NHS are employed directly by an NHS Trust.

The actual figure is likely to be far higher but a further increase in population size does not influence the sample size calculation.

Abbreviations

Research and Development

Royal College of Nursing

• National Health Service
• United Kingdom

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Acknowledgements

Many thanks to Dr. Ercüment Çelik for overseeing this project and for his comments and suggestions relating to protocol development and write-up of the study. Thank you also to Urs A. Fichtner from University Hospital Freiburg Institute for Medical Biometry and Statistics for his advice and suggestions regarding the statistical analysis for the study. This study formed part of a Master’s in Global Urban Health at the University of Freiburg, Germany. Many thanks to Sonia Diaz-Monslave and the GUH master’s team for facilitating the process. Thank you also to the reviewers of the manuscript for their thoughtful and valuable comments and suggestions.

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Sanfey, D. ‘Enough is enough’: a mixed methods study on the key factors driving UK NHS nurses’ decision to strike. BMC Nurs 23 , 247 (2024). https://doi.org/10.1186/s12912-024-01793-4

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• Locum doctor working and quality and safety: a qualitative study in English primary and secondary care
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• http://orcid.org/0000-0002-8129-8376 Jane Ferguson 1 ,
• http://orcid.org/0000-0001-9325-3362 Gemma Stringer 2 ,
• http://orcid.org/0000-0002-0696-480X Kieran Walshe 2 ,
• http://orcid.org/0000-0002-2972-7911 Thomas Allen 3 , 4 ,
• http://orcid.org/0000-0003-1621-8648 Christos Grigoroglou 3 ,
• http://orcid.org/0000-0002-2958-915X Darren M Ashcroft 5 ,
• http://orcid.org/0000-0001-6450-5815 Evangelos Kontopantelis 6 , 7
• 1 Health Services Management Centre, School of Social Policy , University of Birmingham , Birmingham , UK
• 2 Alliance Manchester Business School , University of Manchester , Manchester , UK
• 3 Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care , University of Manchester , Manchester , UK
• 4 Danish Centre for Health Economics , University of Southern Denmark , Odense , Denmark
• 5 NIHR Greater Manchester Patient Safety Research Collaboration (PSRC), Division of Pharmacy and Optometry, Faculty of Biology Medicine and Health , University of Manchester , Manchester , UK
• 6 Division of Informatics, Imaging and Data Sciences , University of Manchester , Manchester , UK
• 7 NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care , University of Manchester , Manchester , UK
• Correspondence to Dr Jane Ferguson, Health Services Management Centre, University of Birmingham, Birmingham, UK; j.ferguson.1{at}bham.ac.uk

Background The use of temporary doctors, known as locums, has been common practice for managing staffing shortages and maintaining service delivery internationally. However, there has been little empirical research on the implications of locum working for quality and safety. This study aimed to investigate the implications of locum working for quality and safety.

Methods Qualitative semi-structured interviews and focus groups were conducted with 130 participants, including locums, patients, permanently employed doctors, nurses and other healthcare professionals with governance and recruitment responsibilities for locums across primary and secondary healthcare organisations in the English NHS. Data were collected between March 2021 and April 2022. Data were analysed using reflexive thematic analysis and abductive analysis.

Results Participants described the implications of locum working for quality and safety across five themes: (1) ‘familiarity’ with an organisation and its patients and staff was essential to delivering safe care; (2) ‘balance and stability’ of services reliant on locums were seen as at risk of destabilisation and lacking leadership for quality improvement; (3) ‘discrimination and exclusion’ experienced by locums had negative implications for morale, retention and patient outcomes; (4) ‘defensive practice’ by locums as a result of perceptions of increased vulnerability and decreased support; (5) clinical governance arrangements, which often did not adequately cover locum doctors.

Conclusion Locum working and how locums were integrated into organisations posed some significant challenges and opportunities for patient safety and quality of care. Organisations should take stock of how they work with the locum workforce to improve not only quality and safety but also locum experience and retention.

• Health services research
• Patient safety
• Qualitative research
• Quality improvement

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This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjqs-2023-016699

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Despite longstanding policy concerns about the implications of locum working for quality and safety, there has been little empirical research. Understanding how organisations engage, support and work with locums and how locum doctors integrate and interact with the complex and changing systems in which they work is essential if quality and safety are to be improved.

WHAT THIS STUDY ADDS

This qualitative study examines the perspectives of locums, patients and people who work with locums to identify the implications of temporary medical working for quality and safety.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Organisations should examine how they engage, support and work with locums. Organisations and locums need to reflect on whether their practices support a collective approach to patient safety and quality of care.

Introduction

Temporary doctors, often known as locums, are a vital resource that enable healthcare organisations to deliver care by flexing capacity and covering staffing gaps. In the United Kingdom, all doctors, other than those in their first year of training after qualifying, can work as a locum. Locum work can vary from very short-term (a single shift) to longer-term assignments (weeks, months or even sometimes years). Locums find work through various platforms, including locum agencies, online job platforms, professional networks or word of mouth. Locum agencies typically have some governance responsibilities (such as compliance with regulations and licensing requirements), but the extent of these responsibilities varies and the NHS in England has no oversight over how recruitment agencies operate. Despite concerns among policymakers, healthcare providers, professional associations and professional regulators about the implications of locum working for quality and safety and cost, 1–3 there is limited robust empirical research to evidence or support those concerns.

The workforce retention crisis is a significant challenge in healthcare internationally 4–6 and persistent understaffing poses a serious risk to patient safety. 7 8 In the UK, high doctor turnover has been linked to poorer service and health outcomes 9 and has led NHS trusts and general practices (GPs) to be ‘overly reliant’ 3 on temporary staff to fill rota gaps. 10 11 Expenditure on temporary staff in the NHS in England increased from £3.45 billion to £5.2 billion between 2021 and 2022. 3 12 The NHS Long Term Workforce Plan aims to reduce reliance on temporary staff and make substantive employment the most cost-effective and attractive option. 3 However, with the vacancy rate in the NHS projected to increase, 13 locums are likely to continue to be essential to maintaining service provision, especially in shortage specialities such as psychiatry. 14

An obvious implication of locum working is a reduced likelihood of organisational and team integration, 15 familiarity and a shared understanding of ‘the way things are done around here’. 16 Locums are likely to be less familiar with teams and other contextual factors relevant to providing safe and effective care 17 and more likely to be situated on the periphery of organisational structures, teams and governance systems 1 18 Teamwork represents a powerful process to improve patient care, 19 20 and trust, shared understanding, communication and collaboration have been associated with better patient outcomes. 21 22 The ability of healthcare teams to develop and maintain team situational awareness, or a shared perception, comprehension and subsequent projection of what is going on in complex and changing clinical environments, has been described as crucial for patient safety. 23 24 Through participation and working together, 25 teams gain an understanding of the roles, skills and competencies of others to demonstrate ‘collective competence’, 26 27 which is critical for healthcare delivery, 28 29 and existing research on locums suggests a need for better integration into teams to improve quality and safety. 30 31

Context matters for patient safety and quality improvement, 32 33 yet the limited evidence 17 relating to locums practice is largely ‘acontextual’ and tends to ignore the role of the organisation in the integration of temporary staff, focusing instead on the potential risks locums present as individual clinicians, 17 30 which is perhaps unsurprising given the liminal space locums occupy. In the UK, responsibility for the quality and safety of healthcare services is shared primarily between organisations and the individual professionals working within them. 34 Organisations are responsible for creating systems and environments that promote and protect clinical governance and enable all doctors to meet their professional obligations, while doctors are expected to participate in the systems and processes put in place by regulators and organisations to protect and improve patient care. 35 However, NHS trusts and primary care organisations procure the services of locum doctors without assuming the responsibilities normally associated with an employer–employee relationship 30 and locums often struggle to participate in teams and governance systems that were designed for doctors working in conventional employment relationships. 18 36

There is longstanding debate about the role of individual accountability in patient safety and how responsibility is distributed between organisations and individuals. 37 A systems approach reasons that adverse events are likely to occur as a result of system failures rather than individual failures, 38 and patients are protected from mistakes by well designed systems and environments that promote safety cultures. 39 But locums are often positioned at the periphery of these systems, 30 and doctors who are new to and also peripheral to organisations, and organisations who are inexperienced with and unsupportive of locums are unlikely to be able to perform optimally. 40

The aim of this research was to provide evidence on how locum working arrangements impact quality and safety and the implications of locum working for patients, locums and health service organisations in primary and secondary care in the English NHS. Locum doctors are an essential and growing part of the healthcare workforce 1 who have been largely ignored in healthcare workforce research. This research addresses a gap in the empirical evidence base on how locum doctor working arrangements affect quality and safety, and provides, for the first time, an in-depth exploration that includes perspectives from patients, locums and the people they work with.

Study design and setting

A qualitative semi-structured interview and focus group study was conducted with locums, people working with locums, and patients with experience of being treated by locums. Participants were purposively sampled through 11 organisations, including NHS trusts, primary care practices, statutory NHS bodies and locum agencies. Locum doctor participants were recruited through these organisations, locum recruitment agencies and networks. We used purposive, snowball and convenience sampling, drawing on intelligence from stakeholders, including our project advisory group, to identify and recruit organisations and participants. Patient participants were recruited through patient and contributor forums. The forum involved active partnership between patients and researchers in the research process to develop research which is relevant and useful to patient and public needs. Participant demographics were monitored to ensure representation across a broad range of roles in primary and secondary care and to increase diversity in terms of gender and ethnicity (see table 1 ).

• View inline

Characteristics of study participants

Data collection

Three semi-structured interview and focus group guides were developed for use with locums, people working with locums and patients with experience of being treated by locums (as shown in online supplemental files 1-3 ). Our previous review of the literature relating to quality and safety and locum work 17 informed the schedules as well as the initial coding and thematic development. Schedules were also refined and informed by our patient and public involvement (PPI) forum and our project advisory group. Each schedule was intended to explore locum doctor working arrangements with a particular focus on understanding how locum doctor working may affect the safety and quality of care and what strategies or systems organisations and individuals used to assure or improve quality and safety. The topic guides for locums and people working with locums also covered governance and support, the impact of the COVID pandemic and policies and initiatives used to support locums.

Supplemental material

Interviews and focus groups were transcribed verbatim by a professional transcription company and organised into codes and themes using the software package NVivo. 41 Reflexive thematic analysis (RTA) 42 was used and involved familiarisation with the data by reading and re-reading the transcripts and field notes; coding the dataset and collating all relevant data extracts; generating initial themes by examining the codes and collated data to identify significant broader patterns of meaning across the dataset; reviewing themes by questioning whether themes answered the research question and told a convincing story of the data and combining, splitting and discarding themes as necessary; defining and naming themes by developing a detailed analysis of each theme; and finally the analytical write up which positioned the analysis in relation to existing literature. 43 RTA acknowledges the active role of researchers in knowledge production and the researcher’s subjectivity as the analytic resource. 42 RTA recognises interpretive variability between researchers based on differences in their knowledge and skills, theoretical assumptions and differences in how they responded to the dataset is acknowledged and expected. 42 The research team worked reflexively discussing their personal biases and their potential impact on the research at regular meetings throughout the data collection and analysis period. Our PPI forum were also involved in data collection and analysis, and offered a form of triangulation to enhance rigour, challenge and alternative interpretations of the findings. 44 Analysis adopted a constructionist epistemology, in that while we acknowledged the importance of recurrence in generating themes, meaning and meaningfulness were the central criteria in the coding process. 42

After themes were developed, an abductive approach was taken to position findings against a background of existing theory and knowledge. 17 30 This provided a way of constructing empirically based theorisations without confining theory to predefined concepts. 45 This approach integrated inductive data-driven coding with deductive theory-driven interpretation; aiming to find a middle ground between inductive and deductive methods and the most logical solution and useful explanation for phenomena. 45

We conducted 130 interviews with 88 participants who worked in healthcare and 42 patients took part in focus groups and one-to-one interviews. Participants included locums, permanently employed doctors; nurses and other health professionals; medical directors/clinical leaders; responsible officers (ROs are accountable for local clinical governance processes and focus on the performance of doctors) and appraisers; leads for medical staffing and clinical governance and practice managers (see table 2 ). Three experienced qualitative researchers (JF, GS and KW) and two members of the PPI forum (MM and MS) carried out five focus groups with 30 patients, and JF and GS carried out 12 one-to-one interviews. Data were collected between March 2021 and April 2022 during the COVID pandemic using video conferencing software (n=126) or over the phone (n=4) at a time convenient to participants. Interviews and focus groups ranged in length from 23 to 171 min, with the average interview being 59 min.

Healthcare organisations and participant roles

Thematic framework

Our findings are presented under five broad and interrelated themes that examine how locum work relates to and impacts quality and safety: ‘familiarity’ with an organisation and its patients and staff; ‘balance and stability’ in services with lots of locums; ‘discrimination and exclusion’ towards locums and their effects; ‘defensive practice’ by locums; and the positioning of locums outside clinical governance arrangements.

Familiarity: knowing who, where and how

Locums described often working in unfamiliar environments, sometimes with minimal induction and varying levels of support. Unfamiliarity, lack of access to or other restrictions on computer systems, policies, procedures and buildings meant that locums were not always able to do their job safely, productively or effectively.

That’s probably the biggest sort of safety aspect that sticks in my mind, is that it is unbelievably frustrating to have to learn a whole new set of patients from day to day … when I was signed up to four different hospitals, plus the locum agencies, I very quickly realised that not only is it the fact that you don’t know the patients from day to day, if you’re chopping and changing site the whole time, then store cupboards are laid out differently, ways of contacting relevant staff members are different, you’ve got to recognise what code to put in to bleep someone that’s different at every single site. (Interview 23, locum, secondary care)

Locum working sometimes created extra work for permanent staff who were responsible for inducting, training and supervising locums. The amount of additional workload was dependent on contextual factors, such as the experience of the locum, organisational support and length of placement, access to systems and what terms and conditions locums or organisations had negotiated. Locum reliance on permanent staff meant that care could be delayed, partially completed or not completed at all, which sometimes caused resentment.

Some of the things that we don’t … like, for example, procedures of limited clinical value that we don’t refer in for, they won’t know about those in our areas … So they’ll do referrals that we then will get pulled on. They’ll maybe prescribe medications that are not first line medications within our own formulary. So we see quite a bit of that, you know, there’s quite a lot of tidying up to be done afterwards or work. They generate that. So whilst we meet the patient numbers, they create a lot of work for the rest of the team. (Interview 3, practice manager, primary care)

Locums mitigated risks related to working in unfamiliar environments by avoiding organisations considered chaotic or unsafe, working below their grade to avoid having responsibility in unfamiliar organisations where they may not be supported or included in the team or working in a limited number of organisations to increase familiarity.

Most locums take jobs, locum work below their grade. So a person who’s at a registrar level would take a locum work as an SHO (senior house officer), because they don't know the trust that well. (Interview 55, locum, secondary care)

However, lack of familiarity and discontinuity could at times be beneficial for patients and organisations as fresh perspectives offered by locums led to different routes of treatment or management, and could alter organisational cultures or practices.

So that [locum] doctor, through that line of questioning and not having any sort of prior history … ordered the right tests and didn’t feel constrained in that practice about what tests that they could order. And someone subsequently … because when you get referred to hospital, the consultant said that that doctor was very much on the ball. And, of course, that’s a change to lifelong medication. And literally within a month of the medication kicking in, it transformed my life. (Focus group A, patient 1)

Balance and stability

The balance between locum and permanent staff had implications for quality and safety, organisational leadership, long-term planning and governance. Locums were often employed to deliver immediate services and consequently were less likely to be involved in team and organisational development. Locums recognised that having ‘an NHS run by locums’ was detrimental to quality and safety, and some avoided organisations that were locum dependent for this reason. Well functioning established teams were regarded as better able to incorporate a small number of locums without being significantly impacted.

Locum work, my view on it is they’re there to fill a gap. They shouldn’t be relied upon to deliver a service Monday to Friday, day in, day out, week in, week out. And unfortunately my trust see it as that, though, that’s my worry that they feel they’re not just plugging a gap, they’re almost as a workforce … (Interview 84, lead GP, primary and secondary care)

Departments that were disproportionately locum dependent were often perceived to lack clinical leadership and direction. An absence of consistent medical leadership meant that quality improvement was slower or less likely to happen, and trusting relationships between staff were harder to establish.

If you get a department that is disproportionately locum dependent, then it stagnates, it doesn't progress. Things like implementation of new NICE guidance, for example, that sort of thing tends not to happen or happen less well, less quickly. (Interview 30, responsible officer, secondary care)

Discrimination and exclusion

Most locums described negative behaviours and attitudes from staff and some patients, which impacted their involvement, inclusion and experiences in organisations. Negative attitudes and behaviours towards locums could affect turnover, locum well-being, team dynamics and potentially patient safety. Perceived disparities between pay, workload, competence and organisational and team commitment between locums and permanent staff could be sources of resentment and influenced how locums were treated and viewed. This compromised staff communication and reduced the sharing of important patient information.

I guess like any temporary post really, you struggle to invest in them, don't necessarily see them as being part of the team. Not very positive about them, particularly junior staff, particularly in the acute trusts. We'd have locums refusing to come back because of the treatment of the midwives. (Interview 86, clinical lead, secondary care)

Negative perceptions of competency and safety meant that locums were often stigmatised, marginalised and excluded. The identity of locum intersected and overlapped with other identities and was described as ‘layering up’ with ethnicity and gender to further exacerbate discrimination.

Oh, doctors coming over from Germany. There was one locum … that administered a dose of something and the patient died, and then there’s this whole layer of extra negativity attached to locum doctors in general because of what one doctor did, and that doctor happened to be someone from a different ethnicity … As a UK born and qualified doctor I can see that those overseas get it but I can also see that I have experienced that as well. So yeah, it can layer up with the whole locum thing. (Interview 59, locum GP, primary care)

A sense of othering and being seen as less was particularly evident during the COVID pandemic when resources were limited. Some locums described how they were not afforded the same protections as permanent members of staff and were sometimes expected to take on riskier work.

I’ve worked in another practice where, because they live on locums and they live on ad hoc locums, you’re a piece of dirt under the shoe. You don’t get gloves, you didn’t have aprons, you didn’t have a face visor, you didn’t have safety specs, you have to ask for a mask. Not only are you not treated as a service provider, you’re not treated as a colleague, someone with knowledge. (Interview 44, locum GP)

Defensive practice by locums

Locums recognised that they were likely to be scapegoated if things went wrong, and some locums described being more likely to practice defensively. Defensive practice has been defined as deviation from standard practice to avoid litigation, complaints or criticism. 46 Participants reported instances of defensive practice which involved providing services (eg, tests, referrals) or avoiding high-risk decisions, usually to reduce the risk of adverse outcomes such as patient complaints or potential termination of contract at short notice. Locums described practicing defensively because they were attempting to practice as safely as possible in complex unfamiliar environments where they were professionally isolated and perceived negatively. Permanent members of staff could perceive that locums practiced defensively because they lacked confidence in their abilities. The diversion of resources away from more clinically relevant activities placed additional burden on teams, who were already facing significant workload challenges.

Being risk averse and practising defensive medicine usually means more tests, more referrals, whereas holding risk tends to be disadvantageous for you as a locum because what’s the benefit to you of not doing that. You’re benefiting the system by rationing resource, the patient won’t thank you. (Interview 35, locum GP)

Locums described avoiding making decisions when risks to employment or medical licenses were perceived as high. Locums felt they were more vulnerable to criticisms of their clinical competence and disempowered to make decisions. Others felt that some locums were simply avoiding work and evaded responsibility for patients by pushing work onto others or into the future.

You don’t interfere, very simple. Over time locums have learned that if you interfere, if you participate in the team, you participate in patient care, [and this] is when you get into trouble … Well most of the locums that I know will just say, okay, there’s already somebody else who’s made a decision, it’s not my job to make a decision, I just follow through. If things go wrong, call the senior person and be done with it, that’s the end of my role. Actually doing something to protect a patient is not important for a locum because the risk is too high. (Interview 55, locum, secondary care)

Locums fall outside clinical governance arrangements

Governance practices in relation to locums varied widely and were not generally regarded as being as robust in comparison to permanently employed doctors. Responsibility for involving locum doctors in performance feedback, supervision, educational opportunities, appraisal and quality improvement was unclear. While some organisations included locums in their governance activities, others regarded locum work as transactional; where the locum was there to provide a finite service and the organisation assumed no responsibilities for their performance, development or oversight. There were concerns that governance structures were modelled on and designed for permanently employed doctors and did not work for locums. When deficits in performance were undetected or unaddressed, doctor performance and patient safety could be jeopardised.

I think it’s a remote world. It’s like a cloud, you know, it’s like the cloud. We talk about the cloud when it comes to storing information. And I think locum world is a bit like that … And I don’t know the doctors anywhere like as much as I did when I was an RO in the NHS, I knew them all personally. If I used to have a problem, I used to get them in my office there and then, chat it all through, sort it. Can’t do that in locum world, it might take me four days to get hold of the doctor, some of them won’t respond immediately … They don’t know me and I don’t know them. (Interview 51, responsible officer, locum agency)

The absence of typical recruitment processes (involving meeting a doctor, carrying out an interview and following up on references) meant that healthcare organisations were reliant on partial information from locum agencies, which made it difficult to determine competency, scope of practice and suitability for a role. However, staff shortages and a requirement to meet safe staffing ratios meant that organisational leaders had little recourse of action if they were unsure about a doctor’s capability, which caused anxiety and frustration. This suggests that the provision of healthcare superseded ensuring safety standards and necessitated accepting one of two objectionable alternatives; accepting gaps in staffing that may jeopardise patient safety or accepting unknown doctors; each of which may compromise patient safety.

If a locum turns up and I have serious doubts about their ability to do the job to the required standard, I don’t have any recourse … And therefore I’m in a position where either I accept this locum or I don’t. There’s not much in the way of middle ground. Not accepting them is a really unpalatable choice because if I say look, I’m sorry, I don’t think you’re up to this, I think you should go home, that leaves me with a gap. (Interview 30, consultant and responsible officer, secondary care)

Similar governance and information sharing problems were described by locum agencies and NHS organisations; both described difficulties in gathering and sharing feedback. When concerns were raised, participants were often uncertain as to what happened to the information they provided and whether it was shared or acted on. Locums often did not get to hear about concerns raised about them, meaning learning opportunities were missed.

It would give you more confidence if you heard back. And sometimes I'll pick up the phone and you try to do the best you can to make sure this information gets passed on. But I just have this nagging doubt that I'm not always convinced it does. (Interview 30, responsible officer, secondary care)

There was also a perception from some locum agency responsible officers that while most locum doctors were excellent, there were some locums who were isolated and in need of organisational and professional support.

You have to accept that whilst within the agency world, 80 per cent of the doctors we place are excellent, and have no problems, and do a great job, perhaps 20 per cent are those that have shaken down to that 20 per cent in the agency world, because they’ve not succeeded in the NHS, they’ve not got a substantive place, they are lost souls. And they are less able to cope with the vicissitudes of busy clinical life and professional life within a large organisation such as the NHS. (Interview 47, responsible officer, locum agency)

Our findings provide some profound and concerning insights for patient safety and quality of care. The ways in which locums were recruited, inducted, deployed and integrated, and supported by organisations undoubtedly affected quality and safety. Our findings indicate that regardless of their level of experience, it was unlikely that locum doctors would be able to function optimally in unfamiliar environments; and organisations who had poor supportive infrastructure and governance mechanisms for locums were less likely to deliver high-quality safe services.

Locums were often regarded as organisational outsiders—positioned at the periphery of the team and the organisation. The implications of transience and peripheral participation were weaker relationships with organisations, teams, peers and patients, leading some to suggest locum working is better suited to experienced doctors. 47 Consistent with previous research, 48 frequent variation in process, systems and equipment, combined with disruption in relationships and a lack of mutual awareness of team skills and competencies, decreased collective competence, placed additional burden on the wider healthcare team and reduced patient safety. As others have found in research on safe staffing and nursing, 49 temporary staff are not effective substitutes for staff who regularly work in the organisation. Safe medical staffing is not just achieved by filling rota gaps, but also team composition and doctors’ familiarity with the team and organisation must be taken into account. Regulatory agencies should consider locum usage in their inspections and perhaps be particularly concerned when organisations have ‘services run on locums’.

Our research found, as others have, 18 that organisations and doctors sometimes struggled to meet their governance obligations and that governance activities differed based on contractual status and organisational policies and norms, with systems being less robust for locums. This research has highlighted that much still needs to be done to develop governance systems that promote and protect the interests of patients and create an environment which supports locum doctors in meeting their professional obligations.

More positively, locum doctors are a potentially valuable source of information about safety concerns, faulty systems or poor conduct. 50 Locums move between organisations, have broad systems knowledge and are perhaps better placed to identify some quality and safety issues than permanent doctors. However, findings indicate opportunities for shared learning were often missed. Locums recognised their precarity and vulnerability when offering second opinions, sharing improvement ideas or voicing safety concerns; meaning opinions were not always offered and concerns were not always raised. Failure to voice concerns is a persistent problem in healthcare, 51 and locums may be even less inclined to offer potentially valuable information about safety concerns because of their perceptions of unsupportive organisational climates.

Our findings shed light on how temporary doctors fit into the enduring debate 37 around how responsibility between organisational systems and individual professionals is distributed. Locums appear to represent a subsection of the medical profession for whom the wider paradigm shift from a focus on individual blame to a systems approach 52 appeared not to have been made. Locums were often not regarded as a part of the organisation, and therefore the system, and not afforded the same protections as permanent staff when things went wrong. Blaming locums when things go wrong and punishing or sanctioning individuals who make errors in contexts that were not designed to incorporate temporary workers may divert attention from understanding inadequately designed, poorly functioning systems, or indeed the individual practice of other doctors. While we should take into account systemic factors that impede locums from performing safely, we should expect high standards of healthcare professionals, be cognisant of individual agency and recognise the distinction between blaming someone and holding them responsible. 53

Strengths and limitations

This large qualitative study explores locum working and quality and safety in an under-researched, yet growing area of the medical workforce. However, sites were all based in England, which means caution should be taken when extrapolating findings. Similar research in other countries and contexts to understand more about locum doctor working and quality and safety is therefore important. It is possible that our sample may have been skewed towards locums, healthcare professionals and patients who had more negative perceptions and experiences, although accounts resonate with previous research 30 and patient perspectives were generally positive. Our data were collected during the COVID pandemic, which may have affected findings as there was a reduction in locum working during that time 10 11 ; it also meant we were unable to carry out observations, which would have strengthened our findings and mitigated some of the inherent limitations of interviews, such as recall bias. We used both one-to-one interviews and focus groups in data collection. Although flexibility in data collection meant that participants had the option to take part in an interview or a focus group, these methods are used for different reasons and produce different data. There may have been differences in what participants disclosed depending on the method

Our findings show that the way in which doctors who worked on a temporary basis were integrated into organisations posed some significant challenges and opportunities for patient safety and quality of care, and that both organisations and locums had a part to play in improvement. Doctors working as locums are a heterogeneous group with differing backgrounds, experiences, skills and capabilities that likely reflect the variability seen in the wider population of doctors. Locums are working in the same pressured and imperfect systems as other health workers; it is vital that systemic problems are not mistaken for problems about individuals and important to recognise that a locum is not a type of doctor but a way of working. Our findings are a call to action for organisations to take stock of how they engage, support and work with locums, and asks both locums and organisations to reflect on whether their practices support a collective approach to patient safety and quality of care.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by the Health Research Authority North West—Haydock Research Ethics Committee 20/NW/0386. Participants gave informed consent to participate in the study before taking part.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
• Data supplement 3
• Data supplement 4

Twitter @janefergo, @@kieran_walshe

Contributors JF, KW, DA, TA and EK conceived the study. Recruitment was led by JF and supported by GS. JF, GS and KW conducted the interviews, reviewed and analysed the transcripts, and JF wrote the first version of the manuscript. Two members of the patient and public involvement (PPI) forum also assisted with focus groups. JF conducted data analysis with input from KW and GS, the PPI forum, and review by all authors. JF and KW were involved in initial critical review and revision of the manuscript, followed by all authors. All authors read and approved the final version of the manuscript. JF is the guarantor.

Funding This study was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR128349), and the NIHR Greater Manchester Patient Safety Research Collaboration (PSRC). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Qualitative Methods in Health Care Research

Vishnu renjith.

School of Nursing and Midwifery, Royal College of Surgeons Ireland - Bahrain (RCSI Bahrain), Al Sayh Muharraq Governorate, Bahrain

Renjulal Yesodharan

1 Department of Mental Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Judith A. Noronha

2 Department of OBG Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Elissa Ladd

3 School of Nursing, MGH Institute of Health Professions, Boston, USA

Anice George

4 Department of Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Healthcare research is a systematic inquiry intended to generate robust evidence about important issues in the fields of medicine and healthcare. Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and conveyed using a qualitative method. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Introduction

Healthcare research is a systematic inquiry intended to generate trustworthy evidence about issues in the field of medicine and healthcare. The three principal approaches to health research are the quantitative, the qualitative, and the mixed methods approach. The quantitative research method uses data, which are measures of values and counts and are often described using statistical methods which in turn aids the researcher to draw inferences. Qualitative research incorporates the recording, interpreting, and analyzing of non-numeric data with an attempt to uncover the deeper meanings of human experiences and behaviors. Mixed methods research, the third methodological approach, involves collection and analysis of both qualitative and quantitative information with an objective to solve different but related questions, or at times the same questions.[ 1 , 2 ]

In healthcare, qualitative research is widely used to understand patterns of health behaviors, describe lived experiences, develop behavioral theories, explore healthcare needs, and design interventions.[ 1 , 2 , 3 ] Because of its ample applications in healthcare, there has been a tremendous increase in the number of health research studies undertaken using qualitative methodology.[ 4 , 5 ] This article discusses qualitative research methods, their significance, and applicability in the arena of healthcare.

Qualitative Research

Diverse academic and non-academic disciplines utilize qualitative research as a method of inquiry to understand human behavior and experiences.[ 6 , 7 ] According to Munhall, “Qualitative research involves broadly stated questions about human experiences and realities, studied through sustained contact with the individual in their natural environments and producing rich, descriptive data that will help us to understand those individual's experiences.”[ 8 ]

Significance of Qualitative Research

The qualitative method of inquiry examines the 'how' and 'why' of decision making, rather than the 'when,' 'what,' and 'where.'[ 7 ] Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena and make sense of the complex reality. Health interventions, explanatory health models, and medical-social theories could be developed as an outcome of qualitative research.[ 9 ] Understanding the richness and complexity of human behavior is the crux of qualitative research.

Differences between Quantitative and Qualitative Research

The quantitative and qualitative forms of inquiry vary based on their underlying objectives. They are in no way opposed to each other; instead, these two methods are like two sides of a coin. The critical differences between quantitative and qualitative research are summarized in Table 1 .[ 1 , 10 , 11 ]

Differences between quantitative and qualitative research

Qualitative Research Questions and Purpose Statements

Qualitative questions are exploratory and are open-ended. A well-formulated study question forms the basis for developing a protocol, guides the selection of design, and data collection methods. Qualitative research questions generally involve two parts, a central question and related subquestions. The central question is directed towards the primary phenomenon under study, whereas the subquestions explore the subareas of focus. It is advised not to have more than five to seven subquestions. A commonly used framework for designing a qualitative research question is the 'PCO framework' wherein, P stands for the population under study, C stands for the context of exploration, and O stands for the outcome/s of interest.[ 12 ] The PCO framework guides researchers in crafting a focused study question.

Example: In the question, “What are the experiences of mothers on parenting children with Thalassemia?”, the population is “mothers of children with Thalassemia,” the context is “parenting children with Thalassemia,” and the outcome of interest is “experiences.”

The purpose statement specifies the broad focus of the study, identifies the approach, and provides direction for the overall goal of the study. The major components of a purpose statement include the central phenomenon under investigation, the study design and the population of interest. Qualitative research does not require a-priori hypothesis.[ 13 , 14 , 15 ]

Example: Borimnejad et al . undertook a qualitative research on the lived experiences of women suffering from vitiligo. The purpose of this study was, “to explore lived experiences of women suffering from vitiligo using a hermeneutic phenomenological approach.” [ 16 ]

Review of the Literature

In quantitative research, the researchers do an extensive review of scientific literature prior to the commencement of the study. However, in qualitative research, only a minimal literature search is conducted at the beginning of the study. This is to ensure that the researcher is not influenced by the existing understanding of the phenomenon under the study. The minimal literature review will help the researchers to avoid the conceptual pollution of the phenomenon being studied. Nonetheless, an extensive review of the literature is conducted after data collection and analysis.[ 15 ]

Reflexivity

Reflexivity refers to critical self-appraisal about one's own biases, values, preferences, and preconceptions about the phenomenon under investigation. Maintaining a reflexive diary/journal is a widely recognized way to foster reflexivity. According to Creswell, “Reflexivity increases the credibility of the study by enhancing more neutral interpretations.”[ 7 ]

Types of Qualitative Research Designs

The qualitative research approach encompasses a wide array of research designs. The words such as types, traditions, designs, strategies of inquiry, varieties, and methods are used interchangeably. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research.[ 1 , 7 , 10 ]

Narrative research

Narrative research focuses on exploring the life of an individual and is ideally suited to tell the stories of individual experiences.[ 17 ] The purpose of narrative research is to utilize 'story telling' as a method in communicating an individual's experience to a larger audience.[ 18 ] The roots of narrative inquiry extend to humanities including anthropology, literature, psychology, education, history, and sociology. Narrative research encompasses the study of individual experiences and learning the significance of those experiences. The data collection procedures include mainly interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences through “re-storying of stories” and developing themes usually in chronological order of events. Rolls and Payne argued that narrative research is a valuable approach in health care research, to gain deeper insight into patient's experiences.[ 19 ]

Example: Karlsson et al . undertook a narrative inquiry to “explore how people with Alzheimer's disease present their life story.” Data were collected from nine participants. They were asked to describe about their life experiences from childhood to adulthood, then to current life and their views about the future life. [ 20 ]

Phenomenological research

Phenomenology is a philosophical tradition developed by German philosopher Edmond Husserl. His student Martin Heidegger did further developments in this methodology. It defines the 'essence' of individual's experiences regarding a certain phenomenon.[ 1 ] The methodology has its origin from philosophy, psychology, and education. The purpose of qualitative research is to understand the people's everyday life experiences and reduce it into the central meaning or the 'essence of the experience'.[ 21 , 22 ] The unit of analysis of phenomenology is the individuals who have had similar experiences of the phenomenon. Interviews with individuals are mainly considered for the data collection, though, documents and observations are also useful. Data analysis includes identification of significant meaning elements, textural description (what was experienced), structural description (how was it experienced), and description of 'essence' of experience.[ 1 , 7 , 21 ] The phenomenological approach is further divided into descriptive and interpretive phenomenology. Descriptive phenomenology focuses on the understanding of the essence of experiences and is best suited in situations that need to describe the lived phenomenon. Hermeneutic phenomenology or Interpretive phenomenology moves beyond the description to uncover the meanings that are not explicitly evident. The researcher tries to interpret the phenomenon, based on their judgment rather than just describing it.[ 7 , 21 , 22 , 23 , 24 ]

Example: A phenomenological study conducted by Cornelio et al . aimed at describing the lived experiences of mothers in parenting children with leukemia. Data from ten mothers were collected using in-depth semi-structured interviews and were analyzed using Husserl's method of phenomenology. Themes such as “pivotal moment in life”, “the experience of being with a seriously ill child”, “having to keep distance with the relatives”, “overcoming the financial and social commitments”, “responding to challenges”, “experience of faith as being key to survival”, “health concerns of the present and future”, and “optimism” were derived. The researchers reported the essence of the study as “chronic illness such as leukemia in children results in a negative impact on the child and on the mother.” [ 25 ]

Grounded Theory Research

Grounded theory has its base in sociology and propagated by two sociologists, Barney Glaser, and Anselm Strauss.[ 26 ] The primary purpose of grounded theory is to discover or generate theory in the context of the social process being studied. The major difference between grounded theory and other approaches lies in its emphasis on theory generation and development. The name grounded theory comes from its ability to induce a theory grounded in the reality of study participants.[ 7 , 27 ] Data collection in grounded theory research involves recording interviews from many individuals until data saturation. Constant comparative analysis, theoretical sampling, theoretical coding, and theoretical saturation are unique features of grounded theory research.[ 26 , 27 , 28 ] Data analysis includes analyzing data through 'open coding,' 'axial coding,' and 'selective coding.'[ 1 , 7 ] Open coding is the first level of abstraction, and it refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory.[ 1 , 7 ] Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings. Strauss and Corbin highlights that “the value of the grounded theory lies not only in its ability to generate a theory but also to ground that theory in the data.”[ 27 ]

Example: Williams et al . conducted a grounded theory research to explore the nature of relationship between the sense of self and the eating disorders. Data were collected form 11 women with a lifetime history of Anorexia Nervosa and were analyzed using the grounded theory methodology. Analysis led to the development of a theoretical framework on the nature of the relationship between the self and Anorexia Nervosa. [ 29 ]

Ethnographic research

Ethnography has its base in anthropology, where the anthropologists used it for understanding the culture-specific knowledge and behaviors. In health sciences research, ethnography focuses on narrating and interpreting the health behaviors of a culture-sharing group. 'Culture-sharing group' in an ethnography represents any 'group of people who share common meanings, customs or experiences.' In health research, it could be a group of physicians working in rural care, a group of medical students, or it could be a group of patients who receive home-based rehabilitation. To understand the cultural patterns, researchers primarily observe the individuals or group of individuals for a prolonged period of time.[ 1 , 7 , 30 ] The scope of ethnography can be broad or narrow depending on the aim. The study of more general cultural groups is termed as macro-ethnography, whereas micro-ethnography focuses on more narrowly defined cultures. Ethnography is usually conducted in a single setting. Ethnographers collect data using a variety of methods such as observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group with emic and etic perspectives. When the researcher reports the views of the participants it is called emic perspectives and when the researcher reports his or her views about the culture, the term is called etic.[ 7 ]

Example: The aim of the ethnographic study by LeBaron et al . was to explore the barriers to opioid availability and cancer pain management in India. The researchers collected data from fifty-nine participants using in-depth semi-structured interviews, participant observation, and document review. The researchers identified significant barriers by open coding and thematic analysis of the formal interview. [ 31 ]

Historical research

Historical research is the “systematic collection, critical evaluation, and interpretation of historical evidence”.[ 1 ] The purpose of historical research is to gain insights from the past and involves interpreting past events in the light of the present. The data for historical research are usually collected from primary and secondary sources. The primary source mainly includes diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The data gathered from these various sources are synthesized and reported as biographical narratives or developmental perspectives in chronological order. The ideas are interpreted in terms of the historical context and significance. The written report describes 'what happened', 'how it happened', 'why it happened', and its significance and implications to current clinical practice.[ 1 , 10 ]

Example: Lubold (2019) analyzed the breastfeeding trends in three countries (Sweden, Ireland, and the United States) using a historical qualitative method. Through analysis of historical data, the researcher found that strong family policies, adherence to international recommendations and adoption of baby-friendly hospital initiative could greatly enhance the breastfeeding rates. [ 32 ]

Case study research

Case study research focuses on the description and in-depth analysis of the case(s) or issues illustrated by the case(s). The design has its origin from psychology, law, and medicine. Case studies are best suited for the understanding of case(s), thus reducing the unit of analysis into studying an event, a program, an activity or an illness. Observations, one to one interviews, artifacts, and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived. A written case study report includes a detailed description of one or more cases.[ 7 , 10 ]

Example: Perceptions of poststroke sexuality in a woman of childbearing age was explored using a qualitative case study approach by Beal and Millenbrunch. Semi structured interview was conducted with a 36- year mother of two children with a history of Acute ischemic stroke. The data were analyzed using an inductive approach. The authors concluded that “stroke during childbearing years may affect a woman's perception of herself as a sexual being and her ability to carry out gender roles”. [ 33 ]

Sampling in Qualitative Research

Qualitative researchers widely use non-probability sampling techniques such as purposive sampling, convenience sampling, quota sampling, snowball sampling, homogeneous sampling, maximum variation sampling, extreme (deviant) case sampling, typical case sampling, and intensity sampling. The selection of a sampling technique depends on the nature and needs of the study.[ 34 , 35 , 36 , 37 , 38 , 39 , 40 ] The four widely used sampling techniques are convenience sampling, purposive sampling, snowball sampling, and intensity sampling.

Convenience sampling

It is otherwise called accidental sampling, where the researchers collect data from the subjects who are selected based on accessibility, geographical proximity, ease, speed, and or low cost.[ 34 ] Convenience sampling offers a significant benefit of convenience but often accompanies the issues of sample representation.

Purposive sampling

Purposive or purposeful sampling is a widely used sampling technique.[ 35 ] It involves identifying a population based on already established sampling criteria and then selecting subjects who fulfill that criteria to increase the credibility. However, choosing information-rich cases is the key to determine the power and logic of purposive sampling in a qualitative study.[ 1 ]

Snowball sampling

The method is also known as 'chain referral sampling' or 'network sampling.' The sampling starts by having a few initial participants, and the researcher relies on these early participants to identify additional study participants. It is best adopted when the researcher wishes to study the stigmatized group, or in cases, where findings of participants are likely to be difficult by ordinary means. Respondent ridden sampling is an improvised version of snowball sampling used to find out the participant from a hard-to-find or hard-to-study population.[ 37 , 38 ]

Intensity sampling

The process of identifying information-rich cases that manifest the phenomenon of interest is referred to as intensity sampling. It requires prior information, and considerable judgment about the phenomenon of interest and the researcher should do some preliminary investigations to determine the nature of the variation. Intensity sampling will be done once the researcher identifies the variation across the cases (extreme, average and intense) and picks the intense cases from them.[ 40 ]

Deciding the Sample Size

A-priori sample size calculation is not undertaken in the case of qualitative research. Researchers collect the data from as many participants as possible until they reach the point of data saturation. Data saturation or the point of redundancy is the stage where the researcher no longer sees or hears any new information. Data saturation gives the idea that the researcher has captured all possible information about the phenomenon of interest. Since no further information is being uncovered as redundancy is achieved, at this point the data collection can be stopped. The objective here is to get an overall picture of the chronicle of the phenomenon under the study rather than generalization.[ 1 , 7 , 41 ]

Data Collection in Qualitative Research

The various strategies used for data collection in qualitative research includes in-depth interviews (individual or group), focus group discussions (FGDs), participant observation, narrative life history, document analysis, audio materials, videos or video footage, text analysis, and simple observation. Among all these, the three popular methods are the FGDs, one to one in-depth interviews and the participant observation.

FGDs are useful in eliciting data from a group of individuals. They are normally built around a specific topic and are considered as the best approach to gather data on an entire range of responses to a topic.[ 42 Group size in an FGD ranges from 6 to 12. Depending upon the nature of participants, FGDs could be homogeneous or heterogeneous.[ 1 , 14 ] One to one in-depth interviews are best suited to obtain individuals' life histories, lived experiences, perceptions, and views, particularly while exporting topics of sensitive nature. In-depth interviews can be structured, unstructured, or semi-structured. However, semi-structured interviews are widely used in qualitative research. Participant observations are suitable for gathering data regarding naturally occurring behaviors.[ 1 ]

Data Analysis in Qualitative Research

Various strategies are employed by researchers to analyze data in qualitative research. Data analytic strategies differ according to the type of inquiry. A general content analysis approach is described herewith. Data analysis begins by transcription of the interview data. The researcher carefully reads data and gets a sense of the whole. Once the researcher is familiarized with the data, the researcher strives to identify small meaning units called the 'codes.' The codes are then grouped based on their shared concepts to form the primary categories. Based on the relationship between the primary categories, they are then clustered into secondary categories. The next step involves the identification of themes and interpretation to make meaning out of data. In the results section of the manuscript, the researcher describes the key findings/themes that emerged. The themes can be supported by participants' quotes. The analytical framework used should be explained in sufficient detail, and the analytic framework must be well referenced. The study findings are usually represented in a schematic form for better conceptualization.[ 1 , 7 ] Even though the overall analytical process remains the same across different qualitative designs, each design such as phenomenology, ethnography, and grounded theory has design specific analytical procedures, the details of which are out of the scope of this article.

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

Until recently, qualitative analysis was done either manually or with the help of a spreadsheet application. Currently, there are various software programs available which aid researchers to manage qualitative data. CAQDAS is basically data management tools and cannot analyze the qualitative data as it lacks the ability to think, reflect, and conceptualize. Nonetheless, CAQDAS helps researchers to manage, shape, and make sense of unstructured information. Open Code, MAXQDA, NVivo, Atlas.ti, and Hyper Research are some of the widely used qualitative data analysis software.[ 14 , 43 ]

Reporting Guidelines

Consolidated Criteria for Reporting Qualitative Research (COREQ) is the widely used reporting guideline for qualitative research. This 32-item checklist assists researchers in reporting all the major aspects related to the study. The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[ 44 , 45 ]

Critical Appraisal of Qualitative Research

Various scales are available to critical appraisal of qualitative research. The widely used one is the Critical Appraisal Skills Program (CASP) Qualitative Checklist developed by CASP network, UK. This 10-item checklist evaluates the quality of the study under areas such as aims, methodology, research design, ethical considerations, data collection, data analysis, and findings.[ 46 ]

Ethical Issues in Qualitative Research

A qualitative study must be undertaken by grounding it in the principles of bioethics such as beneficence, non-maleficence, autonomy, and justice. Protecting the participants is of utmost importance, and the greatest care has to be taken while collecting data from a vulnerable research population. The researcher must respect individuals, families, and communities and must make sure that the participants are not identifiable by their quotations that the researchers include when publishing the data. Consent for audio/video recordings must be obtained. Approval to be in FGDs must be obtained from the participants. Researchers must ensure the confidentiality and anonymity of the transcripts/audio-video records/photographs/other data collected as a part of the study. The researchers must confirm their role as advocates and proceed in the best interest of all participants.[ 42 , 47 , 48 ]

Rigor in Qualitative Research

The demonstration of rigor or quality in the conduct of the study is essential for every research method. However, the criteria used to evaluate the rigor of quantitative studies are not be appropriate for qualitative methods. Lincoln and Guba (1985) first outlined the criteria for evaluating the qualitative research often referred to as “standards of trustworthiness of qualitative research”.[ 49 ] The four components of the criteria are credibility, transferability, dependability, and confirmability.

Credibility refers to confidence in the 'truth value' of the data and its interpretation. It is used to establish that the findings are true, credible and believable. Credibility is similar to the internal validity in quantitative research.[ 1 , 50 , 51 ] The second criterion to establish the trustworthiness of the qualitative research is transferability, Transferability refers to the degree to which the qualitative results are applicability to other settings, population or contexts. This is analogous to the external validity in quantitative research.[ 1 , 50 , 51 ] Lincoln and Guba recommend authors provide enough details so that the users will be able to evaluate the applicability of data in other contexts.[ 49 ] The criterion of dependability refers to the assumption of repeatability or replicability of the study findings and is similar to that of reliability in quantitative research. The dependability question is 'Whether the study findings be repeated of the study is replicated with the same (similar) cohort of participants, data coders, and context?'[ 1 , 50 , 51 ] Confirmability, the fourth criteria is analogous to the objectivity of the study and refers the degree to which the study findings could be confirmed or corroborated by others. To ensure confirmability the data should directly reflect the participants' experiences and not the bias, motivations, or imaginations of the inquirer.[ 1 , 50 , 51 ] Qualitative researchers should ensure that the study is conducted with enough rigor and should report the measures undertaken to enhance the trustworthiness of the study.

Conclusions

Qualitative research studies are being widely acknowledged and recognized in health care practice. This overview illustrates various qualitative methods and shows how these methods can be used to generate evidence that informs clinical practice. Qualitative research helps to understand the patterns of health behaviors, describe illness experiences, design health interventions, and develop healthcare theories. The ultimate strength of the qualitative research approach lies in the richness of the data and the descriptions and depth of exploration it makes. Hence, qualitative methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

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