qualitative research study article

Qualitative Study

Affiliations.

• 1 University of Nebraska Medical Center
• 2 GDB Research and Statistical Consulting
• 3 GDB Research and Statistical Consulting/McLaren Macomb Hospital
• PMID: 29262162
• Bookshelf ID: NBK470395

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. Instead of collecting numerical data points or intervene or introduce treatments just like in quantitative research, qualitative research helps generate hypotheses as well as further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a stand-alone study, purely relying on qualitative data or it could be part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and application of qualitative research.

Qualitative research at its core, ask open-ended questions whose answers are not easily put into numbers such as ‘how’ and ‘why’. Due to the open-ended nature of the research questions at hand, qualitative research design is often not linear in the same way quantitative design is. One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. Phenomena such as experiences, attitudes, and behaviors can be difficult to accurately capture quantitatively, whereas a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a certain time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify and it is important to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore ‘compete’ against each other and the philosophical paradigms associated with each, qualitative and quantitative work are not necessarily opposites nor are they incompatible. While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.

Examples of Qualitative Research Approaches

Ethnography

Ethnography as a research design has its origins in social and cultural anthropology, and involves the researcher being directly immersed in the participant’s environment. Through this immersion, the ethnographer can use a variety of data collection techniques with the aim of being able to produce a comprehensive account of the social phenomena that occurred during the research period. That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc. through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.

Grounded Theory

Grounded Theory is the “generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior.” As opposed to quantitative research which is deductive and tests or verifies an existing theory, grounded theory research is inductive and therefore lends itself to research that is aiming to study social interactions or experiences. In essence, Grounded Theory’s goal is to explain for example how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

Phenomenology is defined as the “study of the meaning of phenomena or the study of the particular”. At first glance, it might seem that Grounded Theory and Phenomenology are quite similar, but upon careful examination, the differences can be seen. At its core, phenomenology looks to investigate experiences from the perspective of the individual. Phenomenology is essentially looking into the ‘lived experiences’ of the participants and aims to examine how and why participants behaved a certain way, from their perspective . Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources whereas Phenomenology focuses on describing and explaining an event or phenomena from the perspective of those who have experienced it.

Narrative Research

One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called ‘thick’ or ‘rich’ description and is a strength of qualitative research. Narrative research is rife with the possibilities of ‘thick’ description as this approach weaves together a sequence of events, usually from just one or two individuals, in the hopes of creating a cohesive story, or narrative. While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be “opportunities for innovation”.

Research Paradigm

Research paradigms are the assumptions, norms, and standards that underpin different approaches to research. Essentially, research paradigms are the ‘worldview’ that inform research. It is valuable for researchers, both qualitative and quantitative, to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontology and epistemologies . Ontology is defined as the "assumptions about the nature of reality” whereas epistemology is defined as the “assumptions about the nature of knowledge” that inform the work researchers do. It is important to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a full understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, it is crucial that researchers understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.

Positivist vs Postpositivist

To further understand qualitative research, we need to discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social as well as natural sciences. Essentially, positivist thinking insists that the social sciences should use natural science methods in its research which stems from positivist ontology that there is an objective reality that exists that is fully independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.

Conversely, postpositivists argue that social reality can never be one hundred percent explained but it could be approximated. Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world” and therefore postpositivist philosophy is often associated with qualitative research. An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.

Constructivist

Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are constructivist as well, meaning they think there is no objective external reality that exists but rather that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. “Constructivism contends that individuals’ views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality”. Essentially, Constructivist thought focuses on how ‘reality’ is not a fixed certainty and experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike in positivist views, that there is not necessarily an ‘objective’ reality we all experience. This is the ‘relativist’ ontological view that reality and the world we live in are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.”

So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have and can even change the role of the researcher themselves. For example, is the researcher an ‘objective’ observer such as in positivist quantitative work? Or is the researcher an active participant in the research itself, as in postpositivist qualitative work? Understanding the philosophical base of the research undertaken allows researchers to fully understand the implications of their work and their role within the research, as well as reflect on their own positionality and bias as it pertains to the research they are conducting.

Data Sampling

The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors at play. The following are examples of participant sampling and selection:

Purposive sampling- selection based on the researcher’s rationale in terms of being the most informative.

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

Snowball sampling- the selection is by referral from other participants or people who know potential participants.

Extreme case sampling- targeted selection of rare cases.

Typical case sampling-selection based on regular or average participants.

Data Collection and Analysis

Qualitative research uses several techniques including interviews, focus groups, and observation. [1] [2] [3] Interviews may be unstructured, with open-ended questions on a topic and the interviewer adapts to the responses. Structured interviews have a predetermined number of questions that every participant is asked. It is usually one on one and is appropriate for sensitive topics or topics needing an in-depth exploration. Focus groups are often held with 8-12 target participants and are used when group dynamics and collective views on a topic are desired. Researchers can be a participant-observer to share the experiences of the subject or a non-participant or detached observer.

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or in the environment of the participants, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed which may then be coded manually or with the use of Computer Assisted Qualitative Data Analysis Software or CAQDAS such as ATLAS.ti or NVivo.

After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data. Results also could be in the form of themes and theory or model development.

Dissemination

To standardize and facilitate the dissemination of qualitative research outcomes, the healthcare team can use two reporting standards. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups. The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a wider range of qualitative research.

Examples of Application

Many times a research question will start with qualitative research. The qualitative research will help generate the research hypothesis which can be tested with quantitative methods. After the data is collected and analyzed with quantitative methods, a set of qualitative methods can be used to dive deeper into the data for a better understanding of what the numbers truly mean and their implications. The qualitative methods can then help clarify the quantitative data and also help refine the hypothesis for future research. Furthermore, with qualitative research researchers can explore subjects that are poorly studied with quantitative methods. These include opinions, individual's actions, and social science research.

A good qualitative study design starts with a goal or objective. This should be clearly defined or stated. The target population needs to be specified. A method for obtaining information from the study population must be carefully detailed to ensure there are no omissions of part of the target population. A proper collection method should be selected which will help obtain the desired information without overly limiting the collected data because many times, the information sought is not well compartmentalized or obtained. Finally, the design should ensure adequate methods for analyzing the data. An example may help better clarify some of the various aspects of qualitative research.

A researcher wants to decrease the number of teenagers who smoke in their community. The researcher could begin by asking current teen smokers why they started smoking through structured or unstructured interviews (qualitative research). The researcher can also get together a group of current teenage smokers and conduct a focus group to help brainstorm factors that may have prevented them from starting to smoke (qualitative research).

In this example, the researcher has used qualitative research methods (interviews and focus groups) to generate a list of ideas of both why teens start to smoke as well as factors that may have prevented them from starting to smoke. Next, the researcher compiles this data. The research found that, hypothetically, peer pressure, health issues, cost, being considered “cool,” and rebellious behavior all might increase or decrease the likelihood of teens starting to smoke.

The researcher creates a survey asking teen participants to rank how important each of the above factors is in either starting smoking (for current smokers) or not smoking (for current non-smokers). This survey provides specific numbers (ranked importance of each factor) and is thus a quantitative research tool.

The researcher can use the results of the survey to focus efforts on the one or two highest-ranked factors. Let us say the researcher found that health was the major factor that keeps teens from starting to smoke, and peer pressure was the major factor that contributed to teens to start smoking. The researcher can go back to qualitative research methods to dive deeper into each of these for more information. The researcher wants to focus on how to keep teens from starting to smoke, so they focus on the peer pressure aspect.

The researcher can conduct interviews and/or focus groups (qualitative research) about what types and forms of peer pressure are commonly encountered, where the peer pressure comes from, and where smoking first starts. The researcher hypothetically finds that peer pressure often occurs after school at the local teen hangouts, mostly the local park. The researcher also hypothetically finds that peer pressure comes from older, current smokers who provide the cigarettes.

The researcher could further explore this observation made at the local teen hangouts (qualitative research) and take notes regarding who is smoking, who is not, and what observable factors are at play for peer pressure of smoking. The researcher finds a local park where many local teenagers hang out and see that a shady, overgrown area of the park is where the smokers tend to hang out. The researcher notes the smoking teenagers buy their cigarettes from a local convenience store adjacent to the park where the clerk does not check identification before selling cigarettes. These observations fall under qualitative research.

If the researcher returns to the park and counts how many individuals smoke in each region of the park, this numerical data would be quantitative research. Based on the researcher's efforts thus far, they conclude that local teen smoking and teenagers who start to smoke may decrease if there are fewer overgrown areas of the park and the local convenience store does not sell cigarettes to underage individuals.

The researcher could try to have the parks department reassess the shady areas to make them less conducive to the smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk population their perceptions of the changes, what factors are still at play, as well as quantitative research that includes teen smoking rates in the community, the incidence of new teen smokers, among others.

Copyright © 2024, StatPearls Publishing LLC.

• Introduction
• Issues of Concern
• Clinical Significance
• Enhancing Healthcare Team Outcomes
• Review Questions

Publication types

• Study Guide

• Open access
• Published: 27 May 2020

How to use and assess qualitative research methods

• Loraine Busetto   ORCID: orcid.org/0000-0002-9228-7875 1 ,
• Wolfgang Wick 1 , 2 &
• Christoph Gumbinger 1  

Neurological Research and Practice volume  2 , Article number:  14 ( 2020 ) Cite this article

686k Accesses

268 Citations

89 Altmetric

Metrics details

This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.

What is qualitative research?

Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].

Why conduct qualitative research?

Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.

While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 , 8 , 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 , 10 , 11 , 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig.  1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.

Iterative research process

While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].

Data collection

The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].

Document study

Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.

Observations

Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].

Semi-structured interviews

Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].

Focus groups

Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.

Choosing the “right” method

As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.

Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig.  2 .

Possible combination of data collection methods

Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project

The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].

Data analysis

To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig.  3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].

From data collection to data analysis

Attributions for icons: see Fig. 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project

How to report qualitative research?

Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 , 25 , 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.

How to assess qualitative research?

A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.

Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].

Reflexivity

While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].

Sampling and saturation

The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].

This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).

Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].

Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.

Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.

Member checking

Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].

Stakeholder involvement

In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 , 32 , 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.

How not to assess qualitative research

The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.

Protocol adherence

Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 , 38 , 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.

Interrater reliability, variability and other “objectivity checks”

The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].

Not being quantitative research

Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.

The main take-away points of this paper are summarised in Table 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

Availability of data and materials

Not applicable.

Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

Philipsen, H., & Vernooij-Dassen, M. (2007). Kwalitatief onderzoek: nuttig, onmisbaar en uitdagend. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [Qualitative research: useful, indispensable and challenging. In: Qualitative research: Practical methods for medical practice (pp. 5–12). Houten: Bohn Stafleu van Loghum.

Chapter   Google Scholar  

Punch, K. F. (2013). Introduction to social research: Quantitative and qualitative approaches . London: Sage.

Kelly, J., Dwyer, J., Willis, E., & Pekarsky, B. (2014). Travelling to the city for hospital care: Access factors in country aboriginal patient journeys. Australian Journal of Rural Health, 22 (3), 109–113.

Article   Google Scholar  

Nilsen, P., Ståhl, C., Roback, K., & Cairney, P. (2013). Never the twain shall meet? - a comparison of implementation science and policy implementation research. Implementation Science, 8 (1), 1–12.

Howick J, Chalmers I, Glasziou, P., Greenhalgh, T., Heneghan, C., Liberati, A., Moschetti, I., Phillips, B., & Thornton, H. (2011). The 2011 Oxford CEBM evidence levels of evidence (introductory document) . Oxford Center for Evidence Based Medicine. https://www.cebm.net/2011/06/2011-oxford-cebm-levels-evidence-introductory-document/ .

Eakin, J. M. (2016). Educating critical qualitative health researchers in the land of the randomized controlled trial. Qualitative Inquiry, 22 (2), 107–118.

May, A., & Mathijssen, J. (2015). Alternatieven voor RCT bij de evaluatie van effectiviteit van interventies!? Eindrapportage. In Alternatives for RCTs in the evaluation of effectiveness of interventions!? Final report .

Google Scholar  

Berwick, D. M. (2008). The science of improvement. Journal of the American Medical Association, 299 (10), 1182–1184.

Article   CAS   Google Scholar  

Christ, T. W. (2014). Scientific-based research and randomized controlled trials, the “gold” standard? Alternative paradigms and mixed methodologies. Qualitative Inquiry, 20 (1), 72–80.

Lamont, T., Barber, N., Jd, P., Fulop, N., Garfield-Birkbeck, S., Lilford, R., Mear, L., Raine, R., & Fitzpatrick, R. (2016). New approaches to evaluating complex health and care systems. BMJ, 352:i154.

Drabble, S. J., & O’Cathain, A. (2015). Moving from Randomized Controlled Trials to Mixed Methods Intervention Evaluation. In S. Hesse-Biber & R. B. Johnson (Eds.), The Oxford Handbook of Multimethod and Mixed Methods Research Inquiry (pp. 406–425). London: Oxford University Press.

Chambers, D. A., Glasgow, R. E., & Stange, K. C. (2013). The dynamic sustainability framework: Addressing the paradox of sustainment amid ongoing change. Implementation Science : IS, 8 , 117.

Hak, T. (2007). Waarnemingsmethoden in kwalitatief onderzoek. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [Observation methods in qualitative research] (pp. 13–25). Houten: Bohn Stafleu van Loghum.

Russell, C. K., & Gregory, D. M. (2003). Evaluation of qualitative research studies. Evidence Based Nursing, 6 (2), 36–40.

Fossey, E., Harvey, C., McDermott, F., & Davidson, L. (2002). Understanding and evaluating qualitative research. Australian and New Zealand Journal of Psychiatry, 36 , 717–732.

Yanow, D. (2000). Conducting interpretive policy analysis (Vol. 47). Thousand Oaks: Sage University Papers Series on Qualitative Research Methods.

Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22 , 63–75.

van der Geest, S. (2006). Participeren in ziekte en zorg: meer over kwalitatief onderzoek. Huisarts en Wetenschap, 49 (4), 283–287.

Hijmans, E., & Kuyper, M. (2007). Het halfopen interview als onderzoeksmethode. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [The half-open interview as research method (pp. 43–51). Houten: Bohn Stafleu van Loghum.

Jansen, H. (2007). Systematiek en toepassing van de kwalitatieve survey. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [Systematics and implementation of the qualitative survey (pp. 27–41). Houten: Bohn Stafleu van Loghum.

Pv, R., & Peremans, L. (2007). Exploreren met focusgroepgesprekken: de ‘stem’ van de groep onder de loep. In L. PLBJ & H. TCo (Eds.), Kwalitatief onderzoek: Praktische methoden voor de medische praktijk . [Exploring with focus group conversations: the “voice” of the group under the magnifying glass (pp. 53–64). Houten: Bohn Stafleu van Loghum.

Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use of triangulation in qualitative research. Oncology Nursing Forum, 41 (5), 545–547.

Boeije H: Analyseren in kwalitatief onderzoek: Denken en doen, [Analysis in qualitative research: Thinking and doing] vol. Den Haag Boom Lemma uitgevers; 2012.

Hunter, A., & Brewer, J. (2015). Designing Multimethod Research. In S. Hesse-Biber & R. B. Johnson (Eds.), The Oxford Handbook of Multimethod and Mixed Methods Research Inquiry (pp. 185–205). London: Oxford University Press.

Archibald, M. M., Radil, A. I., Zhang, X., & Hanson, W. E. (2015). Current mixed methods practices in qualitative research: A content analysis of leading journals. International Journal of Qualitative Methods, 14 (2), 5–33.

Creswell, J. W., & Plano Clark, V. L. (2011). Choosing a Mixed Methods Design. In Designing and Conducting Mixed Methods Research . Thousand Oaks: SAGE Publications.

Mays, N., & Pope, C. (2000). Assessing quality in qualitative research. BMJ, 320 (7226), 50–52.

O'Brien, B. C., Harris, I. B., Beckman, T. J., Reed, D. A., & Cook, D. A. (2014). Standards for reporting qualitative research: A synthesis of recommendations. Academic Medicine : Journal of the Association of American Medical Colleges, 89 (9), 1245–1251.

Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H., & Jinks, C. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization. Quality and Quantity, 52 (4), 1893–1907.

Moser, A., & Korstjens, I. (2018). Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. European Journal of General Practice, 24 (1), 9–18.

Marlett, N., Shklarov, S., Marshall, D., Santana, M. J., & Wasylak, T. (2015). Building new roles and relationships in research: A model of patient engagement research. Quality of Life Research : an international journal of quality of life aspects of treatment, care and rehabilitation, 24 (5), 1057–1067.

Demian, M. N., Lam, N. N., Mac-Way, F., Sapir-Pichhadze, R., & Fernandez, N. (2017). Opportunities for engaging patients in kidney research. Canadian Journal of Kidney Health and Disease, 4 , 2054358117703070–2054358117703070.

Noyes, J., McLaughlin, L., Morgan, K., Roberts, A., Stephens, M., Bourne, J., Houlston, M., Houlston, J., Thomas, S., Rhys, R. G., et al. (2019). Designing a co-productive study to overcome known methodological challenges in organ donation research with bereaved family members. Health Expectations . 22(4):824–35.

Piil, K., Jarden, M., & Pii, K. H. (2019). Research agenda for life-threatening cancer. European Journal Cancer Care (Engl), 28 (1), e12935.

Hofmann, D., Ibrahim, F., Rose, D., Scott, D. L., Cope, A., Wykes, T., & Lempp, H. (2015). Expectations of new treatment in rheumatoid arthritis: Developing a patient-generated questionnaire. Health Expectations : an international journal of public participation in health care and health policy, 18 (5), 995–1008.

Jun, M., Manns, B., Laupacis, A., Manns, L., Rehal, B., Crowe, S., & Hemmelgarn, B. R. (2015). Assessing the extent to which current clinical research is consistent with patient priorities: A scoping review using a case study in patients on or nearing dialysis. Canadian Journal of Kidney Health and Disease, 2 , 35.

Elsie Baker, S., & Edwards, R. (2012). How many qualitative interviews is enough? In National Centre for Research Methods Review Paper . National Centre for Research Methods. http://eprints.ncrm.ac.uk/2273/4/how_many_interviews.pdf .

Sandelowski, M. (1995). Sample size in qualitative research. Research in Nursing & Health, 18 (2), 179–183.

Sim, J., Saunders, B., Waterfield, J., & Kingstone, T. (2018). Can sample size in qualitative research be determined a priori? International Journal of Social Research Methodology, 21 (5), 619–634.

Download references

Acknowledgements

no external funding.

Author information

Authors and affiliations.

Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany

Loraine Busetto, Wolfgang Wick & Christoph Gumbinger

Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany

Wolfgang Wick

You can also search for this author in PubMed   Google Scholar

Contributions

LB drafted the manuscript; WW and CG revised the manuscript; all authors approved the final versions.

Corresponding author

Correspondence to Loraine Busetto .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Busetto, L., Wick, W. & Gumbinger, C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2 , 14 (2020). https://doi.org/10.1186/s42466-020-00059-z

Download citation

Received : 30 January 2020

Accepted : 22 April 2020

Published : 27 May 2020

DOI : https://doi.org/10.1186/s42466-020-00059-z

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Qualitative research
• Mixed methods
• Quality assessment

Neurological Research and Practice

ISSN: 2524-3489

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

About Journal

American Journal of Qualitative Research (AJQR)  is a quarterly peer-reviewed academic journal that publishes qualitative research articles from a number of social science disciplines such as psychology, health science, sociology, criminology, education, political science, and administrative studies. The journal is an international and interdisciplinary focus and greatly welcomes papers from all countries. The journal offers an intellectual platform for researchers, practitioners, administrators, and policymakers to contribute and promote qualitative research and analysis.

ISSN: 2576-2141

Call for Papers- American Journal of Qualitative Research

American Journal of Qualitative Research (AJQR) welcomes original research articles and book reviews for its next issue. The AJQR is a quarterly and peer-reviewed journal published in February, May, August, and November.

We are seeking submissions for a forthcoming issue published in February 2024. The paper should be written in professional English. The length of 6000-10000 words is preferred. All manuscripts should be prepared in MS Word format and submitted online: https://www.editorialpark.com/ajqr

For any further information about the journal, please visit its website: https://www.ajqr.org

Submission Deadline: November 15, 2023

Announcement 

Dear AJQR Readers, 

Due to the high volume of submissions in the American Journal of Qualitative Research , the editorial board decided to publish quarterly since 2023.

Volume 8, Issue 1

Current issue.

Social distancing requirements resulted in many people working from home in the United Kingdom during the COVID-19 pandemic. The topic of working from home was often discussed in the media and online during the pandemic, but little was known about how quality of life (QOL) and remote working interfaced. The purpose of this study was to describe QOL while working from home during the COVID-19 pandemic. The novel topic, unique methodological approach of the General Online Qualitative Study ( D’Abundo & Franco, 2022a), and the strategic Social Distancing Sampling ( D’Abundo & Franco, 2022c) resulted in significant participation throughout the world (n = 709). The United Kingdom subset of participants (n = 234) is the focus of this article. This big qual, large qualitative study (n >100) included the principal investigator-developed, open-ended, online questionnaire entitled the “Quality of Life Home Workplace Questionnaire (QOLHWQ)” and demographic questions. Data were collected peak-pandemic from July to September 2020. Most participants cited increased QOL due to having more time with family/kids/partners/pets, a more comfortable work environment while being at home, and less commuting to work. The most cited issue associated with negative QOL was social isolation. As restrictions have been lifted and public health emergency declarations have been terminated during the post-peak era of the COVID-19 pandemic, the potential for future public health emergencies requiring social distancing still exists. To promote QOL and work-life balance for employees working remotely in the United Kingdom, stakeholders could develop social support networks and create effective planning initiatives to prevent social isolation and maximize the benefits of remote working experiences for both employees and organizations.

Keywords: qualitative research, quality of life, remote work, telework, United Kingdom, work from home.

(no abstract)

This essay reviews classic works on the philosophy of science and contemporary pedagogical guides to scientific inquiry in order to present a discussion of the three logics that underlie qualitative research in political science. The first logic, epistemology, relates to the essence of research as a scientific endeavor and is framed as a debate between positivist and interpretivist orientations within the discipline of political science. The second logic, ontology, relates to the approach that research takes to investigating the empirical world and is framed as a debate between positivist qualitative and quantitative orientations, which together constitute the vast majority of mainstream researchers within the discipline. The third logic, methodology, relates to the means by which research aspires to reach its scientific ends and is framed as a debate among positivist qualitative orientations. Additionally, the essay discusses the present state of qualitative research in the discipline of political science, reviews the various ways in which qualitative research is defined in the relevant literature, addresses the limitations and trade-offs that are inherently associated with the aforementioned logics of qualitative research, explores multimethod approaches to remedying these issues, and proposes avenues for acquiring further information on the topics discussed.

Keywords: qualitative research, epistemology, ontology, methodology

This paper examines the phenomenology of diagnostic crossover in eating disorders, the movement within or between feeding and eating disorder subtypes or diagnoses over time, in two young women who experienced multiple changes in eating disorder diagnosis over 5 years. Using interpretative phenomenological analysis, this study found that transitioning between different diagnostic labels, specifically between bulimia nervosa and anorexia nervosa binge/purge subtype, was experienced as disempowering, stigmatizing, and unhelpful. The findings in this study offer novel evidence that, from the perspective of individuals diagnosed with EDs, using BMI as an indicator of the presence, severity, or change of an ED may have adverse consequences for well-being and recovery and may lead to mischaracterization or misclassification of health status. The narratives discussed in this paper highlight the need for more person-centered practices in the context of diagnostic crossover. Including the perspectives of those with lived experience can help care providers working with individuals with eating disorders gain an in-depth understanding of the potential personal impact of diagnosis changing and inform discussions around developing person-focused diagnostic practices.

Keywords: feeding and eating disorders, bulimia nervosa, diagnostic labels, diagnostic crossover, illness narrative

Often among the first witnesses to child trauma, educators and therapists are on the frontline of an unfolding and multi-pronged occupational crisis. For educators, lack of support and secondary traumatic stress (STS) appear to be contributing to an epidemic in professional attrition. Similarly, therapists who do not prioritize self-care can feel depleted of energy and optimism. The purpose of this phenomenological study was to examine how bearing witness to the traumatic narratives of children impacts similar helping professionals. The study also sought to extrapolate the similarities and differences between compassion fatigue and secondary trauma across these two disciplines. Exploring the common factors and subjective individual experiences related to occupational stress across these two fields may foster a more complete picture of the delicate nature of working with traumatized children and the importance of successful self-care strategies. Utilizing Constructivist Self-Development Theory (CSDT) and focus group interviews, the study explores the significant risk of STS facing both educators and therapists.

Keywords: qualitative, secondary traumatic stress, self-care, child trauma, educators, therapists.

This study explored the lived experiences of residents of the Gulf Coast in the USA during Hurricane Katrina, which made landfall in August 2005 and caused insurmountable destruction throughout the area. A heuristic process and thematic analysis were employed to draw observations and conclusions about the lived experiences of each participant and make meaning through similar thoughts, feelings, and themes that emerged in the analysis of the data. Six themes emerged: (1) fear, (2) loss, (3) anger, (4) support, (5) spirituality, and (6) resilience. The results of this study allude to the possible psychological outcomes as a result of experiencing a traumatic event and provide an outline of what the psychological experience of trauma might entail. The current research suggests that preparedness and expectation are key to resilience and that people who feel that they have power over their situation fare better than those who do not.

Keywords: mass trauma, resilience, loss, natural disaster, mental health.

Women from rural, low-income backgrounds holding positions within the academy are the exception and not the rule. Most women faculty in the academy are from urban/suburban areas and middle- and upper-income family backgrounds. As women faculty who do not represent this norm, our primary goal with this article is to focus on the unique barriers we experienced as girls from rural, low-income areas in K-12 schools that influenced the possibilities for successfully transitioning to and engaging with higher education. We employed a qualitative duoethnographic and narrative research design to respond to the research questions, and we generated our data through semi-structured, critical, ethnographic dialogic conversations. Our duoethnographic-narrative analyses revealed six major themes: (1) independence and other   benefits of having a working-class mom; (2) crashing into middle-class norms and expectations; (3) lucking and falling into college; (4) fish out of water; (5) overcompensating, playing middle class, walking on eggshells, and pushing back; and (6) transitioning from a working-class kid to a working class academic, which we discuss in relation to our own educational attainment.

Keywords: rurality, working-class, educational attainment, duoethnography, higher education, women.

This article draws on the findings of a qualitative study that focused on the perspectives of four Indian American mothers of youth with developmental disabilities on the process of transitioning from school to post-school environments. Data were collected through in-depth ethnographic interviews. The findings indicate that in their efforts to support their youth with developmental disabilities, the mothers themselves navigate multiple transitions across countries, constructs, dreams, systems of schooling, and services. The mothers’ perspectives have to be understood against the larger context of their experiences as citizens of this country as well as members of the South Asian diaspora. The mothers’ views on services, their journey, their dreams for their youth, and their interpretation of the ideas anchored in current conversations on transition are continually evolving. Their attempts to maintain their resilience and their indigenous understandings while simultaneously negotiating their experiences in the United States with supporting their youth are discussed.  

Keywords: Indian-American mothers, transitioning, diaspora, disability, dreams.

This study explored the influence of yoga on practitioners’ lives ‘off the mat’ through a phenomenological lens. Central to the study was the lived experience of yoga in a purposive sample of self-identified New Zealand practitioners (n=38; 89.5% female; aged 18 to 65 years; 60.5% aged 36 to 55 years). The study’s aim was to explore whether habitual yoga practitioners experience any pro-health downstream effects of their practice ‘off the mat’ via their lived experience of yoga. A qualitative mixed methodology was applied via a phenomenological lens that explicitly acknowledged the researcher’s own experience of the research topic. Qualitative methods comprised an open-ended online survey for all participants (n=38), followed by in-depth semi-structured interviews (n=8) on a randomized subset. Quantitative methods included online outcome measures (health habits, self-efficacy, interoceptive awareness, and physical activity), practice component data (tenure, dose, yoga styles, yoga teacher status, meditation frequency), and socio-demographics. This paper highlights the qualitative findings emerging from participant narratives. Reported benefits of practice included the provision of a filter through which to engage with life and the experience of self-regulation and mindfulness ‘off the mat’. Practitioners experienced yoga as a self-sustaining positive resource via self-regulation guided by an embodied awareness. The key narrative to emerge was an attunement to embodiment through movement. Embodied movement can elicit self-regulatory pathways that support health behavior.

Keywords: embodiment, habit, interoception, mindfulness, movement practice, qualitative, self-regulation, yoga.

Historically and in the present day, Black women’s positionality in the U.S. has paradoxically situated them in a society where they are both intrinsically essential and treated as expendable. This positionality, known as gendered racism, manifests commonly in professional environments and results in myriad harms. In response, Black women have developed, honed, and practiced a range of coping styles to mitigate the insidious effects of gendered racism. While often effective in the short-term, these techniques frequently complicate Black women’s well-being. For Black female clinicians who experience gendered racism and work on the frontlines of community mental health, myriad bio-psycho-social-spiritual harms compound. This project provided an opportunity for Black female clinicians from across the U.S. to share their experiences during the dual pandemics of COVID-19 and anti-Black violence. I conducted in-depth interviews with clinicians (n=14) between the ages of 30 and 58. Using the Listening Guide voice-centered approach to data generation and analysis, I identified four voices to help answer this project’s central question: How do you experience being a Black female clinician in the U.S.? The voices of self, pride, vigilance, and mediating narrated the complex ways participants experienced their workplaces. This complexity seemed to be context-specific, depending on whether the clinicians worked in predominantly White workplaces (PWW), a mix of PWW and private practice, or private practice exclusively. Participants who worked only in PWW experienced the greatest stress, oppression, and burnout risk, while participants who worked exclusively in private practice reported more joy, more authenticity, and more job satisfaction. These findings have implications for mentoring, supporting, and retaining Black female clinicians.

Keywords: Black female clinicians, professional experiences, gendered racism, Listening Guide voice-centered approach.

The purpose of this article is to speak directly to the paucity of research regarding Dominican American women and identity narratives. To do so, this article uses the Listening Guide Method of Qualitative Inquiry (Gilligan, et al., 2006) to explore how 1.5 and second-generation Dominican American women narrated their experiences of individual identity within American cultural contexts and constructs. The results draw from the emergence of themes across six participant interviews and showed two distinct voices: The Voice of Cultural Explanation and the Tides of Dominican American Female Identity. Narrative examples from five participants are offered to illustrate where 1.5 and second-generation Dominican American women negotiate their identity narratives at the intersection of their Dominican and American selves. The article offers two conclusions. One, that participant women use the Voice of Cultural Explanation in order to discuss their identity as reflected within the broad cultural tensions of their daily lives. Two, that the Tides of Dominican American Female Identity are used to express strong emotions that manifest within their personal narratives as the unwanted distance from either the Dominican or American parts of their person.

Keywords: Dominican American, women, identity, the Listening Guide, narratives

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

• Qualitative studies
• Research design
• Get an email alert for Qualitative studies
• Get the RSS feed for Qualitative studies

Showing 1 - 13 of 1,118

View by: Cover Page List Articles

Sort by: Recent Popular

Firefighters’ medical use and Korean Medicine experience in Korea: A qualitative study protocol

Jisu Ha, Inae Youn,  [ ... ], Jungtae Leem

Medical school department chair performance improvement: A qualitative study

Mohammad Mahboubi, Soleiman Ahmady,  [ ... ], Noushin Kohan

Add-on effects of Chinese herbal medicine external application (FZHFZY) to topical urea for mild-to-moderate psoriasis vulgaris: Protocol for a double-blinded randomized controlled pilot trial embedded with a qualitative study

Junyue Wang, Claire Shuiqing Zhang,  [ ... ], Chuanjian Lu

The impact of COVID-19 on young people’s mental health, wellbeing and routine from a European perspective: A co-produced qualitative systematic review

Lindsay H. Dewa, Lily Roberts,  [ ... ], Steph Scott

Examining how goals of care communication are conducted between doctors and patients with severe acute illness in hospital settings: A realist systematic review

Jamie Gross, Jonathan Koffman

Mental health and mental health help-seeking behaviors among first-generation voluntary African migrants: A systematic review

Edith N. Botchway-Commey, Obed Adonteng-Kissi,  [ ... ], Uchechukwu Levi Osuagwu

Good psychiatric management for borderline personality disorder: A qualitative study of its implementation in a supported employment team

Noëllie Dunand, Philippe Golay,  [ ... ], Valentino Pomini

”Daddy comforts me”–Young Swedish children’s perspectives on their family relations before and after their parents’ participation in a parenting programme

Anton Dahlberg, Karin Fängström

A mixed methods analysis of youth mental health intervention feasibility and acceptability in a North American city: Perspectives from Seattle, Washington

Augustina Mensa-Kwao, Ingrid Sub Cuc,  [ ... ], Pamela Y. Collins

Affectation of COVID-19 pandemic on the use and abundance of wild resources in Tabasco, Mexico: A qualitative assessment

José Luis Martínez-Sánchez, Carolina Zequeira Larios, Florisel Hernandez Ramirez

Factors associated with informal human milk sharing among donors and recipients: A mixed-methods systematic review

Niamh Vickers, Anne Matthews, Gillian Paul

Barriers to implementing patient safety incident reporting and learning guidelines in specialised care units, KwaZulu-Natal: A qualitative study

T. M. H. Gqaleni, Sipho W. Mkhize

Developing a disease-specific patient reported outcome measure to enhance understanding of the lived experiences of ANCA associated vasculitis: A protocol paper

Lauren Floyd, Ajay Dhaygude, Sandip Mitra, Christine Rowland

Connect with Us

• PLOS ONE on Twitter
• PLOS on Facebook

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, generate accurate citations for free.

• Knowledge Base

Methodology

• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analyzing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organization?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, other interesting articles, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography , action research , phenomenological research, and narrative research. They share some similarities, but emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

Prevent plagiarism. Run a free check.

Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves “instruments” in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analyzing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organize your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorize your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analyzing qualitative data. Although these methods share similar processes, they emphasize different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

Researchers must consider practical and theoretical limitations in analyzing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analyzing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalizability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalizable conclusions because the data may be biased and unrepresentative of the wider population .

• Labor-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Chi square goodness of fit test
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Inclusion and exclusion criteria

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organization to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organize your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

Bhandari, P. (2023, June 22). What Is Qualitative Research? | Methods & Examples. Scribbr. Retrieved March 25, 2024, from https://www.scribbr.com/methodology/qualitative-research/

Is this article helpful?

Pritha Bhandari

Other students also liked, qualitative vs. quantitative research | differences, examples & methods, how to do thematic analysis | step-by-step guide & examples, "i thought ai proofreading was useless but..".

I've been using Scribbr for years now and I know it's a service that won't disappoint. It does a good job spotting mistakes”

• Research article
• Open access
• Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

• Jannine van Schothorst–van Roekel 1 ,
• Anne Marie J.W.M. Weggelaar-Jansen 1 ,
• Carina C.G.J.M. Hilders 1 ,
• Antoinette A. De Bont 1 &
• Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

16k Accesses

4 Citations

1 Altmetric

Metrics details

Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Peer Review reports

The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

Allen D. Nursing and the future of ‘care’ in health care systems. J Health Serv Res Policy. 2015;20(3):129–30. https://doi.org/10.1177/1355819615577806 .

Article   PubMed   Google Scholar  

NHS England. Leading change, adding value. A framework for nursing, midwifery and care staff. 2016. https://www.england.nhs.uk/wp-content/uploads/2016/05/nursing-framework.pdf . Accessed 11 Nov 2020.

Institute of Medicine (IOM). The future of nursing; Leading change, advancing Health. Washington (DC): National Academies Press; 2011.

Google Scholar  

World Health Organization (WHO). Gloabal strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: WHO Press; 2016.

Dawson AJ, Stasa H, Roche MA, et al. Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies. BMC Nurs. 2014;13:11. https://doi.org/10.1186/1472-6955-13-11 .

Article   PubMed   PubMed Central   Google Scholar  

Hayes LJ, O’Brien-Pallas L, Duffield C, et al. Nurse turnover: a literature review–an update. Intern J Nurs Stud. 2012;49(7):887–905. https://doi.org/10.1016/j.ijnurstu.2011.10.001 .

Article   Google Scholar  

Persson U, Carlson E. Conceptions of professional work in contemporary health care—Perspectives from registered nurses in somatic care: A phenomenographic study. J Clin Nurs. 2019;28(1–2):201–8. https://doi.org/10.1111/jocn.14628 .

Senek M, Robertson S, Ryan T, et al. Determinants of nurse job dissatisfaction-findings from a cross-sectional survey analysis in the UK. BMC Nurs. 2020;19(1):1–10. https://doi.org/10.1186/s12912-020-00481-3 .

Jacob ER, McKenna L, D’Amore A. The changing skill mix in nursing: considerations for and against different levels of nurse. J Nurs Manag. 2015;23(4):421–6. https://doi.org/10.1111/jonm.12162 .

Sermeus W, Aiken LH, Van den Heede K, et al. Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology. BMC Nurs. 2011;10:6. https://doi.org/10.1186/1472-6955-10-6 .

de Bont A, van Exel Job, Coretti S, Ökem ZG, Janssen M, Hope KL, Ludwicki T, Zander B, Zvonickova M, Bond C, Wallenburg I. Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe. BMC Health Serv Res. 2016;16(1).

Poitras ME, Chouinard MC, Fortin M, et al. How to report professional practice in nursing? A scoping review. BMC Nurs. 2016;15(1):31. https://doi.org/10.1186/s12912-016-0154-6 .

Jones ML. Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis. J Adv Nurs. 2005;49(2):191–209. https://doi.org/10.1111/j.1365-2648.2004.03279.x .

Ranchal A, Jolley MJ, Keogh J, et al. The challenge of the standardization of nursing specializations in Europe. Int Nurs Rev. 2015;62(4):445–52. https://doi.org/10.1111/inr.12204 .

Article   CAS   PubMed   Google Scholar  

Lowe G, Plummer V, O’Brien AP, et al. Time to clarify–the value of advanced practice nursing roles in health care. J Adv Nurs. 2012;68(3):677–85. https://doi.org/10.1111/j.1365-2648.2011.05790.x .

Fealy GM, Casey M, O’Leary DF, et al. Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers. J Clin Nurs. 2018;27(19–20):3797–809. https://doi.org/10.1111/jocn.14550 .

Aiken LH, Sermeus W, Van den Heede K, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344;e1717. https://doi.org/10.1136/bmj.e1717

Lu H, Zhao Y, While A. Job satisfaction among hospital nurses: A literature review. Intern J Nurs Stud. 2019;94:21–31. https://doi.org/10.1016/j.ijnurstu.2019.01.011 .

Duffield C, Roche M, Twigg D, et al. Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment. J Clin Nurs. 2018;27(19–20):3768–79. https://doi.org/10.1111/jocn.14632 .

Chua WL, Legido-Quigley H, Ng PY, et al. Seeing the whole picture in enrolled and registered nurses’ experiences in recognizing clinical deterioration in general ward patients: A qualitative study. Intern J Nurs Stud. 2019;95:56–64. https://doi.org/10.1016/j.ijnurstu.2019.04.012 .

van Oostveen CJ, Mathijssen E, Vermeulen H. Nurse staffing issues are just the tip of the iceberg: a qualitative study about nurses’ perceptions of nurse staffing. Intern J Nurs Stud. 2015;52(8):1300–9. https://doi.org/10.1016/j.ijnurstu.2015.04.002 .

Saville CE, Griffiths P, Ball JE, et al. How many nurses do we need? A review and discussion of operational research techniques applied to nurse staffing. Intern J Nurs Stud. 2019;97:7–13. https://doi.org/10.1016/j.ijnurstu.2019.04.015 .

Vatnøy TK, Sundlisæter Skinner M, Karlsen T, et al. Nursing competence in municipal in-patient acute care in Norway: a cross-sectional study. BMC Nurs. 2020;9:70. https://doi.org/10.1186/s12912-020-00463-5 .

De Jong JHJ, Kerstens JAM, Sesink EM, et al. Deskundigheidsbevordering en professionalisering. In: Handboek verpleegkunde. Houten: Bohn Stafleu van Loghum; 2003. p. 396–421. https://doi.org/10.1007/978-90-313-9699-3_13 .

Lalleman P, Stalpers D, Goossens L, et al. RN2Blend: meerjarig onderzoek naar gedifferentieerde inzet van verpleegkundigen. Verpleegkunde. 2020;1:4–6.

Endacott R, O’Connor M, Williams A, et al. Roles and functions of enrolled nurses in Australia: Perspectives of enrolled nurses and registered nurses. J Clin Nurs. 2018;27(5–6):e913–20. https://doi.org/10.1111/jocn.13987 .

Jacob E, Sellick K, McKenna L. Australian registered and enrolled nurses: Is there a difference? Intern J Nurs Pract. 2012;18(3):303–7. https://doi.org/10.1111/j.1440-172X.2012.02037.x .

Matthias AD. Educational pathways for differentiated nursing practice: a continuing dilemma. In: Lewenson SB, McAllister A, Smith KM, editors. Nursing History for Contemporary Role Development. New York: Springer Publishing Company; 2017. p. 121–40.

Boston-Fleischhauer C. Another Look at Differentiating Nursing Practice. J Nurs Adm. 2019;49(6):291–3. https://doi.org/10.1097/NNA.0000000000000754 .

Gardner G, Duffield C, Doubrovsky A, et al. Identifying advanced practice: a national survey of a nursing workforce. Intern J Nurs Stud. 2016;55:60–70. https://doi.org/10.1016/j.ijnurstu.2015.12.001 .

Duffield C, Twigg D, Roche M, et al. Uncovering the disconnect between nursing workforce policy intentions, implementation, and outcomes: Lessons learned from the addition of a nursing assistant role. Policy Polit Nurs Pract. 2019;20(4):228–238. https://doi.org/10.1177/1527154419877571

Terpstra D, Van den Berg A, Van Mierlo C, et al. Toekomstbestendige beroepen in de verpleging en verzorging: rapport stuurgroep over de beroepsprofielen en de overgangsregeling. 2015. http://www.nfu.nl/img/pdf/Rapport_toekomstbestendige-beroepen-in-de-verpleging-en-verzorging.pdf

Bohmer RM. The hard work of health care transformation. N Engl J Med 2016;375(8):709–11. doi: https://doi.org/10.1056/NEJMp1606458

Ellström PE. Integrating learning and work: Problems and prospects. Hum Res Dev Q. 2001;12(4):421–35. https://doi.org/10.1002/hrdq.1006 .

Lyman B, Hammond E, Cox J. Organizational learning in hospitals: A concept analysis. J Nurs Manag. 2019;27:633–46. https://doi.org/10.1111/jonm.12722 .

van Schothorst J, van Roekel AM,  Weggelaar-Jansen JWM, de Bont A, Wallenburg I. The balancing act of organizing professionals and managers: An ethnographic account of nursing role development and unfolding nurse-manager relationships. J Professions an Orga. 2020;7(3):283–99.

Reay T, Golden-Biddle K, Germann K. Legitimizing a New Role: Small Wins and Microprocesses of Change. Acad Manag J. 2006;49(5):977–98. https://doi.org/10.5465/amj.2006.22798178 .

Mannix J, Wilkes L, Jackson D. Marking out the clinical expert/clinical leader/clinical scholar: perspectives from nurses in the clinical arena. BMC Nurs. 2013:12;12. https://doi.org/10.1186/1472-6955-12-12

Nelson-Brantley HV, Ford DJ. Leading change: a concept analysis. J Adv Nurs. 2017;73(4):834–46. https://doi.org/10.1111/jan.13223 .

Boamah SA. Emergence of informal clinical leadership as a catalyst for improving patient care quality and job satisfaction. J Adv Nurs. 2019;75(5):1000–9. https://doi.org/10.1111/jan.13895 .

Abbott A. Linked ecologies: States and universities as environments for professions. Sociol Theory. 2005;23(3):245–74. https://doi.org/10.1111/j.0735-2751.2005.00253.x .

Hughes D. Nursing and the division of labour: sociological perspectives. In: Allen D, Hughes D, editors. Nursing and the Division of Labour in Healthcare. Hampshire and New York: Palgrave Macmillan; 2017. p. 1–21.

Ayala RA. Towards a Sociology of Nursing. Palgrave Macmillan; 2020.

Chua WF, Clegg S. Professional closure. Theory Soc. 1990;19(2):135–72.

Roper JM, Shapira J. Ethnography in nursing research. Thousand Oaks: Sage Publications; 2000.

Book   Google Scholar  

Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice, 8th Edition. Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2008.

Atkinson P, Hammersley M. Ethnography: Principles in practice. New York: Routledge; 2007.

Draper J. Ethnography: Principles, practice and potential. Nurs Stand. 2015;29(36):36–41. https://doi.org/10.7748/ns.29.36.36.e8937 .

Allen D. The invisible work of nurses: Hospitals, organisation and healthcare. The Invisible Work of Nurses: Hospitals, Organisation and Healthcare. Oxfordshire and New York: Routledge; 2014.

Lalleman P, Bouma J, Smid G, et al. Peer-to-peer shadowing as a technique for the development of nurse middle managers clinical leadership: An explorative study. Leader Health Serv. 2017;30(4):475–90. https://doi.org/10.1108/LHS-12-2016-0065 .

Atkins S, Lewin S, Smith H, et al. Conducting a meta-ethnography of qualitative literature: lessons learned. BMC Med Res Methodol. 2008;8:21. https://doi.org/10.1186/1471-2288-8-21

Houghton C, Casey D, Shaw D, et al. Rigour in qualitative case-study researh. Nurse Res. 2013;20(4):12–7. https://doi.org/10.7748/nr2013.03.20.4.12.e326 .

Denzin NK, Lincoln YS, editors. The Sage handbook of Qualitative research. Thousands Oak: Sage; 2011.

Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract. 2000;39(3):124–30. https://doi.org/10.1207/s15430421tip3903_2 .

Baker L, Observation. A complex research method. Library Trends. 2006;55(1):171–89.

Kanuha VK. “Being” native versus “going native”: Conducting social work research as an insider. Social Work. 2000;45(5):439–47. https://doi.org/10.1093/sw/45.5.439 .

Dwyer SC, Buckle JL. The space between: On being an insider-outsider in qualitative research. Intern J Qual Methods. 2009;8(1):54–63. https://doi.org/10.1177/160940690900800105 .

Star SL, Strauss A. Layers of silence, arenas of voice: The ecology of visible and invisible work. Comp Support Coop Work. 1999;8(1–2):9–30. https://doi.org/10.1023/A:1008651105359 .

Allen DA, Lyne PA. Nurses’ flexible working practices: some ethnographic insights into clinical effectiveness. Clin Effective Nurs. 1997;1(3):131–8. https://doi.org/10.1016/S1361-9004(97)80048-9 .

Allen D. Translational mobilisation theory: a new paradigm for understanding the organisational elements of nursing work. Intern J Nurs Stud. 2018;79:36–42. https://doi.org/10.1016/j.ijnurstu.2017.10.010 .

Arrowsmith V, Lau-Walker M, Norman I, et al. Nurses’ perceptions and experiences of work role transitions: a mixed methods systematic review of the literature. J Adv Nurs. 2016;72(8):1735–50. https://doi.org/10.1111/jan.12912 .

Apker J, Propp KM, Ford WSZ, et al. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs. 2006;22(3):180–9. https://doi.org/10.1016/j.profnurs.2006.03.002 .

Currie G, Koteyko N, Nerlich B. The dynamics of professions and development of new roles in public services organizations. The case of modern matrons in the English NHS. Public Adm. 2009;87(2):295–311. https://doi.org/10.1111/j.1467-9299.2009.01755.x .

Skela-Savič B, Hvalič-Touzery S, Pesjak K. Professional values and competencies as explanatory factors for the use of evidence-based practice in nursing. J Adv Nurs. 2017;73(8):1910–23. https://doi.org/10.1111/jan.13280 .

FURÅKER C. Registered Nurses’ views on their professional role. J Nurs Manag. 2008;16(8):933–41. https://doi.org/10.1111/j.1365-2834.2008.00872.x .

Stokke K, Olsen NR, Espehaug B, et al. Evidence based practice beliefs and implementation among nurses: a cross-sectional study. BMC Nurs. 2014;13(1):8.

Abbott A. The system of professions: an essay on the expert division of labor. Chicago: The University of Chicago Press; 1988.

Clegg SR, Kornberger M, Rhodes C. Learning/becoming/organizing. Organization. 2005;12(2):147–67. https://doi.org/10.1177/1350508405051186 .

Download references

Acknowledgements

The authors would like to thank all participants for their contribution to this study.

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

Author information

Authors and affiliations.

Erasmus School of Health Policy & Management (ESHPM), Erasmus University, Rotterdam, The Netherlands

Jannine van Schothorst–van Roekel, Anne Marie J.W.M. Weggelaar-Jansen, Carina C.G.J.M. Hilders, Antoinette A. De Bont & Iris Wallenburg

You can also search for this author in PubMed   Google Scholar

Contributions

A.W. and I.W. developed the study design. J.S. and A.W. were responsible for data collection, enhanced by I.W. for data analysis and drafting the manuscript. C.H. and A.B. critically revised the paper. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Jannine van Schothorst–van Roekel .

Ethics declarations

Ethics approval and consent to participate.

All methods were carried out in accordance with relevant guidelines and regulations. The research was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215) and all participants gave their informed consent.

Consent for publication

Not applicable.

Competing interests

No competing interests has been declared by the authors.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

Download citation

Received : 11 November 2020

Accepted : 19 May 2021

Published : 14 June 2021

DOI : https://doi.org/10.1186/s12912-021-00613-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Evidence-based practice
• nursing practice
• Registered nurses
• Vocational-trained nurses
• Role development
• Role distinctions
• Qualitative study

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

What is Qualitative in Qualitative Research

• Open access
• Published: 27 February 2019
• Volume 42 , pages 139–160, ( 2019 )

Cite this article

You have full access to this open access article

• Patrik Aspers 1 , 2 &
• Ugo Corte 3  

571k Accesses

275 Citations

24 Altmetric

Explore all metrics

What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

Similar content being viewed by others

What is Qualitative in Research

Patrik Aspers & Ugo Corte

Unsettling Definitions of Qualitative Research

Japonica Brown-Saracino

What is “Qualitative” in Qualitative Research? Why the Answer Does not Matter but the Question is Important

Mario L. Small

Avoid common mistakes on your manuscript.

If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.

To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker ( 1963 ) asks ‘How does one become a marijuana user?’ In contrast to pre-dispositional and psychological-individualistic theories of deviant behavior, Becker’s inherently social explanation contends that becoming a user of this substance is the result of a three-phase sequential learning process. First, potential users need to learn how to smoke it properly to produce the “correct” effects. If not, they are likely to stop experimenting with it. Second, they need to discover the effects associated with it; in other words, to get “high,” individuals not only have to experience what the drug does, but also to become aware that those sensations are related to using it. Third, they require learning to savor the feelings related to its consumption – to develop an acquired taste. Becker, who played music himself, gets close to the phenomenon by observing, taking part, and by talking to people consuming the drug: “half of the fifty interviews were conducted with musicians, the other half covered a wide range of people, including laborers, machinists, and people in the professions” (Becker 1963 :56).

Another central aspect derived through the common-to-all-research interplay between induction and deduction (Becker 2017 ), is that during the course of his research Becker adds scientifically meaningful new distinctions in the form of three phases—distinctions, or findings if you will, that strongly affect the course of his research: its focus, the material that he collects, and which eventually impact his findings. Each phase typically unfolds through social interaction, and often with input from experienced users in “a sequence of social experiences during which the person acquires a conception of the meaning of the behavior, and perceptions and judgments of objects and situations, all of which make the activity possible and desirable” (Becker 1963 :235). In this study the increased understanding of smoking dope is a result of a combination of the meaning of the actors, and the conceptual distinctions that Becker introduces based on the views expressed by his respondents. Understanding is the result of research and is due to an iterative process in which data, concepts and evidence are connected with one another (Becker 2017 ).

Indeed, there are many definitions of qualitative research, but if we look for a definition that addresses its distinctive feature of being “qualitative,” the literature across the broad field of social science is meager. The main reason behind this article lies in the paradox, which, to put it bluntly, is that researchers act as if they know what it is, but they cannot formulate a coherent definition. Sociologists and others will of course continue to conduct good studies that show the relevance and value of qualitative research addressing scientific and practical problems in society. However, our paper is grounded in the idea that providing a clear definition will help us improve the work that we do. Among researchers who practice qualitative research there is clearly much knowledge. We suggest that a definition makes this knowledge more explicit. If the first rationale for writing this paper refers to the “internal” aim of improving qualitative research, the second refers to the increased “external” pressure that especially many qualitative researchers feel; pressure that comes both from society as well as from other scientific approaches. There is a strong core in qualitative research, and leading researchers tend to agree on what it is and how it is done. Our critique is not directed at the practice of qualitative research, but we do claim that the type of systematic work we do has not yet been done, and that it is useful to improve the field and its status in relation to quantitative research.

The literature on the “internal” aim of improving, or at least clarifying qualitative research is large, and we do not claim to be the first to notice the vagueness of the term “qualitative” (Strauss and Corbin 1998 ). Also, others have noted that there is no single definition of it (Long and Godfrey 2004 :182), that there are many different views on qualitative research (Denzin and Lincoln 2003 :11; Jovanović 2011 :3), and that more generally, we need to define its meaning (Best 2004 :54). Strauss and Corbin ( 1998 ), for example, as well as Nelson et al. (1992:2 cited in Denzin and Lincoln 2003 :11), and Flick ( 2007 :ix–x), have recognized that the term is problematic: “Actually, the term ‘qualitative research’ is confusing because it can mean different things to different people” (Strauss and Corbin 1998 :10–11). Hammersley has discussed the possibility of addressing the problem, but states that “the task of providing an account of the distinctive features of qualitative research is far from straightforward” ( 2013 :2). This confusion, as he has recently further argued (Hammersley 2018 ), is also salient in relation to ethnography where different philosophical and methodological approaches lead to a lack of agreement about what it means.

Others (e.g. Hammersley 2018 ; Fine and Hancock 2017 ) have also identified the treat to qualitative research that comes from external forces, seen from the point of view of “qualitative research.” This threat can be further divided into that which comes from inside academia, such as the critique voiced by “quantitative research” and outside of academia, including, for example, New Public Management. Hammersley ( 2018 ), zooming in on one type of qualitative research, ethnography, has argued that it is under treat. Similarly to Fine ( 2003 ), and before him Gans ( 1999 ), he writes that ethnography’ has acquired a range of meanings, and comes in many different versions, these often reflecting sharply divergent epistemological orientations. And already more than twenty years ago while reviewing Denzin and Lincoln’ s Handbook of Qualitative Methods Fine argued:

While this increasing centrality [of qualitative research] might lead one to believe that consensual standards have developed, this belief would be misleading. As the methodology becomes more widely accepted, querulous challengers have raised fundamental questions that collectively have undercut the traditional models of how qualitative research is to be fashioned and presented (1995:417).

According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” ( 2018 :1). He lists five external treats: (1) that social research must be accountable and able to show its impact on society; (2) the current emphasis on “big data” and the emphasis on quantitative data and evidence; (3) the labor market pressure in academia that leaves less time for fieldwork (see also Fine and Hancock 2017 ); (4) problems of access to fields; and (5) the increased ethical scrutiny of projects, to which ethnography is particularly exposed. Hammersley discusses some more or less insufficient existing definitions of ethnography.

The current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.

Towards a Definition of Qualitative Research

Seen in an historical light, what is today called qualitative, or sometimes ethnographic, interpretative research – or a number of other terms – has more or less always existed. At the time the founders of sociology – Simmel, Weber, Durkheim and, before them, Marx – were writing, and during the era of the Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods (cf. Swedberg 1990 ), we can at least speak of qualitative forerunners.

Perhaps the most extended discussion of what later became known as qualitative methods in a classic work is Bronisław Malinowski’s ( 1922 ) Argonauts in the Western Pacific , although even this study does not explicitly address the meaning of “qualitative.” In Weber’s ([1921–-22] 1978) work we find a tension between scientific explanations that are based on observation and quantification and interpretative research (see also Lazarsfeld and Barton 1982 ).

If we look through major sociology journals like the American Sociological Review , American Journal of Sociology , or Social Forces we will not find the term qualitative sociology before the 1970s. And certainly before then much of what we consider qualitative classics in sociology, like Becker’ study ( 1963 ), had already been produced. Indeed, the Chicago School often combined qualitative and quantitative data within the same study (Fine 1995 ). Our point being that before a disciplinary self-awareness the term quantitative preceded qualitative, and the articulation of the former was a political move to claim scientific status (Denzin and Lincoln 2005 ). In the US the World War II seem to have sparked a critique of sociological work, including “qualitative work,” that did not follow the scientific canon (Rawls 2018 ), which was underpinned by a scientifically oriented and value free philosophy of science. As a result the attempts and practice of integrating qualitative and quantitative sociology at Chicago lost ground to sociology that was more oriented to surveys and quantitative work at Columbia under Merton-Lazarsfeld. The quantitative tradition was also able to present textbooks (Lundberg 1951 ) that facilitated the use this approach and its “methods.” The practices of the qualitative tradition, by and large, remained tacit or was part of the mentoring transferred from the renowned masters to their students.

This glimpse into history leads us back to the lack of a coherent account condensed in a definition of qualitative research. Many of the attempts to define the term do not meet the requirements of a proper definition: A definition should be clear, avoid tautology, demarcate its domain in relation to the environment, and ideally only use words in its definiens that themselves are not in need of definition (Hempel 1966 ). A definition can enhance precision and thus clarity by identifying the core of the phenomenon. Preferably, a definition should be short. The typical definition we have found, however, is an ostensive definition, which indicates what qualitative research is about without informing us about what it actually is :

Qualitative research is multimethod in focus, involving an interpretative, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives. (Denzin and Lincoln 2005 :2)

Flick claims that the label “qualitative research” is indeed used as an umbrella for a number of approaches ( 2007 :2–4; 2002 :6), and it is not difficult to identify research fitting this designation. Moreover, whatever it is, it has grown dramatically over the past five decades. In addition, courses have been developed, methods have flourished, arguments about its future have been advanced (for example, Denzin and Lincoln 1994) and criticized (for example, Snow and Morrill 1995 ), and dedicated journals and books have mushroomed. Most social scientists have a clear idea of research and how it differs from journalism, politics and other activities. But the question of what is qualitative in qualitative research is either eluded or eschewed.

We maintain that this lacuna hinders systematic knowledge production based on qualitative research. Paul Lazarsfeld noted the lack of “codification” as early as 1955 when he reviewed 100 qualitative studies in order to offer a codification of the practices (Lazarsfeld and Barton 1982 :239). Since then many texts on “qualitative research” and its methods have been published, including recent attempts (Goertz and Mahoney 2012 ) similar to Lazarsfeld’s. These studies have tried to extract what is qualitative by looking at the large number of empirical “qualitative” studies. Our novel strategy complements these endeavors by taking another approach and looking at the attempts to codify these practices in the form of a definition, as well as to a minor extent take Becker’s study as an exemplar of what qualitative researchers actually do, and what the characteristic of being ‘qualitative’ denotes and implies. We claim that qualitative researchers, if there is such a thing as “qualitative research,” should be able to codify their practices in a condensed, yet general way expressed in language.

Lingering problems of “generalizability” and “how many cases do I need” (Small 2009 ) are blocking advancement – in this line of work qualitative approaches are said to differ considerably from quantitative ones, while some of the former unsuccessfully mimic principles related to the latter (Small 2009 ). Additionally, quantitative researchers sometimes unfairly criticize the first based on their own quality criteria. Scholars like Goertz and Mahoney ( 2012 ) have successfully focused on the different norms and practices beyond what they argue are essentially two different cultures: those working with either qualitative or quantitative methods. Instead, similarly to Becker ( 2017 ) who has recently questioned the usefulness of the distinction between qualitative and quantitative research, we focus on similarities.

The current situation also impedes both students and researchers in focusing their studies and understanding each other’s work (Lazarsfeld and Barton 1982 :239). A third consequence is providing an opening for critiques by scholars operating within different traditions (Valsiner 2000 :101). A fourth issue is that the “implicit use of methods in qualitative research makes the field far less standardized than the quantitative paradigm” (Goertz and Mahoney 2012 :9). Relatedly, the National Science Foundation in the US organized two workshops in 2004 and 2005 to address the scientific foundations of qualitative research involving strategies to improve it and to develop standards of evaluation in qualitative research. However, a specific focus on its distinguishing feature of being “qualitative” while being implicitly acknowledged, was discussed only briefly (for example, Best 2004 ).

In 2014 a theme issue was published in this journal on “Methods, Materials, and Meanings: Designing Cultural Analysis,” discussing central issues in (cultural) qualitative research (Berezin 2014 ; Biernacki 2014 ; Glaeser 2014 ; Lamont and Swidler 2014 ; Spillman 2014). We agree with many of the arguments put forward, such as the risk of methodological tribalism, and that we should not waste energy on debating methods separated from research questions. Nonetheless, a clarification of the relation to what is called “quantitative research” is of outmost importance to avoid misunderstandings and misguided debates between “qualitative” and “quantitative” researchers. Our strategy means that researchers, “qualitative” or “quantitative” they may be, in their actual practice may combine qualitative work and quantitative work.

In this article we accomplish three tasks. First, we systematically survey the literature for meanings of qualitative research by looking at how researchers have defined it. Drawing upon existing knowledge we find that the different meanings and ideas of qualitative research are not yet coherently integrated into one satisfactory definition. Next, we advance our contribution by offering a definition of qualitative research and illustrate its meaning and use partially by expanding on the brief example introduced earlier related to Becker’s work ( 1963 ). We offer a systematic analysis of central themes of what researchers consider to be the core of “qualitative,” regardless of style of work. These themes – which we summarize in terms of four keywords: distinction, process, closeness, improved understanding – constitute part of our literature review, in which each one appears, sometimes with others, but never all in the same definition. They serve as the foundation of our contribution. Our categories are overlapping. Their use is primarily to organize the large amount of definitions we have identified and analyzed, and not necessarily to draw a clear distinction between them. Finally, we continue the elaboration discussed above on the advantages of a clear definition of qualitative research.

In a hermeneutic fashion we propose that there is something meaningful that deserves to be labelled “qualitative research” (Gadamer 1990 ). To approach the question “What is qualitative in qualitative research?” we have surveyed the literature. In conducting our survey we first traced the word’s etymology in dictionaries, encyclopedias, handbooks of the social sciences and of methods and textbooks, mainly in English, which is common to methodology courses. It should be noted that we have zoomed in on sociology and its literature. This discipline has been the site of the largest debate and development of methods that can be called “qualitative,” which suggests that this field should be examined in great detail.

In an ideal situation we should expect that one good definition, or at least some common ideas, would have emerged over the years. This common core of qualitative research should be so accepted that it would appear in at least some textbooks. Since this is not what we found, we decided to pursue an inductive approach to capture maximal variation in the field of qualitative research; we searched in a selection of handbooks, textbooks, book chapters, and books, to which we added the analysis of journal articles. Our sample comprises a total of 89 references.

In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: qualitative (which was always included), definition, empirical, research, methodology, studies, fieldwork, interview and observation .

As a second phase of our research we searched within nine major sociological journals ( American Journal of Sociology , Sociological Theory , American Sociological Review , Contemporary Sociology , Sociological Forum , Sociological Theory , Qualitative Research , Qualitative Sociology and Qualitative Sociology Review ) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.

Lastly we picked two additional journals, Qualitative Research and Qualitative Sociology , in which we could expect to find texts addressing the notion of “qualitative.” From Qualitative Research we chose Volume 14, Issue 6, December 2014, and from Qualitative Sociology we chose Volume 36, Issue 2, June 2017. Within each of these we selected the first article; then we picked the second article of three prior issues. Again we went back another three issues and investigated article number three. Finally we went back another three issues and perused article number four. This selection criteria was used to get a manageable sample for the analysis.

The coding process of the 89 references we gathered in our selected review began soon after the first round of material was gathered, and we reduced the complexity created by our maximum variation sampling (Snow and Anderson 1993 :22) to four different categories within which questions on the nature and properties of qualitative research were discussed. We call them: Qualitative and Quantitative Research, Qualitative Research, Fieldwork, and Grounded Theory. This – which may appear as an illogical grouping – merely reflects the “context” in which the matter of “qualitative” is discussed. If the selection process of the material – books and articles – was informed by pre-knowledge, we used an inductive strategy to code the material. When studying our material, we identified four central notions related to “qualitative” that appear in various combinations in the literature which indicate what is the core of qualitative research. We have labeled them: “distinctions”, “process,” “closeness,” and “improved understanding.” During the research process the categories and notions were improved, refined, changed, and reordered. The coding ended when a sense of saturation in the material arose. In the presentation below all quotations and references come from our empirical material of texts on qualitative research.

Analysis – What is Qualitative Research?

In this section we describe the four categories we identified in the coding, how they differently discuss qualitative research, as well as their overall content. Some salient quotations are selected to represent the type of text sorted under each of the four categories. What we present are examples from the literature.

Qualitative and Quantitative

This analytic category comprises quotations comparing qualitative and quantitative research, a distinction that is frequently used (Brown 2010 :231); in effect this is a conceptual pair that structures the discussion and that may be associated with opposing interests. While the general goal of quantitative and qualitative research is the same – to understand the world better – their methodologies and focus in certain respects differ substantially (Becker 1966 :55). Quantity refers to that property of something that can be determined by measurement. In a dictionary of Statistics and Methodology we find that “(a) When referring to *variables, ‘qualitative’ is another term for *categorical or *nominal. (b) When speaking of kinds of research, ‘qualitative’ refers to studies of subjects that are hard to quantify, such as art history. Qualitative research tends to be a residual category for almost any kind of non-quantitative research” (Stiles 1998:183). But it should be obvious that one could employ a quantitative approach when studying, for example, art history.

The same dictionary states that quantitative is “said of variables or research that can be handled numerically, usually (too sharply) contrasted with *qualitative variables and research” (Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read:

Qualitative Analysis. For methods of obtaining, analyzing, and describing data, see [the various entries:] CONTENT ANALYSIS; COUNTED DATA; EVALUATION RESEARCH, FIELD WORK; GRAPHIC PRESENTATION; HISTORIOGRAPHY, especially the article on THE RHETORIC OF HISTORY; INTERVIEWING; OBSERVATION; PERSONALITY MEASUREMENT; PROJECTIVE METHODS; PSYCHOANALYSIS, article on EXPERIMENTAL METHODS; SURVEY ANALYSIS, TABULAR PRESENTATION; TYPOLOGIES. (Vol. 13:225)

Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists” (Alford 1998 :12). Qualitative research uses a variety of methods, such as intensive interviews or in-depth analysis of historical materials, and it is concerned with a comprehensive account of some event or unit (King et al. 1994 :4). Like quantitative research it can be utilized to study a variety of issues, but it tends to focus on meanings and motivations that underlie cultural symbols, personal experiences, phenomena and detailed understanding of processes in the social world. In short, qualitative research centers on understanding processes, experiences, and the meanings people assign to things (Kalof et al. 2008 :79).

Others simply say that qualitative methods are inherently unscientific (Jovanović 2011 :19). Hood, for instance, argues that words are intrinsically less precise than numbers, and that they are therefore more prone to subjective analysis, leading to biased results (Hood 2006 :219). Qualitative methodologies have raised concerns over the limitations of quantitative templates (Brady et al. 2004 :4). Scholars such as King et al. ( 1994 ), for instance, argue that non-statistical research can produce more reliable results if researchers pay attention to the rules of scientific inference commonly stated in quantitative research. Also, researchers such as Becker ( 1966 :59; 1970 :42–43) have asserted that, if conducted properly, qualitative research and in particular ethnographic field methods, can lead to more accurate results than quantitative studies, in particular, survey research and laboratory experiments.

Some researchers, such as Kalof, Dan, and Dietz ( 2008 :79) claim that the boundaries between the two approaches are becoming blurred, and Small ( 2009 ) argues that currently much qualitative research (especially in North America) tries unsuccessfully and unnecessarily to emulate quantitative standards. For others, qualitative research tends to be more humanistic and discursive (King et al. 1994 :4). Ragin ( 1994 ), and similarly also Becker, ( 1996 :53), Marchel and Owens ( 2007 :303) think that the main distinction between the two styles is overstated and does not rest on the simple dichotomy of “numbers versus words” (Ragin 1994 :xii). Some claim that quantitative data can be utilized to discover associations, but in order to unveil cause and effect a complex research design involving the use of qualitative approaches needs to be devised (Gilbert 2009 :35). Consequently, qualitative data are useful for understanding the nuances lying beyond those processes as they unfold (Gilbert 2009 :35). Others contend that qualitative research is particularly well suited both to identify causality and to uncover fine descriptive distinctions (Fine and Hallett 2014 ; Lichterman and Isaac Reed 2014 ; Katz 2015 ).

There are other ways to separate these two traditions, including normative statements about what qualitative research should be (that is, better or worse than quantitative approaches, concerned with scientific approaches to societal change or vice versa; Snow and Morrill 1995 ; Denzin and Lincoln 2005 ), or whether it should develop falsifiable statements; Best 2004 ).

We propose that quantitative research is largely concerned with pre-determined variables (Small 2008 ); the analysis concerns the relations between variables. These categories are primarily not questioned in the study, only their frequency or degree, or the correlations between them (cf. Franzosi 2016 ). If a researcher studies wage differences between women and men, he or she works with given categories: x number of men are compared with y number of women, with a certain wage attributed to each person. The idea is not to move beyond the given categories of wage, men and women; they are the starting point as well as the end point, and undergo no “qualitative change.” Qualitative research, in contrast, investigates relations between categories that are themselves subject to change in the research process. Returning to Becker’s study ( 1963 ), we see that he questioned pre-dispositional theories of deviant behavior working with pre-determined variables such as an individual’s combination of personal qualities or emotional problems. His take, in contrast, was to understand marijuana consumption by developing “variables” as part of the investigation. Thereby he presented new variables, or as we would say today, theoretical concepts, but which are grounded in the empirical material.

Qualitative Research

This category contains quotations that refer to descriptions of qualitative research without making comparisons with quantitative research. Researchers such as Denzin and Lincoln, who have written a series of influential handbooks on qualitative methods (1994; Denzin and Lincoln 2003 ; 2005 ), citing Nelson et al. (1992:4), argue that because qualitative research is “interdisciplinary, transdisciplinary, and sometimes counterdisciplinary” it is difficult to derive one single definition of it (Jovanović 2011 :3). According to them, in fact, “the field” is “many things at the same time,” involving contradictions, tensions over its focus, methods, and how to derive interpretations and findings ( 2003 : 11). Similarly, others, such as Flick ( 2007 :ix–x) contend that agreeing on an accepted definition has increasingly become problematic, and that qualitative research has possibly matured different identities. However, Best holds that “the proliferation of many sorts of activities under the label of qualitative sociology threatens to confuse our discussions” ( 2004 :54). Atkinson’s position is more definite: “the current state of qualitative research and research methods is confused” ( 2005 :3–4).

Qualitative research is about interpretation (Blumer 1969 ; Strauss and Corbin 1998 ; Denzin and Lincoln 2003 ), or Verstehen [understanding] (Frankfort-Nachmias and Nachmias 1996 ). It is “multi-method,” involving the collection and use of a variety of empirical materials (Denzin and Lincoln 1998; Silverman 2013 ) and approaches (Silverman 2005 ; Flick 2007 ). It focuses not only on the objective nature of behavior but also on its subjective meanings: individuals’ own accounts of their attitudes, motivations, behavior (McIntyre 2005 :127; Creswell 2009 ), events and situations (Bryman 1989) – what people say and do in specific places and institutions (Goodwin and Horowitz 2002 :35–36) in social and temporal contexts (Morrill and Fine 1997). For this reason, following Weber ([1921-22] 1978), it can be described as an interpretative science (McIntyre 2005 :127). But could quantitative research also be concerned with these questions? Also, as pointed out below, does all qualitative research focus on subjective meaning, as some scholars suggest?

Others also distinguish qualitative research by claiming that it collects data using a naturalistic approach (Denzin and Lincoln 2005 :2; Creswell 2009 ), focusing on the meaning actors ascribe to their actions. But again, does all qualitative research need to be collected in situ? And does qualitative research have to be inherently concerned with meaning? Flick ( 2007 ), referring to Denzin and Lincoln ( 2005 ), mentions conversation analysis as an example of qualitative research that is not concerned with the meanings people bring to a situation, but rather with the formal organization of talk. Still others, such as Ragin ( 1994 :85), note that qualitative research is often (especially early on in the project, we would add) less structured than other kinds of social research – a characteristic connected to its flexibility and that can lead both to potentially better, but also worse results. But is this not a feature of this type of research, rather than a defining description of its essence? Wouldn’t this comment also apply, albeit to varying degrees, to quantitative research?

In addition, Strauss ( 2003 ), along with others, such as Alvesson and Kärreman ( 2011 :10–76), argue that qualitative researchers struggle to capture and represent complex phenomena partially because they tend to collect a large amount of data. While his analysis is correct at some points – “It is necessary to do detailed, intensive, microscopic examination of the data in order to bring out the amazing complexity of what lies in, behind, and beyond those data” (Strauss 2003 :10) – much of his analysis concerns the supposed focus of qualitative research and its challenges, rather than exactly what it is about. But even in this instance we would make a weak case arguing that these are strictly the defining features of qualitative research. Some researchers seem to focus on the approach or the methods used, or even on the way material is analyzed. Several researchers stress the naturalistic assumption of investigating the world, suggesting that meaning and interpretation appear to be a core matter of qualitative research.

We can also see that in this category there is no consensus about specific qualitative methods nor about qualitative data. Many emphasize interpretation, but quantitative research, too, involves interpretation; the results of a regression analysis, for example, certainly have to be interpreted, and the form of meta-analysis that factor analysis provides indeed requires interpretation However, there is no interpretation of quantitative raw data, i.e., numbers in tables. One common thread is that qualitative researchers have to get to grips with their data in order to understand what is being studied in great detail, irrespective of the type of empirical material that is being analyzed. This observation is connected to the fact that qualitative researchers routinely make several adjustments of focus and research design as their studies progress, in many cases until the very end of the project (Kalof et al. 2008 ). If you, like Becker, do not start out with a detailed theory, adjustments such as the emergence and refinement of research questions will occur during the research process. We have thus found a number of useful reflections about qualitative research scattered across different sources, but none of them effectively describe the defining characteristics of this approach.

Although qualitative research does not appear to be defined in terms of a specific method, it is certainly common that fieldwork, i.e., research that entails that the researcher spends considerable time in the field that is studied and use the knowledge gained as data, is seen as emblematic of or even identical to qualitative research. But because we understand that fieldwork tends to focus primarily on the collection and analysis of qualitative data, we expected to find within it discussions on the meaning of “qualitative.” But, again, this was not the case.

Instead, we found material on the history of this approach (for example, Frankfort-Nachmias and Nachmias 1996 ; Atkinson et al. 2001), including how it has changed; for example, by adopting a more self-reflexive practice (Heyl 2001), as well as the different nomenclature that has been adopted, such as fieldwork, ethnography, qualitative research, naturalistic research, participant observation and so on (for example, Lofland et al. 2006 ; Gans 1999 ).

We retrieved definitions of ethnography, such as “the study of people acting in the natural courses of their daily lives,” involving a “resocialization of the researcher” (Emerson 1988 :1) through intense immersion in others’ social worlds (see also examples in Hammersley 2018 ). This may be accomplished by direct observation and also participation (Neuman 2007 :276), although others, such as Denzin ( 1970 :185), have long recognized other types of observation, including non-participant (“fly on the wall”). In this category we have also isolated claims and opposing views, arguing that this type of research is distinguished primarily by where it is conducted (natural settings) (Hughes 1971:496), and how it is carried out (a variety of methods are applied) or, for some most importantly, by involving an active, empathetic immersion in those being studied (Emerson 1988 :2). We also retrieved descriptions of the goals it attends in relation to how it is taught (understanding subjective meanings of the people studied, primarily develop theory, or contribute to social change) (see for example, Corte and Irwin 2017 ; Frankfort-Nachmias and Nachmias 1996 :281; Trier-Bieniek 2012 :639) by collecting the richest possible data (Lofland et al. 2006 ) to derive “thick descriptions” (Geertz 1973 ), and/or to aim at theoretical statements of general scope and applicability (for example, Emerson 1988 ; Fine 2003 ). We have identified guidelines on how to evaluate it (for example Becker 1996 ; Lamont 2004 ) and have retrieved instructions on how it should be conducted (for example, Lofland et al. 2006 ). For instance, analysis should take place while the data gathering unfolds (Emerson 1988 ; Hammersley and Atkinson 2007 ; Lofland et al. 2006 ), observations should be of long duration (Becker 1970 :54; Goffman 1989 ), and data should be of high quantity (Becker 1970 :52–53), as well as other questionable distinctions between fieldwork and other methods:

Field studies differ from other methods of research in that the researcher performs the task of selecting topics, decides what questions to ask, and forges interest in the course of the research itself . This is in sharp contrast to many ‘theory-driven’ and ‘hypothesis-testing’ methods. (Lofland and Lofland 1995 :5)

But could not, for example, a strictly interview-based study be carried out with the same amount of flexibility, such as sequential interviewing (for example, Small 2009 )? Once again, are quantitative approaches really as inflexible as some qualitative researchers think? Moreover, this category stresses the role of the actors’ meaning, which requires knowledge and close interaction with people, their practices and their lifeworld.

It is clear that field studies – which are seen by some as the “gold standard” of qualitative research – are nonetheless only one way of doing qualitative research. There are other methods, but it is not clear why some are more qualitative than others, or why they are better or worse. Fieldwork is characterized by interaction with the field (the material) and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.

Grounded Theory

Another major category we identified in our sample is Grounded Theory. We found descriptions of it most clearly in Glaser and Strauss’ ([1967] 2010 ) original articulation, Strauss and Corbin ( 1998 ) and Charmaz ( 2006 ), as well as many other accounts of what it is for: generating and testing theory (Strauss 2003 :xi). We identified explanations of how this task can be accomplished – such as through two main procedures: constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” (for example, Strauss and Corbin 1998 :1). We also read descriptions of its main traits, what it entails and fosters – for instance, an exceptional flexibility, an inductive approach (Strauss and Corbin 1998 :31–33; 1990; Esterberg 2002 :7), an ability to step back and critically analyze situations, recognize tendencies towards bias, think abstractly and be open to criticism, enhance sensitivity towards the words and actions of respondents, and develop a sense of absorption and devotion to the research process (Strauss and Corbin 1998 :5–6). Accordingly, we identified discussions of the value of triangulating different methods (both using and not using grounded theory), including quantitative ones, and theories to achieve theoretical development (most comprehensively in Denzin 1970 ; Strauss and Corbin 1998 ; Timmermans and Tavory 2012 ). We have also located arguments about how its practice helps to systematize data collection, analysis and presentation of results (Glaser and Strauss [1967] 2010 :16).

Grounded theory offers a systematic approach which requires researchers to get close to the field; closeness is a requirement of identifying questions and developing new concepts or making further distinctions with regard to old concepts. In contrast to other qualitative approaches, grounded theory emphasizes the detailed coding process, and the numerous fine-tuned distinctions that the researcher makes during the process. Within this category, too, we could not find a satisfying discussion of the meaning of qualitative research.

Defining Qualitative Research

In sum, our analysis shows that some notions reappear in the discussion of qualitative research, such as understanding, interpretation, “getting close” and making distinctions. These notions capture aspects of what we think is “qualitative.” However, a comprehensive definition that is useful and that can further develop the field is lacking, and not even a clear picture of its essential elements appears. In other words no definition emerges from our data, and in our research process we have moved back and forth between our empirical data and the attempt to present a definition. Our concrete strategy, as stated above, is to relate qualitative and quantitative research, or more specifically, qualitative and quantitative work. We use an ideal-typical notion of quantitative research which relies on taken for granted and numbered variables. This means that the data consists of variables on different scales, such as ordinal, but frequently ratio and absolute scales, and the representation of the numbers to the variables, i.e. the justification of the assignment of numbers to object or phenomenon, are not questioned, though the validity may be questioned. In this section we return to the notion of quality and try to clarify it while presenting our contribution.

Broadly, research refers to the activity performed by people trained to obtain knowledge through systematic procedures. Notions such as “objectivity” and “reflexivity,” “systematic,” “theory,” “evidence” and “openness” are here taken for granted in any type of research. Next, building on our empirical analysis we explain the four notions that we have identified as central to qualitative work: distinctions, process, closeness, and improved understanding. In discussing them, ultimately in relation to one another, we make their meaning even more precise. Our idea, in short, is that only when these ideas that we present separately for analytic purposes are brought together can we speak of qualitative research.

Distinctions

We believe that the possibility of making new distinctions is one the defining characteristics of qualitative research. It clearly sets it apart from quantitative analysis which works with taken-for-granted variables, albeit as mentioned, meta-analyses, for example, factor analysis may result in new variables. “Quality” refers essentially to distinctions, as already pointed out by Aristotle. He discusses the term “qualitative” commenting: “By a quality I mean that in virtue of which things are said to be qualified somehow” (Aristotle 1984:14). Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required (cf. Habermas [1981] 1987 ; Davidsson [ 1988 ] 2001) to identify what is new and relevant scientific knowledge. Relatedly, Ragin alludes to the idea of new and useful knowledge at a more concrete level: “Qualitative methods are appropriate for in-depth examination of cases because they aid the identification of key features of cases. Most qualitative methods enhance data” (1994:79). When Becker ( 1963 ) studied deviant behavior and investigated how people became marihuana smokers, he made distinctions between the ways in which people learned how to smoke. This is a classic example of how the strategy of “getting close” to the material, for example the text, people or pictures that are subject to analysis, may enable researchers to obtain deeper insight and new knowledge by making distinctions – in this instance on the initial notion of learning how to smoke. Others have stressed the making of distinctions in relation to coding or theorizing. Emerson et al. ( 1995 ), for example, hold that “qualitative coding is a way of opening up avenues of inquiry,” meaning that the researcher identifies and develops concepts and analytic insights through close examination of and reflection on data (Emerson et al. 1995 :151). Goodwin and Horowitz highlight making distinctions in relation to theory-building writing: “Close engagement with their cases typically requires qualitative researchers to adapt existing theories or to make new conceptual distinctions or theoretical arguments to accommodate new data” ( 2002 : 37). In the ideal-typical quantitative research only existing and so to speak, given, variables would be used. If this is the case no new distinction are made. But, would not also many “quantitative” researchers make new distinctions?

Process does not merely suggest that research takes time. It mainly implies that qualitative new knowledge results from a process that involves several phases, and above all iteration. Qualitative research is about oscillation between theory and evidence, analysis and generating material, between first- and second -order constructs (Schütz 1962 :59), between getting in contact with something, finding sources, becoming deeply familiar with a topic, and then distilling and communicating some of its essential features. The main point is that the categories that the researcher uses, and perhaps takes for granted at the beginning of the research process, usually undergo qualitative changes resulting from what is found. Becker describes how he tested hypotheses and let the jargon of the users develop into theoretical concepts. This happens over time while the study is being conducted, exemplifying what we mean by process.

In the research process, a pilot-study may be used to get a first glance of, for example, the field, how to approach it, and what methods can be used, after which the method and theory are chosen or refined before the main study begins. Thus, the empirical material is often central from the start of the project and frequently leads to adjustments by the researcher. Likewise, during the main study categories are not fixed; the empirical material is seen in light of the theory used, but it is also given the opportunity to kick back, thereby resisting attempts to apply theoretical straightjackets (Becker 1970 :43). In this process, coding and analysis are interwoven, and thus are often important steps for getting closer to the phenomenon and deciding what to focus on next. Becker began his research by interviewing musicians close to him, then asking them to refer him to other musicians, and later on doubling his original sample of about 25 to include individuals in other professions (Becker 1973:46). Additionally, he made use of some participant observation, documents, and interviews with opiate users made available to him by colleagues. As his inductive theory of deviance evolved, Becker expanded his sample in order to fine tune it, and test the accuracy and generality of his hypotheses. In addition, he introduced a negative case and discussed the null hypothesis ( 1963 :44). His phasic career model is thus based on a research design that embraces processual work. Typically, process means to move between “theory” and “material” but also to deal with negative cases, and Becker ( 1998 ) describes how discovering these negative cases impacted his research design and ultimately its findings.

Obviously, all research is process-oriented to some degree. The point is that the ideal-typical quantitative process does not imply change of the data, and iteration between data, evidence, hypotheses, empirical work, and theory. The data, quantified variables, are, in most cases fixed. Merging of data, which of course can be done in a quantitative research process, does not mean new data. New hypotheses are frequently tested, but the “raw data is often the “the same.” Obviously, over time new datasets are made available and put into use.

Another characteristic that is emphasized in our sample is that qualitative researchers – and in particular ethnographers – can, or as Goffman put it, ought to ( 1989 ), get closer to the phenomenon being studied and their data than quantitative researchers (for example, Silverman 2009 :85). Put differently, essentially because of their methods qualitative researchers get into direct close contact with those being investigated and/or the material, such as texts, being analyzed. Becker started out his interview study, as we noted, by talking to those he knew in the field of music to get closer to the phenomenon he was studying. By conducting interviews he got even closer. Had he done more observations, he would undoubtedly have got even closer to the field.

Additionally, ethnographers’ design enables researchers to follow the field over time, and the research they do is almost by definition longitudinal, though the time in the field is studied obviously differs between studies. The general characteristic of closeness over time maximizes the chances of unexpected events, new data (related, for example, to archival research as additional sources, and for ethnography for situations not necessarily previously thought of as instrumental – what Mannay and Morgan ( 2015 ) term the “waiting field”), serendipity (Merton and Barber 2004 ; Åkerström 2013 ), and possibly reactivity, as well as the opportunity to observe disrupted patterns that translate into exemplars of negative cases. Two classic examples of this are Becker’s finding of what medical students call “crocks” (Becker et al. 1961 :317), and Geertz’s ( 1973 ) study of “deep play” in Balinese society.

By getting and staying so close to their data – be it pictures, text or humans interacting (Becker was himself a musician) – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often (but certainly not always), and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly (Fine 2003 ; Becker 1970 ). This testing nonetheless often leads to new directions for the research. Becker, for example, says that he was initially reading psychological theories, but when facing the data he develops a theory that looks at, you may say, everything but psychological dispositions to explain the use of marihuana. Especially researchers involved with ethnographic methods have a fairly unique opportunity to dig up and then test (in a circular, continuous and temporal way) new research questions and findings as the research progresses, and thereby to derive previously unimagined and uncharted distinctions by getting closer to the phenomenon under study.

Let us stress that getting close is by no means restricted to ethnography. The notion of hermeneutic circle and hermeneutics as a general way of understanding implies that we must get close to the details in order to get the big picture. This also means that qualitative researchers can literally also make use of details of pictures as evidence (cf. Harper 2002). Thus, researchers may get closer both when generating the material or when analyzing it.

Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables (Franzosi 2016 :138). The data may originally have been “qualitative,” but once reduced to numbers there can only be a type of “hermeneutics” about what the number may stand for. The numbers themselves, however, are non-ambiguous. Thus, in quantitative research, interpretation, if done, is not about the data itself—the numbers—but what the numbers stand for. It follows that the interpretation is essentially done in a more “speculative” mode without direct empirical evidence (cf. Becker 2017 ).

Improved Understanding

While distinction, process and getting closer refer to the qualitative work of the researcher, improved understanding refers to its conditions and outcome of this work. Understanding cuts deeper than explanation, which to some may mean a causally verified correlation between variables. The notion of explanation presupposes the notion of understanding since explanation does not include an idea of how knowledge is gained (Manicas 2006 : 15). Understanding, we argue, is the core concept of what we call the outcome of the process when research has made use of all the other elements that were integrated in the research. Understanding, then, has a special status in qualitative research since it refers both to the conditions of knowledge and the outcome of the process. Understanding can to some extent be seen as the condition of explanation and occurs in a process of interpretation, which naturally refers to meaning (Gadamer 1990 ). It is fundamentally connected to knowing, and to the knowing of how to do things (Heidegger [1927] 2001 ). Conceptually the term hermeneutics is used to account for this process. Heidegger ties hermeneutics to human being and not possible to separate from the understanding of being ( 1988 ). Here we use it in a broader sense, and more connected to method in general (cf. Seiffert 1992 ). The abovementioned aspects – for example, “objectivity” and “reflexivity” – of the approach are conditions of scientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something (Heidegger [1927] 2001 ; Gadamer 1990 :368–384). We propose that this iterative process in which the process of understanding occurs is characteristic of qualitative research.

Improved understanding means that we obtain scientific knowledge of something that we as a scholarly community did not know before, or that we get to know something better. It means that we understand more about how parts are related to one another, and to other things we already understand (see also Fine and Hallett 2014 ). Understanding is an important condition for qualitative research. It is not enough to identify correlations, make distinctions, and work in a process in which one gets close to the field or phenomena. Understanding is accomplished when the elements are integrated in an iterative process.

It is, moreover, possible to understand many things, and researchers, just like children, may come to understand new things every day as they engage with the world. This subjective condition of understanding – namely, that a person gains a better understanding of something –is easily met. To be qualified as “scientific,” the understanding must be general and useful to many; it must be public. But even this generally accessible understanding is not enough in order to speak of “scientific understanding.” Though we as a collective can increase understanding of everything in virtually all potential directions as a result also of qualitative work, we refrain from this “objective” way of understanding, which has no means of discriminating between what we gain in understanding. Scientific understanding means that it is deemed relevant from the scientific horizon (compare Schütz 1962 : 35–38, 46, 63), and that it rests on the pre-understanding that the scientists have and must have in order to understand. In other words, the understanding gained must be deemed useful by other researchers, so that they can build on it. We thus see understanding from a pragmatic, rather than a subjective or objective perspective. Improved understanding is related to the question(s) at hand. Understanding, in order to represent an improvement, must be an improvement in relation to the existing body of knowledge of the scientific community (James [ 1907 ] 1955). Scientific understanding is, by definition, collective, as expressed in Weber’s famous note on objectivity, namely that scientific work aims at truths “which … can claim, even for a Chinese, the validity appropriate to an empirical analysis” ([1904] 1949 :59). By qualifying “improved understanding” we argue that it is a general defining characteristic of qualitative research. Becker‘s ( 1966 ) study and other research of deviant behavior increased our understanding of the social learning processes of how individuals start a behavior. And it also added new knowledge about the labeling of deviant behavior as a social process. Few studies, of course, make the same large contribution as Becker’s, but are nonetheless qualitative research.

Understanding in the phenomenological sense, which is a hallmark of qualitative research, we argue, requires meaning and this meaning is derived from the context, and above all the data being analyzed. The ideal-typical quantitative research operates with given variables with different numbers. This type of material is not enough to establish meaning at the level that truly justifies understanding. In other words, many social science explanations offer ideas about correlations or even causal relations, but this does not mean that the meaning at the level of the data analyzed, is understood. This leads us to say that there are indeed many explanations that meet the criteria of understanding, for example the explanation of how one becomes a marihuana smoker presented by Becker. However, we may also understand a phenomenon without explaining it, and we may have potential explanations, or better correlations, that are not really understood.

We may speak more generally of quantitative research and its data to clarify what we see as an important distinction. The “raw data” that quantitative research—as an idealtypical activity, refers to is not available for further analysis; the numbers, once created, are not to be questioned (Franzosi 2016 : 138). If the researcher is to do “more” or “change” something, this will be done by conjectures based on theoretical knowledge or based on the researcher’s lifeworld. Both qualitative and quantitative research is based on the lifeworld, and all researchers use prejudices and pre-understanding in the research process. This idea is present in the works of Heidegger ( 2001 ) and Heisenberg (cited in Franzosi 2010 :619). Qualitative research, as we argued, involves the interaction and questioning of concepts (theory), data, and evidence.

Ragin ( 2004 :22) points out that “a good definition of qualitative research should be inclusive and should emphasize its key strengths and features, not what it lacks (for example, the use of sophisticated quantitative techniques).” We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. Qualitative research, as defined here, is consequently a combination of two criteria: (i) how to do things –namely, generating and analyzing empirical material, in an iterative process in which one gets closer by making distinctions, and (ii) the outcome –improved understanding novel to the scholarly community. Is our definition applicable to our own study? In this study we have closely read the empirical material that we generated, and the novel distinction of the notion “qualitative research” is the outcome of an iterative process in which both deduction and induction were involved, in which we identified the categories that we analyzed. We thus claim to meet the first criteria, “how to do things.” The second criteria cannot be judged but in a partial way by us, namely that the “outcome” —in concrete form the definition-improves our understanding to others in the scientific community.

We have defined qualitative research, or qualitative scientific work, in relation to quantitative scientific work. Given this definition, qualitative research is about questioning the pre-given (taken for granted) variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.

We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables (Small 2008 ). Variables are epistemically fixed, but can vary in terms of dimensions, such as frequency or number. Age is an example; as a variable it can take on different numbers. In relation to quantitative research, qualitative research does not reduce its material to number and variables. If this is done the process of comes to a halt, the researcher gets more distanced from her data, and it makes it no longer possible to make new distinctions that increase our understanding. We have above discussed the components of our definition in relation to quantitative research. Our conclusion is that in the research that is called quantitative there are frequent and necessary qualitative elements.

Further, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands (see Goertz and Mahoney 2012 ). Our point is nonetheless that prejudices and preconceptions about researchers are unproductive, and that as other researchers have argued, differences may be exaggerated (e.g., Becker 1996 : 53, 2017 ; Marchel and Owens 2007 :303; Ragin 1994 ), and that a qualitative dimension is present in both kinds of work.

Several things follow from our findings. The most important result is the relation to quantitative research. In our analysis we have separated qualitative research from quantitative research. The point is not to label individual researchers, methods, projects, or works as either “quantitative” or “qualitative.” By analyzing, i.e., taking apart, the notions of quantitative and qualitative, we hope to have shown the elements of qualitative research. Our definition captures the elements, and how they, when combined in practice, generate understanding. As many of the quotations we have used suggest, one conclusion of our study holds that qualitative approaches are not inherently connected with a specific method. Put differently, none of the methods that are frequently labelled “qualitative,” such as interviews or participant observation, are inherently “qualitative.” What matters, given our definition, is whether one works qualitatively or quantitatively in the research process, until the results are produced. Consequently, our analysis also suggests that those researchers working with what in the literature and in jargon is often called “quantitative research” are almost bound to make use of what we have identified as qualitative elements in any research project. Our findings also suggest that many” quantitative” researchers, at least to some extent, are engaged with qualitative work, such as when research questions are developed, variables are constructed and combined, and hypotheses are formulated. Furthermore, a research project may hover between “qualitative” and “quantitative” or start out as “qualitative” and later move into a “quantitative” (a distinct strategy that is not similar to “mixed methods” or just simply combining induction and deduction). More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg 2017 ). Our results open up for an interaction not characterized by differences, but by different emphasis, and similarities.

Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi ( 2010 ) has discussed the relations between quantitative and qualitative approaches, and more specifically the relation between words and numbers. He analyzes texts and argues that scientific meaning cannot be reduced to numbers. Put differently, the meaning of the numbers is to be understood by what is taken for granted, and what is part of the lifeworld (Schütz 1962 ). Franzosi shows how one can go about using qualitative and quantitative methods and data to address scientific questions analyzing violence in Italy at the time when fascism was rising (1919–1922). Aspers ( 2006 ) studied the meaning of fashion photographers. He uses an empirical phenomenological approach, and establishes meaning at the level of actors. In a second step this meaning, and the different ideal-typical photographers constructed as a result of participant observation and interviews, are tested using quantitative data from a database; in the first phase to verify the different ideal-types, in the second phase to use these types to establish new knowledge about the types. In both of these cases—and more examples can be found—authors move from qualitative data and try to keep the meaning established when using the quantitative data.

A second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley 2007 ), to see whether new distinctions are made and whether this improves our understanding of what is researched, in addition to the evaluation of how the research was conducted. By making what is qualitative research explicit it becomes easier to communicate findings, and it is thereby much harder to fly under the radar with substandard research since there are standards of evaluation which make it easier to separate “good” from “not so good” qualitative research.

To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.

Åkerström, Malin. 2013. Curiosity and serendipity in qualitative research. Qualitative Sociology Review 9 (2): 10–18.

Google Scholar  

Alford, Robert R. 1998. The craft of inquiry. Theories, methods, evidence . Oxford: Oxford University Press.

Alvesson, Mats, and Dan Kärreman. 2011. Qualitative research and theory development. Mystery as method . London: SAGE Publications.

Book   Google Scholar  

Aspers, Patrik. 2006. Markets in Fashion, A Phenomenological Approach. London Routledge.

Atkinson, Paul. 2005. Qualitative research. Unity and diversity. Forum: Qualitative Social Research 6 (3): 1–15.

Becker, Howard S. 1963. Outsiders. Studies in the sociology of deviance . New York: The Free Press.

Becker, Howard S. 1966. Whose side are we on? Social Problems 14 (3): 239–247.

Article   Google Scholar  

Becker, Howard S. 1970. Sociological work. Method and substance . New Brunswick: Transaction Books.

Becker, Howard S. 1996. The epistemology of qualitative research. In Ethnography and human development. Context and meaning in social inquiry , ed. Jessor Richard, Colby Anne, and Richard A. Shweder, 53–71. Chicago: University of Chicago Press.

Becker, Howard S. 1998. Tricks of the trade. How to think about your research while you're doing it . Chicago: University of Chicago Press.

Becker, Howard S. 2017. Evidence . Chigaco: University of Chicago Press.

Becker, Howard, Blanche Geer, Everett Hughes, and Anselm Strauss. 1961. Boys in White, student culture in medical school . New Brunswick: Transaction Publishers.

Berezin, Mabel. 2014. How do we know what we mean? Epistemological dilemmas in cultural sociology. Qualitative Sociology 37 (2): 141–151.

Best, Joel. 2004. Defining qualitative research. In Workshop on Scientific Foundations of Qualitative Research , eds . Charles, Ragin, Joanne, Nagel, and Patricia White, 53-54. http://www.nsf.gov/pubs/2004/nsf04219/nsf04219.pdf .

Biernacki, Richard. 2014. Humanist interpretation versus coding text samples. Qualitative Sociology 37 (2): 173–188.

Blumer, Herbert. 1969. Symbolic interactionism: Perspective and method . Berkeley: University of California Press.

Brady, Henry, David Collier, and Jason Seawright. 2004. Refocusing the discussion of methodology. In Rethinking social inquiry. Diverse tools, shared standards , ed. Brady Henry and Collier David, 3–22. Lanham: Rowman and Littlefield.

Brown, Allison P. 2010. Qualitative method and compromise in applied social research. Qualitative Research 10 (2): 229–248.

Charmaz, Kathy. 2006. Constructing grounded theory . London: Sage.

Corte, Ugo, and Katherine Irwin. 2017. “The Form and Flow of Teaching Ethnographic Knowledge: Hands-on Approaches for Learning Epistemology” Teaching Sociology 45(3): 209-219.

Creswell, John W. 2009. Research design. Qualitative, quantitative, and mixed method approaches . 3rd ed. Thousand Oaks: SAGE Publications.

Davidsson, David. 1988. 2001. The myth of the subjective. In Subjective, intersubjective, objective , ed. David Davidsson, 39–52. Oxford: Oxford University Press.

Denzin, Norman K. 1970. The research act: A theoretical introduction to Ssociological methods . Chicago: Aldine Publishing Company Publishers.

Denzin, Norman K., and Yvonna S. Lincoln. 2003. Introduction. The discipline and practice of qualitative research. In Collecting and interpreting qualitative materials , ed. Norman K. Denzin and Yvonna S. Lincoln, 1–45. Thousand Oaks: SAGE Publications.

Denzin, Norman K., and Yvonna S. Lincoln. 2005. Introduction. The discipline and practice of qualitative research. In The Sage handbook of qualitative research , ed. Norman K. Denzin and Yvonna S. Lincoln, 1–32. Thousand Oaks: SAGE Publications.

Emerson, Robert M., ed. 1988. Contemporary field research. A collection of readings . Prospect Heights: Waveland Press.

Emerson, Robert M., Rachel I. Fretz, and Linda L. Shaw. 1995. Writing ethnographic fieldnotes . Chicago: University of Chicago Press.

Esterberg, Kristin G. 2002. Qualitative methods in social research . Boston: McGraw-Hill.

Fine, Gary Alan. 1995. Review of “handbook of qualitative research.” Contemporary Sociology 24 (3): 416–418.

Fine, Gary Alan. 2003. “ Toward a Peopled Ethnography: Developing Theory from Group Life.” Ethnography . 4(1):41-60.

Fine, Gary Alan, and Black Hawk Hancock. 2017. The new ethnographer at work. Qualitative Research 17 (2): 260–268.

Fine, Gary Alan, and Timothy Hallett. 2014. Stranger and stranger: Creating theory through ethnographic distance and authority. Journal of Organizational Ethnography 3 (2): 188–203.

Flick, Uwe. 2002. Qualitative research. State of the art. Social Science Information 41 (1): 5–24.

Flick, Uwe. 2007. Designing qualitative research . London: SAGE Publications.

Frankfort-Nachmias, Chava, and David Nachmias. 1996. Research methods in the social sciences . 5th ed. London: Edward Arnold.

Franzosi, Roberto. 2010. Sociology, narrative, and the quality versus quantity debate (Goethe versus Newton): Can computer-assisted story grammars help us understand the rise of Italian fascism (1919- 1922)? Theory and Society 39 (6): 593–629.

Franzosi, Roberto. 2016. From method and measurement to narrative and number. International journal of social research methodology 19 (1): 137–141.

Gadamer, Hans-Georg. 1990. Wahrheit und Methode, Grundzüge einer philosophischen Hermeneutik . Band 1, Hermeneutik. Tübingen: J.C.B. Mohr.

Gans, Herbert. 1999. Participant Observation in an Age of “Ethnography”. Journal of Contemporary Ethnography 28 (5): 540–548.

Geertz, Clifford. 1973. The interpretation of cultures . New York: Basic Books.

Gilbert, Nigel. 2009. Researching social life . 3rd ed. London: SAGE Publications.

Glaeser, Andreas. 2014. Hermeneutic institutionalism: Towards a new synthesis. Qualitative Sociology 37: 207–241.

Glaser, Barney G., and Anselm L. Strauss. [1967] 2010. The discovery of grounded theory. Strategies for qualitative research. Hawthorne: Aldine.

Goertz, Gary, and James Mahoney. 2012. A tale of two cultures: Qualitative and quantitative research in the social sciences . Princeton: Princeton University Press.

Goffman, Erving. 1989. On fieldwork. Journal of Contemporary Ethnography 18 (2): 123–132.

Goodwin, Jeff, and Ruth Horowitz. 2002. Introduction. The methodological strengths and dilemmas of qualitative sociology. Qualitative Sociology 25 (1): 33–47.

Habermas, Jürgen. [1981] 1987. The theory of communicative action . Oxford: Polity Press.

Hammersley, Martyn. 2007. The issue of quality in qualitative research. International Journal of Research & Method in Education 30 (3): 287–305.

Hammersley, Martyn. 2013. What is qualitative research? Bloomsbury Publishing.

Hammersley, Martyn. 2018. What is ethnography? Can it survive should it? Ethnography and Education 13 (1): 1–17.

Hammersley, Martyn, and Paul Atkinson. 2007. Ethnography. Principles in practice . London: Tavistock Publications.

Heidegger, Martin. [1927] 2001. Sein und Zeit . Tübingen: Max Niemeyer Verlag.

Heidegger, Martin. 1988. 1923. Ontologie. Hermeneutik der Faktizität, Gesamtausgabe II. Abteilung: Vorlesungen 1919-1944, Band 63, Frankfurt am Main: Vittorio Klostermann.

Hempel, Carl G. 1966. Philosophy of the natural sciences . Upper Saddle River: Prentice Hall.

Hood, Jane C. 2006. Teaching against the text. The case of qualitative methods. Teaching Sociology 34 (3): 207–223.

James, William. 1907. 1955. Pragmatism . New York: Meredian Books.

Jovanović, Gordana. 2011. Toward a social history of qualitative research. History of the Human Sciences 24 (2): 1–27.

Kalof, Linda, Amy Dan, and Thomas Dietz. 2008. Essentials of social research . London: Open University Press.

Katz, Jack. 2015. Situational evidence: Strategies for causal reasoning from observational field notes. Sociological Methods & Research 44 (1): 108–144.

King, Gary, Robert O. Keohane, S. Sidney, and S. Verba. 1994. Designing social inquiry. In Scientific inference in qualitative research . Princeton: Princeton University Press.

Chapter   Google Scholar  

Lamont, Michelle. 2004. Evaluating qualitative research: Some empirical findings and an agenda. In Report from workshop on interdisciplinary standards for systematic qualitative research , ed. M. Lamont and P. White, 91–95. Washington, DC: National Science Foundation.

Lamont, Michèle, and Ann Swidler. 2014. Methodological pluralism and the possibilities and limits of interviewing. Qualitative Sociology 37 (2): 153–171.

Lazarsfeld, Paul, and Alan Barton. 1982. Some functions of qualitative analysis in social research. In The varied sociology of Paul Lazarsfeld , ed. Patricia Kendall, 239–285. New York: Columbia University Press.

Lichterman, Paul, and Isaac Reed I (2014), Theory and Contrastive Explanation in Ethnography. Sociological methods and research. Prepublished 27 October 2014; https://doi.org/10.1177/0049124114554458 .

Lofland, John, and Lyn Lofland. 1995. Analyzing social settings. A guide to qualitative observation and analysis . 3rd ed. Belmont: Wadsworth.

Lofland, John, David A. Snow, Leon Anderson, and Lyn H. Lofland. 2006. Analyzing social settings. A guide to qualitative observation and analysis . 4th ed. Belmont: Wadsworth/Thomson Learning.

Long, Adrew F., and Mary Godfrey. 2004. An evaluation tool to assess the quality of qualitative research studies. International Journal of Social Research Methodology 7 (2): 181–196.

Lundberg, George. 1951. Social research: A study in methods of gathering data . New York: Longmans, Green and Co..

Malinowski, Bronislaw. 1922. Argonauts of the Western Pacific: An account of native Enterprise and adventure in the archipelagoes of Melanesian New Guinea . London: Routledge.

Manicas, Peter. 2006. A realist philosophy of science: Explanation and understanding . Cambridge: Cambridge University Press.

Marchel, Carol, and Stephanie Owens. 2007. Qualitative research in psychology. Could William James get a job? History of Psychology 10 (4): 301–324.

McIntyre, Lisa J. 2005. Need to know. Social science research methods . Boston: McGraw-Hill.

Merton, Robert K., and Elinor Barber. 2004. The travels and adventures of serendipity. A Study in Sociological Semantics and the Sociology of Science . Princeton: Princeton University Press.

Mannay, Dawn, and Melanie Morgan. 2015. Doing ethnography or applying a qualitative technique? Reflections from the ‘waiting field‘. Qualitative Research 15 (2): 166–182.

Neuman, Lawrence W. 2007. Basics of social research. Qualitative and quantitative approaches . 2nd ed. Boston: Pearson Education.

Ragin, Charles C. 1994. Constructing social research. The unity and diversity of method . Thousand Oaks: Pine Forge Press.

Ragin, Charles C. 2004. Introduction to session 1: Defining qualitative research. In Workshop on Scientific Foundations of Qualitative Research , 22, ed. Charles C. Ragin, Joane Nagel, Patricia White. http://www.nsf.gov/pubs/2004/nsf04219/nsf04219.pdf

Rawls, Anne. 2018. The Wartime narrative in US sociology, 1940–7: Stigmatizing qualitative sociology in the name of ‘science,’ European Journal of Social Theory (Online first).

Schütz, Alfred. 1962. Collected papers I: The problem of social reality . The Hague: Nijhoff.

Seiffert, Helmut. 1992. Einführung in die Hermeneutik . Tübingen: Franke.

Silverman, David. 2005. Doing qualitative research. A practical handbook . 2nd ed. London: SAGE Publications.

Silverman, David. 2009. A very short, fairly interesting and reasonably cheap book about qualitative research . London: SAGE Publications.

Silverman, David. 2013. What counts as qualitative research? Some cautionary comments. Qualitative Sociology Review 9 (2): 48–55.

Small, Mario L. 2009. “How many cases do I need?” on science and the logic of case selection in field-based research. Ethnography 10 (1): 5–38.

Small, Mario L 2008. Lost in translation: How not to make qualitative research more scientific. In Workshop on interdisciplinary standards for systematic qualitative research, ed in Michelle Lamont, and Patricia White, 165–171. Washington, DC: National Science Foundation.

Snow, David A., and Leon Anderson. 1993. Down on their luck: A study of homeless street people . Berkeley: University of California Press.

Snow, David A., and Calvin Morrill. 1995. New ethnographies: Review symposium: A revolutionary handbook or a handbook for revolution? Journal of Contemporary Ethnography 24 (3): 341–349.

Strauss, Anselm L. 2003. Qualitative analysis for social scientists . 14th ed. Chicago: Cambridge University Press.

Strauss, Anselm L., and Juliette M. Corbin. 1998. Basics of qualitative research. Techniques and procedures for developing grounded theory . 2nd ed. Thousand Oaks: Sage Publications.

Swedberg, Richard. 2017. Theorizing in sociological research: A new perspective, a new departure? Annual Review of Sociology 43: 189–206.

Swedberg, Richard. 1990. The new 'Battle of Methods'. Challenge January–February 3 (1): 33–38.

Timmermans, Stefan, and Iddo Tavory. 2012. Theory construction in qualitative research: From grounded theory to abductive analysis. Sociological Theory 30 (3): 167–186.

Trier-Bieniek, Adrienne. 2012. Framing the telephone interview as a participant-centred tool for qualitative research. A methodological discussion. Qualitative Research 12 (6): 630–644.

Valsiner, Jaan. 2000. Data as representations. Contextualizing qualitative and quantitative research strategies. Social Science Information 39 (1): 99–113.

Weber, Max. 1904. 1949. Objectivity’ in social Science and social policy. Ed. Edward A. Shils and Henry A. Finch, 49–112. New York: The Free Press.

Download references

Acknowledgements

Financial Support for this research is given by the European Research Council, CEV (263699). The authors are grateful to Susann Krieglsteiner for assistance in collecting the data. The paper has benefitted from the many useful comments by the three reviewers and the editor, comments by members of the Uppsala Laboratory of Economic Sociology, as well as Jukka Gronow, Sebastian Kohl, Marcin Serafin, Richard Swedberg, Anders Vassenden and Turid Rødne.

Author information

Authors and affiliations.

Department of Sociology, Uppsala University, Uppsala, Sweden

Patrik Aspers

Seminar for Sociology, Universität St. Gallen, St. Gallen, Switzerland

Department of Media and Social Sciences, University of Stavanger, Stavanger, Norway

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Patrik Aspers .

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Reprints and permissions

About this article

Aspers, P., Corte, U. What is Qualitative in Qualitative Research. Qual Sociol 42 , 139–160 (2019). https://doi.org/10.1007/s11133-019-9413-7

Download citation

Published : 27 February 2019

Issue Date : 01 June 2019

DOI : https://doi.org/10.1007/s11133-019-9413-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Qualitative research
• Epistemology
• Philosophy of science
• Phenomenology
• Find a journal
• Publish with us
• Track your research

• Open access
• Published: 21 March 2024

How older adults manage misinformation and information overload - A qualitative study

• M. Vivion 1 , 2 ,
• V. Reid 2 , 3 ,
• E. Dubé 2 , 4 ,
• A. Coutant 3 , 5 ,
• A. Benoit 6 &
• A. Tourigny 7 , 8  

BMC Public Health volume  24 , Article number:  871 ( 2024 ) Cite this article

311 Accesses

4 Altmetric

Metrics details

The COVID-19 pandemic was characterized by an abundance of information, some of it reliable and some of it misinformation. Evidence-based data on the impact of misinformation on attitudes and behaviours remains limited. Studies indicate that older adults are more likely to embrace and disseminate misinformation than other population groups, making them vulnerable to misinformation. The purpose of this article is to explore the effects of misinformation and information overload on older adults, and to present the management strategies put in place to deal with such effects, in the context of COVID-19.

A qualitative exploratory approach was adopted to conduct this research. A total of 36 semi-structured interviews were conducted with older adults living in Quebec, Canada. The interviews were fully transcribed and subjected to a thematic content analysis.

Participants said they could easily spot misinformation online. Despite this, misinformation and its treatment by the media could generate fear, stress and anxiety. Moreover, the polarization induced by misinformation resulted in tensions and even friendship breakdowns. Participants also denounced the information overload produced largely by the media. To this end, the participants set up information routines targeting the sources of information and the times at which they consulted the information.

Conclusions

This article questions the concept of vulnerability to misinformation by highlighting older adults’ agency in managing misinformation and information overload. Furthermore, this study invites us to rethink communication strategies by distinguishing between information overload and misinformation.

Peer Review reports

The COVID-19 pandemic was accompanied by a steady stream of information that was described by the World Health Organization as an “infodemic,” referring to an epidemic of information, some of which was reliable while other items of information were erroneous or false [ 1 ]. This information overload refers to a state where and individual’s efficiency in selecting, using, processing, and making sense of information is hampered by the quantity of pertinent and possibly valuable information [ 2 ]. Information overload is closely linked to information redundancy, as they mutually increase each other [ 3 ]. Information redundancy designates repeated messages within a sequence of received messages [ 3 ]. In addition to pertinent information, information overload is further exacerbated by disinformation and misinformation [ 1 ]. This state can be accompanied by a feeling of loss of control and anxiety [ 2 ]. Information overload has essentially been studied in relation to the issues of misinformation and disinformation, rather than as a separate phenomenon [ 4 , 5 ]. Disinformation and misinformation refer to incorrect information [ 6 , 7 ]. While disinformation implies malicious intent, and is associated with fake news and conspiracy theories, for example, misinformation does not imply malicious intent [ 6 , 8 ]. The distinction therefore lies in the intention to deceive or not, which is difficult to prove. For this reason, the term “misinformation” will be used in this article to refer to information created and disseminated irrespective of any intention to deceive.

Health misinformation refers, more specifically, to “information that is contrary to the epistemic consensus of the scientific community regarding a phenomenon” [ 9 ]. Misinformation is most often characterized by a negative tone, the preponderance of anecdotes and personal experiences, the promotion of anti-scientific narratives, and rapid dissemination [ 9 ]. In health, misinformation is particularly problematic, as it can lead to misperceptions leading to potentially harmful action [ 9 , 10 ]. For example, a false connection between the measles-mumps and rubella vaccine and autism led to decrease in vaccination coverage at the end of the 1990s and is still a common reason for vaccine refusal today [ 11 ]. In fact, during the pandemic, misinformation first took the the form of calls suggesting the necessity to stock up on certain supplies (e.g, toilet paper, food), and then focused mainly on unproven “treatments” or techniques to prevent infection (drinking water with lemon or coconut oil, probiotics) and then to forms of denials of the data about the number of cases and deaths– or even the existence of the disease [ 12 , 13 ]. It would also discredit the scientific community and public health authorities, or make it more difficult for people to determine which information to believe, and fuel a sense of panic [ 14 ]. More generally, misinformation can lead to various forms of violence (xenophobia, bullying, verbal or physical violence), discrimination such as anti-Asian attitudes and behaviors during the COVID-19 pandemic, and psychological distress [ 11 , 15 ]. Also, during the pandemic, an increase in uncertainty and a heightened need for new information, especially in healthcare, to address it led to an information overload [ 14 ].

Despite this, the effects of misinformation remain unclear, and empirical evidence of its impact on behaviour and attitudes is limited [ 10 ]. A systematic review reveals that articles reporting concrete cases of damage caused by misinformation are rather rare [ 16 ]. Concerns about misinformation persist, rooted in the belief that it can significantly influence people’s thoughts and behaviors [ 10 ]. This, in turn, poses a potential threat to both public health and the integrity of democracy [ 10 ].

As social media can rapidly and widely disseminate information, they are frequently mentioned in articles discussing misinformation [ 13 , 17 ]. In this regard, studies on the dissemination of misinformation indicate that older adults are more “vulnerable” to misinformation, as they tend to subscribe to erroneous messages spread online and are more responsible for their dissemination than other population groups [ 14 , 15 , 18 , 19 , 20 , 21 ]. Studies explain this “vulnerability” by the lack of skills needed to find and evaluate online information [ 15 , 22 , 23 , 24 ]. Some authors associate this lack of skill with a “cognitive deficit” which refers to the decline in cognitive abilities that occurs with aging, [ 19 , 20 , 25 , 26 , 27 , 28 ] affecting the ability to distinguish true from false information. This one-size-fits-all approach, which most often groups together adults aged 65 and over, is criticized for neglecting the diversity of uses and experiences of the Internet, and also for denying older adults’ agency, thus perpetuating ageism [ 29 , 30 ]. Moreover, most studies focused on older adults’ engagement with misinformation come from the realm of politics or the media [ 19 , 31 ], rather than health-related issues [ 9 , 32 ]. This raises the question of the transferability of the results from these studies on the vulnerability of older people to health misinformation [ 9 ].

The purpose of this article is to explore the effects of misinformation and information overload for older adults, and to present the management strategies put in place to deal with them. This article is part of a larger research project to study the informational practices of Quebec older adults in the context of the COVID-19 pandemic. The general results of this research were presented in another article [ 33 ].

Research ethics

The study protocol was approved by the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l’Île-de-Montréal (CIUSSS) Ethics Committee (Project 2022 − 829).

Design and settings

This research employed an exploratory approach based on the principles of the sociology of uses [ 34 ]. The relevance of the sociology of uses approach for analyzing informational practices has been established by several studies [ 35 , 36 , 37 , 38 , 39 ]. This approach recontextualizes the uses of information and communication technologies within their social and everyday contexts [ 40 ]. The concept of ‘’usages’’ as mobilized by the sociology of uses emphasizes the autonomy of users and their appropriation of technical devices [ 38 ]. This approach thus opposes a deterministic view of technology. In this study, participants were questioned about the devices used and their routines associated with information practices (time of day, order in which sources are consulted, activities performed simultaneously). We also made sure to account for the complexity of informational practices, which is essential to consider in accordance with sociology of uses [ 38 ]. For instance, the interview framework was designed to inquire about participants’ multiple sources of information and material supports they used [ 38 ]. This approach also guided our analysis by focusing on the potentialities related to the agency of individuals when they consume media content. The research project was developed in collaboration with the Conference of the Regional Roundtables for Older Adults in Quebec (CTRCAQ).

Participants

Participants were recruited through a list created as part of weekly surveys designed to assess adherence to COVID-19-related health measures among the Quebec population. These surveys were conducted by the Institut National de Santé Publique du Québec (INSPQ). More information on the survey methods and limitation is available here [ 41 ].The database contained participants’ age, self-identified gender, place of residence, and email addresses, but was not linked with complete answers to the survey. During the surveys, participants could indicate whether they wished to be contacted by other research teams to participate in studies. The research team sent an invitation email to the participants based on criteria such as age, gender, and residency. During the surveys, participants could indicate whether they wished to be contacted by other research teams to participate in studies. The research team sent an invitation email to the participants [ 41 ]. The participants had to be aged 60 or older, residing in the province of Quebec, and fluent in either French or English. The participants were informed that the study would delve into how they obtain information during the pandemic, including the sources they use, and how they assess its credibility. Participants received financial compensation of $30. Informed consent, either written or oral, was obtained before each interview.

To comply with preventive measures, the interviews were conducted online during the summer of 2021, 15 months after the start of the pandemic. Lasting approximately one hour, they were conducted in French. Topics covered included: sources of information used, their information needs arising from the pandemic, ways of appropriating information and assessing its validity or credibility, and the impact of this information on their health-related behaviours. Participants were also asked about the change in their information practices as a result of the COVID-19 pandemic, and about how they perceived misinformation. The English interview guide is provided in a supplementary file.

Data analysis

Interviews were transcribed in full. We conducted a thematic analysis that involves categorizing a given dataset into predetermined themes that accurately represent the analyzed content, tailored to the research objectives [ 42 ]. Although the coding was guided by theoretical framework of informational practice, new themes could be added over the course of coding, as in the case of the information overload management strategies theme. Verbatim could be associated with more than one theme. The categorization of verbatim excerpts into different categories was carried out using NVivo software. For this paper, we translated verbatim excerpts from French to English, ensuring the quality of our work by validating it with a certified translator. An initial coding was carried out by A.B, then revised by M.V. A comparison of the two researchers’ coding led to a consensus on the meaning of certain ambiguous extracts and their association with a theme.

First, we will present the participant profiles. Subsequently, we will highlight the study’s results, organized around four main themes: information sources; effects of misinformation; consequences of information overload; and strategies for managing misinformation and information overload.

Participant profiles

A total of 36 semi-structured interviews were conducted with Quebec men ( n  = 18) and women ( n  = 18), living in a house or apartment in an urban ( n  = 20) or rural ( n  = 16) setting. Only one participant lived in a seniors’ residence. The majority of participants were aged between 60 and 69 ( n  = 28), with the remainder aged 70 and over. The distribution of participants according to high school, college or university level of education was the same ( n  = 12). Participant demographics are presented in Table  1 .

Information sources

During the pandemic, older adults in our study consulted multiple sources of information. Traditional media outlets, including television, were the preferred sources. Social media, especially Facebook, were used more to consult Market Place, for entertainment purposes and to communicate with their loved ones. As one participant had put it:

“With a cousin who lives in the greater Vancouver area, we don’t see her regularly, so we chat about stuff on Facebook. Then, I was faced with some mortality, people who passed away recently, so Messenger or Facebook would allow us to communicate. So it’s more about keeping in touch with people you don’t see very often, or with people you haven’t seen in a long time.” (P 27; 62 years old).

Some sources are more closely associated with the presence of misinformation. For one participant, using social media to stay in touch sometimes meant being exposed to what they perceived as misinformation: “I look at my son, my youngest, who sends me videos, stuff on Facebook… I don’t know where he gets this stuff… no. [sigh] It’s arrogance, I call it fake news.” (P 30; 64 years old).

The effects of misinformation

According to a number of participants, misinformation was generally easy to detect, as the information often “makes no sense at all,” so that “it’s often almost easy to see” (P 14;71 years old). While most report the harmful effects of this phenomenon (confusion, fear, worry, anxiety), one participant pointed out that misinformation at least had the advantage of potentially raising questions: ‘’Fake news, their only positive aspect is that it can make us question things a bit’’ (P 36; 71 years old).

Although misinformation affected participants, many indicated that it was more detrimental to their loved ones. Firstly, emotional responses such as confusion or fear were mentioned:

“Well, I think it’s a shame because it confuses people. It scares people; you know, I find it, uh, stupid that people invent things like… a friend of mine, she told me “you know, those who get vaccinated will all be dead in two years,” and I said “well yes, well yes.” But in my head I’m thinking… Come on, wake up. That makes no sense, there won’t be anyone left on Earth.” (P 33; 65 years old).

Another participant explained: “When we have our seniors’ meetings. A lot of things are said on social media and they hear it and it scares them. Often, it’s out of fear…”. (P 31; 72 years old).

Exposure to misinformation also led to worry: “I was reading [on social media] at first, then when I saw that it was starting to get me worried, I stopped that too, because it didn’t make sense, on social media, there’s really nothing serious about it.“(P 33;65 years old).

For many, misinformation was generating anxiety, and for some, even aggression, to which exposure to repeated negative information in the media was also contributing:

“We don’t have any hopeful news, it’s always about getting bad news fed into our heads, which creates a climate of anxiety, a climate that I consider unhealthy. There’s a huge level of aggression in Quebec right now, which is totally unacceptable. I blame the news a lot for that, because it creates chaos and enormous stress in society by repeating… non-stop, nothing but bad news. Also, there’s a lot of misinformation circulating and that creates anxiety, anguish and aggression in many communities.” (P 29; 64 years old).

The second type of effect identified and denounced by the participants was the resulting polarization. Misinformation was associated with heated debates between friends. A participant claimed to have occasionally listened to conspiracy theorists but did not like them. They mentioned engaging in debates at times with a politically far-right friend who is associated by the participant with such theories: “I have friends on the right, on the far right, I don’t have many, but I have one, but we often bump into each other, but it’s a good omen, as they say.” (P 9; 65 years old).

On this subject, one participant denounced the term “covidiot” used by the media during the pandemic, which she felt contributed to polarization. This portmanteau, combining the words “covid” and “idiot”, refers to someone who behaves in a stupid way that risks spreading the infectious disease covid-19. The expression is often attributed to individuals who refuse to accept vaccines or question preventive measures. Polarization had, for some, led to broken friendships:

“Apart from that, I’d say we had one friend who we cast aside because she became completely… and I mean completely conspiratorial. It was ridiculous. She was so exaggerated that we didn’t even question it anymore. We respected her, we didn’t laugh in front of her, but the minute she was gone… In fact, in my opinion, it’s mental illness. I don’t know why it’s called mental illness due to fear of the pandemic, but for me it’s clearly that. I’m not a doctor or a psychologist, but… […] She was affected in the head.” (P 18; 64 years old).

Consequences of information overload

In addition to misinformation, most participants deplored information overload and redundancy in the media. Faced with the repetition of information, participants were “fed up with hearing about it” (P 15; 66 years old) and were irritated. “At first, it was awful. It was just that” (P 22; 63 years old). Another participant lamented the way the media operates under the logic of streaming:

“Also, it’s repetitive […]. In these times, the news is non-stop, so it becomes a show. Then, at a certain point, it’s clear that we’re fed up. It’s become so repetitive […] We’re buried in information. We receive an enormous amount of information.” (P 29; 64 years old).

While information overload was a source of stress for many participants, it was especially the type of information conveyed by the media that seemed responsible. The daily presentation of the number of cases and deaths, as well as the description of situations in hospitals and Long-Term Care Facilities (CHSLDs), were considered particularly anxiety-provoking by participants. As one participant had put it: “When they started mentioning the number of cases per day… When we saw that, well, when we saw that going up, it was a bit stressful as well.” (P 4; 64 years old).

The major concern about the situation in CHSLDs and the treatment of the older adults was also explained by the particular point of view of our participants, some of whom dread the day when they will have to move to this type of facility for people who are not self-sufficient:

“[…] for me personally, it was very stressful to - it seems to me that I was so glued to the TV. Just to find out what was happening, well, as much in the CH [SLD] for the elderly. It certainly made me wonder, in the sense that I’m coming from there. You know, I’m going that way. […]. But it’s worrying. When you look at how they’ve been treated and everything. My God, to think I’m going in that direction. It’s like, it’s not very reassuring.” (P 2; 64 years old).

Strategies for managing misinformation and information overload

Analysis of the data revealed that participants implement several strategies to limit the effects of misinformation and information overload, or anxiety-provoking information.

First, most of them claimed to limit themselves to so-called reliable sources, meaning for them traditional media such as Radio-Canada and TVA Nouvelles, which for many participants provide access to “real” information and “real” news:

“How can I put this… the real news…, the verified news, comes from television media: TVA or Radio-Canada or RDI. If it’s fake news that comes through them, they’re the ones with a hell of a problem, because they haven’t checked the news. So, in principle, if it comes from Wikipedia, the news […] from another site that isn’t an official site, well, I don’t even pay attention to it. When I get news that doesn’t come from a place that’s known and approved by me, let’s put it this way, it’s quickly passed over, forget it, I don’t even pay attention to it.” (P 32; 64 years old).

To avoid misinformation, most participants did not seek information on social media, which they consider not to be reliable. Older adults in our research therefore appeared particularly critical of the validity of information on social media. One participant stated that he prefers to rely on specialists, “good sources of information,” since social media offers quick access to information that is not necessarily reliable:

“Who else is going to give me real information? Not Facebook, it’s not real, it’s not the so-called Facebook specialists with degrees as long as your arm. That’s where you come in, you do a Google search on them, and you can’t find them. That’s not where the real information is going to come from, so get informed, talk to your doctor, turn to WHO, turn to your government, we’ve got government specialists there… Caroline Quach, she’s no pushover. We have good sources of information, but the world wants to have fast information (P 1; 67 years old).

In short, many participants said they don’t pay attention to the kind of information associated with social media. For one participant, ignoring the misinformation circulating on social media reflected his general disinterest in these platforms: “Because there’s information out there for everyone, as the English term fake news says. So, since I’m not a big fan of social media, I wasn’t interested either. […]” (P 17; 68 years old). The same participant asserted that he doesn’t let himself be influenced by misinformation, and follows his own opinion, whatever the cost:

“And when they [social media users] said things about the pandemic, the vaccine or whatever, I let them talk, but that didn’t influence me […] I formed an opinion and then I said to myself, ‘I have an idea, it may not be the best one, but I tell myself I’m going to go all the way’, quite simply. (P 17;68 years old)

Then, among the participants using social media, many said they have unsubscribed or blocked people spreading misinformation, so as not to be exposed to it themselves. Referring to some of these people, one participant mentioned:

“[…] And their response was, “Well, you go ahead, and as soon as you’re all vaccinated, I won’t have to go. So I thought, “Okay, it’s the same as what you think, because your freedom is more important than your collective freedom,” and then it was “Okay, unsubscribe. I’m not stubborn with people who’ve gone that route, and there’s nothing that’s going to make them change their minds. […]. I used to have a certain number of friends on Facebook, and now I have a few less, because the ones who were… who were spreading false and misleading information, well, they’ve disappeared from my Facebook friends list.” (P 27; 62 years old).

One participant shared that blocking these people has helped her feel better in general:

“Then those who put on too much, well, I blocked them. […]. Because I don’t want anyone messing with my head, so I blocked them, you know, there are fanatics in everything […] So I blocked people on that, anti-covid, and my God, I’ve been feeling good ever since.” (P 33; 65 years old).

As it was highlighted previously, disregarding of ignoring statements from friends who share misinformation is also a strategy applied in face-to-face interactions.

Finally, to cope with information overload, some of the older adults interviewed mentioned setting up special information routines during the pandemic. Indeed, many said they stopped listening to the news all day long, but that they preserved a specific period in their daily schedule to get informed, whether it was the time of a radio program or the newscast. “We stopped listening to the news all day long; at a certain point, it’s too depressing, and we listened to it once at the end of the day, on TV,” shares one (P 14; 71 years old). This strategy consists in taking a step back and limiting the time devoted to news, so as not to be overwhelmed by it.

Very similar to the statistics on information sources consulted by older adults, the participants in our study favoured traditional media [ 43 ]. The fear, anxiety, stress and worry generated by misinformation and information overload are consistent with the findings of other studies [ 12 , 14 ]. However, for the participants, these harmful effects of misinformation would affect those closest to them more, illustrating the third-person effect, i.e., the perception that others are more vulnerable to misinformation than the self, highlighted by other studies [ 44 , 45 ]. Beyond negative emotions, our results reveal that misinformation contributes to polarization between individuals, sometimes leading to friendship breakdowns. Thus, it is social relationships that suffer from the conflicts caused by misinformation. For older adults, who may have a fragile social network [ 46 ], this issue can be crucial, as they risk finding themselves alone [ 47 ].

The susceptibility of older adults to online misinformation is based on the idea that they are “lagging behind” the rest of the population in their use of digital technology [ 23 , 30 , 48 , 49 ]. However, the participants in our study claim to be able to spot misinformation easily, and although they are sometimes exposed to it, this does not mean that they adhere to it. In fact, our results show that older people are critical, active and make sure to implement strategies to protect themselves, regardless of their gender or level of education. These findings are in line with those of a study which found that older adults understand the necessity for a degree of caution while using the internet [ 50 ]. Based on these results, it seems appropriate to question the concept of vulnerability to misinformation and its association with older people. Indeed, while advanced age is negatively associated with internet skills [ 23 , 29 , 32 ], other factors also need to be taken into account, such as level of education, socio-economic position and user experience [ 23 , 29 ]. One study reveals that, compared to the use of the internet for capital-enhancing activities, age is a less relevant variable than “autonomy of use” and the ability to surf the web [ 29 ]. In other words, the “age divide” in relation to digital media is often more complex than it seems as it involves multiple factors such as physical access, digital literacy, information and communication technologies utilization as well as socio-economic factors [ 29 ]. The results of our research seem to concur with the conclusion that age alone does not explain the ability to spot misinformation and suggest significant heterogeneity among older adults. It is crucial to be attuned to social and cultural variances among older people [ 51 ]. Differences within this group are all the more numerous as older adults have accumulated many life experiences [ 51 ], and the experience of aging varies from person to person [ 48 ]. In public health, standardizing approaches to older people can be harmful, as they tend to favour ageist approaches [ 33 ].

Lastly, several studies are alarmed by information avoidance [ 52 , 53 ], which is a strategy for avoiding exposure to information deemed threatening or undesirable [ 54 ]. Establishing an information routine by targeting information sources to be consulted at specific times can, on the contrary, be seen as a healthy strategy for preserving mental health and better managing the information overload created in particular by the media, while remaining informed.

Research and practice recommendations

Initiatives developed to combat information overload focus primarily on misinformation. However, our study suggests treating information overload as a distinct phenomenon, as this will enable us to rethink public health communication strategies and target the messages that are essential for limiting information overload.

Furthermore, our study reveals that health misinformation circulating on social media can not only generate negative emotions, but the polarization that breaks down dialogue and isolates individuals also appears to be crucial to health issues [ 55 , 56 , 57 ]. This is why it is essential to consider polarization in the development of public health interventions and communication strategies [ 58 , 59 ].

Finally, the results of our study highlight the agency of older adults to implement strategies for managing misinformation and information overload. Our research illustrate the relevance of relying on older adults’ ability to act [ 20 , 60 , 61 ] for the development of public health interventions [ 62 , 63 ].

This study has a number of limitations. Older adults living in residential facilities are often excluded from studies, due to the added difficulty of accessing this group. As these individuals are likely to have more physical and cognitive limitations, this aspect of recruitment taints research results, over-representing the realities of healthy older adults [ 48 ]. This is the case for this research, given that only one participant lived in a seniors’ residence. Indeed, this is a frequent limitation characterizing studies of internet use by older adults in general [ 48 ]. In addition, as recruitment was online this assumes that participants possessed some familiarity with the internet and computers. Another limitation of this study concerns the social desirability bias on the part of participants, characteristic of qualitative research. This bias was limited by the fact that the interviews were conducted by people trained in qualitative research. Qualitative researchers are trained to establish trust with participants. Moreover, they employ questioning techniques such as formulating open-ended questions and adopted an attitude of active listening during the interview.

Our results show that, although older adults may have a facility for detecting misinformation, they are affected by polarization and information overload. We therefore suggest that communication strategies be developed to minimize polarization and information overload.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l ’Île-de-Montréal (CIUSSS) Ethics Committee regulation. Data are available upon reasonable request. Inquiries for data access should be sent to the corresponding author who then contact the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l ’Île-de-Montréal (CIUSSS) Ethics Committee for permission to openly share the data.

Abbreviations

World Health Organization (Organisation Mondiale de la santé, OMS)

Conference of the Regional Roundtables for Seniors in Quebec

Centres d’hébergement de soins de longue durée (residential and long-term care centres/residential centres)

Centre-Sud-de-l’Île-de-Montréal

World Health O. Infodemic mangement-Infodemiology. WHO 2020.

Link E. Information avoidance during health crises: predictors of avoiding information about the COVID-19 pandemic among German news consumers. Inf Process Manag. 2021;58(6):102714.

Article   PubMed   PubMed Central   Google Scholar  

Liang H, Fu K-w. Information overload, similarity, and redundancy: Unsubscribing Information sources on Twitter. J Computer-Mediated Communication. 2016;22(1):1–17.

Article   ADS   CAS   Google Scholar  

Aïm O, Depoux A. Naissance de l’infodémiologie. Le Cas De l’OMS: vers une nouvelle organisation mondiale de l’information sanitaire? Questions de Communication. 2022;41(1):159–72.

Article   Google Scholar  

Gallotti R, Valle F, Castaldo N, Sacco P, De Domenico M. Assessing the risks of ‘infodemics’ in response to COVID-19 epidemics. Nat Hum Behav. 2020;4(12):1285–93.

Article   PubMed   Google Scholar  

Parsons Leigh J. Sensibiliser, mobiliser et outiller: des repères pour la population face à l’infodémie et à la COVID-19. Instituts de recherche en santé du Canada 2021.

Vivion M, Gauvin L. Intégrer L’infosurveillance, l’infodémiologie et une recherche interventionnelle conséquente dans nos systèmes de santé publique pour mieux protéger et promouvoir la santé de la population Au Canada: idées et perspectives. Can J Public Health. 2022;113:147–54.

El Mikati IK, Hoteit R, Harb T, El Zein O, Piggott T, Melki J, Mustafa RA, Akl EA. Defining misinformation and related terms in Health-related literature: scoping review. J Med Internet Res. 2023;25:e45731.

Swire-Thompson B, Lazer D. Public health and online misinformation: challenges and recommendations. Annu Rev Public Health. 2020;41(1):433–51.

Nan X, Wang Y, Thier K. Health misinformation. The Routledge Handbook of Health Communication. edn.: Routledge; 2021. pp. 318–32.

Ali S. Combatting against Covid-19 & misinformation: a systematic review. Hum Arenas. 2022;5(2):337–52.

Article   MathSciNet   Google Scholar  

Radwan E, Radwan A, Radwan W. Challenges facing older adults during the COVID-19 outbreak. Eur J Environ Public Health. 2020;5(1):em0059.

Bora K, Das D, Barman B, Borah P. Are internet videos useful sources of information during global public health emergencies? A case study of YouTube videos during the 2015–16 Zika virus pandemic. Pathogens Global Health. 2018;112(6):320–8.

Rocha YM, de Moura GA, Desidério GA, de Oliveira CH, Lourenço FD, de Figueiredo Nicolete LD. The impact of fake news on social media and its influence on health during the COVID-19 pandemic: a systematic review. J Public Health 2021:1–10.

Brashier NM, Schacter DL. Aging in an era of fake news. Curr Dir Psychol Sci. 2020;29(3):316–23.

Crocco AG, Villasis-Keever M, Jadad AR. Analysis of cases of harm associated with use of health information on the internet. JAMA. 2002;287(21):2869–71.

Rebillard F. La Rumeur Du PizzaGate Durant La présidentielle de 2016 aux États-Unis: Les Appuis Documentaires Du numérique Et De l’Internet à L’agitation Politique. Réseaux 2017(2):273–310.

Buchanan T. Why do people spread false information online? The effects of message and viewer characteristics on self-reported likelihood of sharing social media disinformation. PLoS ONE. 2020;15(10):e0239666.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Guess A, Nagler J, Tucker J. Less than you think: prevalence and predictors of fake news dissemination on Facebook. Sci Adv. 2019;5(1):eaau4586.

Article   ADS   PubMed   PubMed Central   Google Scholar  

Moore RC, Hancock JT. A digital media literacy intervention for older adults improves resilience to fake news. Sci Rep. 2022;12(1):6008.

Article   ADS   CAS   PubMed   PubMed Central   Google Scholar  

Sun Z, Yang B, Zhang R, Cheng X. Influencing factors of understanding COVID-19 risks and coping behaviors among the elderly population. Int J Environ Res Public Health. 2020;17(16):5889.

Hargittai E, Piper AM, Morris MR. From internet access to internet skills: digital inequality among older adults. Univ Access Inf Soc. 2019;18:881–90.

Van Deursen A, Van Dijk J. Internet skills and the digital divide. New Media Soc. 2011;13(6):893–911.

Verma R, Saldanha C, Ellis U, Sattar S, Haase KR. eHealth literacy among older adults living with cancer and their caregivers: a scoping review. J Geriatric Oncol. 2022;13(5):555–62.

Article   CAS   Google Scholar  

Allcott H, Gentzkow M. Social Media and fake news in the 2016 election. J Economic Perspect. 2017;31(2):211–36.

Hess TM, Smith BT, Sharifian N. Aging and effort expenditure: the impact of subjective perceptions of task demands. Psychol Aging. 2016;31(7):653.

Pennycook G, Cannon TD, Rand DG. Prior exposure increases perceived accuracy of fake news. J Exp Psychol Gen. 2018;147(12):1865.

Salthouse TA. When does age-related cognitive decline begin? Neurobiol Aging. 2009;30(4):507–14.

Hargittai E, Dobransky K. Old dogs, new clicks: Digital inequality in skills and uses among older adults. Can J Communication. 2017;42(2):195–212.

Rasi P, Vuojärvi H, Rivinen S. Promoting media literacy among older people: a systematic review. Adult Educ Quarterly: J Res Theory. 2021;71(1):37–54.

Grinberg N, Joseph K, Friedland L, Swire-Thompson B, Lazer D. Fake news on Twitter during the 2016 US presidential election. Science. 2019;363(6425):374–8.

Article   ADS   CAS   PubMed   Google Scholar  

Seo H, Blomberg M, Altschwager D, Vu HT. Vulnerable populations and misinformation: a mixed-methods approach to underserved older adults’ online information assessment. New Media Soc. 2021;23(7):2012–33.

Guzun N, Tourigny A, Dubé E, Coutant A, Vivion M. Ageism through the informational practices during COVID-19 pandemic: a qualitative study. Can J Public Health.

Millette M, Myles D, Millerand F, Latzko-Toth G. Méthodes De recherche en contexte numérique: une orientation qualitative. les Presses de l’université de Montréal; 2020.

Jouet E, Flora LG, Las Vergnas O. Construction Et reconnaissance des savoirs expérientiels des patients. Pratiques de formation-Analyses. 2010;2010:58–9.

Google Scholar  

Pasquier D. Les pratiques numériques en milieu populaire. Études 2019(6):51–60.

Pasquier D. Classes populaires en ligne: des «oubliés» de la recherche? Réseaux 2018(2):9–23.

Proulx S, Rueff J. Actualité des méthodes de recherche en sciences sociales sur les pratiques informationnelles. Centre d’études sur les médias; 2018.

Wagner MC, Boczkowski PJ. The reception of fake news: the interpretations and practices that shape the consumption of perceived misinformation. Digit Journalism. 2019;7(7):870–85.

Proulx S. La Sociologie Des usages, et après? Revue française des Sci de l’information et de la Communication 2015(6).

COVID-19. Sondages sur les atttitudes et comportements des adultes québécois [ https://www.inspq.qc.ca/covid-19/sondages-attitudes-comportements-quebecois ].

Guest G, MacQueen K, Namey E. Applied Thematic Analysis. In. Thousand Oaks, California; 2012.

Académie de la transformation n. NetTendances. Actualités en ligne, réseaux sociaux et balados. In.; 2023.

Altay S, Acerbi A. People believe misinformation is a threat because they assume others are gullible. New Media Soc 2023, 0(0).

Corbu N, Oprea D-A, Negrea-Busuioc E, Radu L. They can’t fool me, but they can fool the others!’Third person effect and fake news detection. Eur J Communication. 2020;35(2):165–80.

Dahlberg L, McKee KJ, Frank A, Naseer M. A systematic review of longitudinal risk factors for loneliness in older adults. Aging Ment Health. 2022;26(2):225–49.

Donovan NJ, Blazer D. Social isolation and loneliness in older adults: review and commentary of a National academies Report. Am J Geriatric Psychiatry. 2020;28(12):1233–44.

Hunsaker A, Hargittai E. A review of internet use among older adults. New Media Soc. 2018;20(10):3937–54.

Jacobson J, Lin CZ, McEwen R. Aging with technology: seniors and mobile connections. Can J Communication. 2017;42(2):331–57.

De Gottrau L. Les quêtes d’informations de santé des personnes âgées sur internet: engagement et désengagement numérique. 2016.

Givskov C, Deuze M. Researching new media and social diversity in later life. New Media Soc. 2018;20(1):399–412.

Barbour JB, Rintamaki LS, Ramsey JA, Brashers DE. Avoiding Health Information. J Health Communication. 2012;17(2):212–29.

Soroya SH, Farooq A, Mahmood K, Isoaho J, Zara S-e. From information seeking to information avoidance: understanding the health information behavior during a global health crisis. Inf Process Manag. 2021;58(2):102440.

Howell JL, Crosier BS, Shepperd JA. Does lacking threat-management resources increase information avoidance? A multi-sample, multi-method investigation. J Res Pers. 2014;50:102–9.

Jiang X, Su M-H, Hwang J, Lian R, Brauer M, Kim S, Shah D. Polarization over vaccination: ideological differences in Twitter expression about COVID-19 vaccine favorability and specific hesitancy concerns. Social Media + Soc. 2021;7:205630512110484.

Mønsted B, Lehmann S. Characterizing polarization in online vaccine discourse—A large-scale study. PLoS ONE. 2022;17(2):e0263746.

Nicola GD, Mambou VT, Kauermann G. COVID-19 and social media: beyond polarization. PNAS Nexus 2022, 2(8).

Sylvester S, Motta M, Trujillo KL, Callaghan T. Vaccinating across the aisle: using co-partisan source cues to encourage COVID-19 vaccine uptake in the ideological right. J Behav Med. 2023;46(1–2):311–23.

Whitehead HS, French CE, Caldwell DM, Letley L, Mounier-Jack S. A systematic review of communication interventions for countering vaccine misinformation. Vaccine. 2023;41(5):1018–34.

Leist AK. Social media use of older adults: a mini-review. Gerontology. 2013;59(4):378–84.

Trentham B, Sokoloff S, Tsang A, Neysmith S. Social media and senior citizen advocacy: an inclusive tool to resist ageism? Politics Groups Identities. 2015;3(3):558–71.

Nef T, Ganea RL, Müri RM, Mosimann UP. Social networking sites and older users–a systematic review. Int Psychogeriatr. 2013;25(7):1041–53.

Welch V, Petkovic J, Pardo JP, Rader T, Tugwell P. Interactive social media interventions to promote health equity: an overview of reviews. Health Promotion Chronic Disease Prev Canada: Res Policy Pract. 2016;36(4):63.

Download references

Acknowledgements

We are immensely grateful for the collaborative efforts of the Conference of the Regional Roundtables for Seniors in Quebec (CTRCAQ) throughout this entire project, as well as all the participants who generously dedicated their time to our project. Additionally, we would like to thank Catherine Girard and Alexandre Tremblay for their valuable contributions to data collection and analysis. We are also grateful to Christopher Fletcher (Université Laval) for his sound advice and comments offered during the data collection and analysis.

This study was supported by the Canadian Institutes of Health Research (Award Number: (MM1: 174884). The development of the research project was supported by the Reseau de recherche en santé des populations du Québec (RRSPQ) (Quebec Population Health Research Network) .

Author information

Authors and affiliations.

Department of Social and Preventive Medecine, Université Laval, Quebec, Canada

CHU de Québec-Université Laval Research Center, Quebec, Canada

M. Vivion, V. Reid & E. Dubé

Laboratoire sur la communication et le numérique (LabCMO), Montreal, Canada

V. Reid & A. Coutant

Department of Anthropology, Université Laval, Quebec, Canada

Université du Québec à Montréal (UQAM), Montreal, Canada

GDR AREES (Groupe de recherche: Arctique: Enjeux pour l’environnement et les sociétés) du CRNS, Paris, France

Institut sur le vieillissement et la participation sociale des aînés de l’Université Laval, Quebec, Canada

A. Tourigny

VITAM Centre de recherche en santé durable, Quebec, Canada

You can also search for this author in PubMed   Google Scholar

Contributions

The authors confirm contributions to the paper as follows: study development and design: MV; ED; AC; AT; data collection: MV; AB Author; analysis and interpretation of results: MV; ED; AC; AB; AT; draft manuscript preparation: MV and VR. All authors reviewed the results and approved the final version of the manuscript.

Corresponding author

Correspondence to M. Vivion .

Ethics declarations

Ethics approval and consent to participate.

The study protocol was approved by the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l ’Île-de-Montréal (CIUSSS) Ethics Committee (Project 2022 − 829). Informed consent, either written or oral, was obtained before each interview. Some participants provided only written informed consent, while others provided only oral informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Vivion, M., Reid, V., Dubé, E. et al. How older adults manage misinformation and information overload - A qualitative study. BMC Public Health 24 , 871 (2024). https://doi.org/10.1186/s12889-024-18335-x

Download citation

Received : 24 January 2024

Accepted : 12 March 2024

Published : 21 March 2024

DOI : https://doi.org/10.1186/s12889-024-18335-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Misinformation
• Information overload, social media, informational practices
• Older adults, Quebec

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Open access
• Published: 19 March 2024

Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study

• Easter Olwanda 1 ,
• Kennedy Opondo 2 ,
• Dorothy Oluoch 1 ,
• Kevin Croke 2 ,
• Justinah Maluni 1 ,
• Joyline Jepkosgei 1 &
• Jacinta Nzinga 1  

BMC Women's Health volume  24 , Article number:  181 ( 2024 ) Cite this article

109 Accesses

1 Altmetric

Metrics details

Maternal and neonatal outcomes in, Kakamega County is characterized by a maternal mortality rate of 316 per 100,000 live births and a neonatal mortality rate of 19 per 1,000 live births. In 2018, approximately 70,000 births occurred in the county, with 35% at home, 28% in primary care facilities, and 37% in hospitals. A maternal and child health service delivery redesign (SDR) that aims to reorganize maternal and newborn health services is being implemented in Kakamega County in Kenya to improve the progress of these indicators. Research has shown that women’s ability to make decisions (voice, agency, and autonomy) is critical for gender equality, empowerment and an important determinant of access and utilization. As part of the Kakamega SDR process evaluation, this study sought to understand women’s processes of decision-making in seeking maternal health care and how these affect women’s ability to access and use antenatal, delivery, and post-natal services.

We adapted the International Centre for Research on Women (ICRW) conceptual framework for reproductive empowerment to focus on the interrelated concepts of “female autonomy”, and “women’s agency” with the latter incorporating ‘voice’, ‘choice’ and ‘power’. Our adaptation did not consider the influence of sexual relationships and leadership on SRH decision-making. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. A thematic analysis approach was used to analyze the data in NVivo 12.

The results revealed notable findings across three dimensions of agency. Women with previous birthing experiences, high self-esteem, and support from their social networks exhibited greater agency. Additionally, positive previous birthing experiences were associated with increased confidence in making reproductive health choices. Women who had control over financial resources and experienced respectful communication with their partners exhibited higher levels of agency within their households. Distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women’s agency and autonomy. Finally, women who faced barriers such as long waiting times or limited staff availability experienced reduced agency in seeking healthcare.

Conclusions

Individual agency, immediate relational agency, and distance relational agency all play crucial roles in shaping women’s decision-making power and control over their utilization of maternal health services. This study offers valuable insights that can guide the ongoing implementation of an innovative service delivery redesign model, emphasizing the critical need for developing context-specific strategies to promote women’s voices for sustained use.

Peer Review reports

Globally, the provision of health care is evolving towards providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions [ 1 ]. Patient-centered care, in relation to clinical decision-making, is grounded in concepts of intrinsic values, personal preferences, and partnership [ 2 ]. A patient-centered approach, empowers women by involving them in decision-making processes and respecting their choices [ 3 ]. Women’s empowerment, in turn, enhances their autonomy and ability to seek appropriate and timely maternal health care [ 4 ], ultimately affording women agency for their overall well-being. When women are not empowered or lack autonomy, they may face barriers to accessing quality care, resulting in adverse maternal health outcomes [ 5 ].

Research on patient-centered care for women shows that women’s autonomy (i.e., the freedom of women to exercise their judgment in order to act for their own interests) influences reproductive, maternal, and child health outcomes [ 6 , 7 , 8 , 9 , 10 , 11 ]. Conversely, the absence of women’s autonomy in decision-making results in delays and poor utilization of maternal health services and ultimately increased maternal morbidity and mortality [ 12 ]. Thus, empowered women can make informed decisions about their reproductive health, including family planning, timing and spacing of pregnancies, and the type of care they receive during pregnancy and childbirth [ 13 , 14 , 15 , 16 ].

Freedom of mobility, participation in household decision-making, and self-efficacy are key dimensions of women’s empowerment [ 17 , 18 ]. Empowering women to make their own decisions, pursue goals, and control their lives and resources is a crucial aspect of Sustainable Development Goal (SDG) 5, which seeks to attain gender equality and empower all women and girls [ 19 ]. Moreover, empowering women in reproductive and sexual matters is crucial, as intimate relationships often involve significant power imbalances that can limit women’s ability to negotiate with their partners on sexual issues [ 20 ].

The International Centre for Research on Women (ICRW) has developed a conceptual framework for reproductive empowerment merging “female autonomy” and “women’s agency”, which includes ‘voice’, ‘choice’, and ‘power’. This framework is relevant to women’s autonomy in Kakamega as it provides a comprehensive approach to understanding the factors influencing women’s agency and empowerment, informing targeted interventions and policies in the region. Women’s individual agency involves expressing opinions, making decisions about their lives, and pursuing their aspirations, which empowers them to assert their voices and seek personal and professional growth. Immediate relational agency focuses on the influence of close relationships such as family, friends, and intimate partners on an individual’s agency [ 21 ]. These relationships can either support or restrict a woman’s ability to exercise her voice, make choices, and pursue empowerment. Supportive relationships enable women to exercise their agency freely, while oppressive ones may limit their ability to make decisions and assert their voice, hindering empowerment. Distant relational agency refers to the broader social, cultural, and institutional influences that shape women’s agency and empowerment [ 22 ]. Societies that prioritize gender equality, offer legal protections, ensure access to education and healthcare, and promote women’s participation in decision-making enhance women’s agency. Conversely, gender inequalities and limited opportunities hinder women’s agency and empowerment.

The relationship between individual, immediate, and distant relational agency is complex and interconnected, with individual agency influenced by both immediate and distant relational agency. Supportive immediate relationships and equitable social structures can enhance individual agency, enabling women to exercise their voice and make choices while repressive immediate relationships and restrictive social structures can limit women’s agency [ 23 ]. Aligning all three levels of agency positively leads to women’s voice, choice, power, and empowerment. These concepts are illustrated in Fig.  1 below.

Borrowed from the Conceptual Framework of Reproductive Empowerment by the International Center for Research on Women (ICRW)

Evidence suggests that increasing women’s mobility can empower them to exercise greater control over their lives by increasing their access to healthcare, education, markets and information [ 6 , 24 ]. Additionally, women with strong sense of self-efficacy have the potential to anticipate different success scenarios, persevere in the face of obstacles, take action against the existing social norms [ 25 ], and navigate complicated healthcare contexts to receive care [ 26 ]. Relative to maternal and child health, increased postpartum maternal self-efficacy been has associated with improved functional status in the postpartum period [ 27 ]. Furthermore, women’s control over resources and decision-making within a household plays a crucial role in enhancing healthcare-seeking behaviors and maternal and child health outcomes [ 28 ]. Changes in women’s intra-household bargaining power, also increases a woman’s status and impacts her decision-making ability [ 29 , 30 ]. All these are key considerations in determining the implementation process and success of maternal and child health interventions and reforms. Existing literature primarily emphasizes the impact of women’s choice and agency on health decision-making and service use, but there is limited documentation on how women’s autonomy experiences can inform the implementation of improved maternal and child health interventions.

The implementation context

Kakamega County was selected due to its high maternal mortality rate of 316 per 100,000 live births and neonatal mortality rate of 19 per 1,000 live births, alongside approximately 70,000 births in 2018, distributed with 35% at home, 28% in primary care facilities, and 37% in hospitals. Part of recommendations from the Lancet Global Health Commission on High Quality Health Systems for improving quality of care is the implementation of “Service Delivery Redesign for Maternal and Newborn Health”, (SDR) reform. Kakamega County started the phased implemention of SDR in 2021 and is currently in its improvement phase.

During the SDR implementation period, improvements were made to health facilities, including the commissioning of a new Maternity wing and an increase in bed capacity at Malava. The Linda Mama health scheme provides affordable maternal and child health services, and Malava sub-county hospital increased its claims from 34 to 79%. Additionally, a newborn unit was constructed, and the facility currently has a resident pediatrician, surgeon and gynecologist supported by nurses, clinicians, and medical officers.

Similarly, Lumakanda sub-county hospital has reorganized its infrastructure at the maternity wing and the newborn unit, introduced emergency evacuation services, implemented pseudo-facility improvement fund (FIF) disbursements, enhanced accountability and visibility of blood resources through a blood tracker dashboard, enrolled women for pregnancy care text prompts, and provided Emergency obstetric and newborn care (EmONC) training to its staff while also training health workers from primary health care facilities. A summary of the SDR related implementation activities can be found in the Supplementary file 1 .

This paper aimed at examining how women’s processes of decision-making in seeking maternal and neonatal health care both influences and is influenced by the implementation of SDR in Kakamega county. It is anticipated that the learning from this paper will inform the implementation of SDR by highlighting patient voice in reforming delivery of MCH services.

Study setting

The study took place in Malava and Lumakanda sub-County hospitals which are maternity centers of excellence where the Kakamega Service Delivery Redesign (SDR) is being implemented. The Kakamega maternal and child health Service Delivery Redesign (SDR) is a structural reform that aims to reorganize the maternal and newborn health services by shifting deliveries for all women to advanced facilities that offer definitive care for complications. The reform is now being implemented by the Kakamega County government with the aim of improving the quality of antenatal, delivery and postnatal care. It purposes to ensure that all women can give birth in safe environments, with skilled providers that have the tools and competencies to care for women during uncomplicated birth and who can detect and deal with complications if and when they occur [ 31 ].

Study design

This was a cross-sectional exploratory study using qualitative research methods with purposively selected participants. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men in Kakamega County. In this context, small group interviews involved a small group of individuals, allowing for in-depth exploration of individual perspectives within a group setting, while focus group discussions were conversations guided by a moderator, emphasizing interactions among 8–10 participants to explore shared perspectives and group dynamics.

The FGDs had an average of 8 individuals while the small group discussions had an average of 4 individuals. For the FGDs demographic dynamics such as gender and age were managed through the selection of participants to ensure diverse representation within the groups. We formed homogeneous groups based on specific demographic criteria, to foster open and comfortable discussions among participants with shared characteristics. In this case we had FGDs specifically for younger women, another for older women, and lastly with the men separately. Conversely, for small groups, we intentionally chose participants representing various demographic profiles to capture a range of perspectives and experiences. The FGDs lasted between 45 and 60 min, the IDIs lasted between 30- 45 min and the KII lasted an average of 45 min.

See the Table  1 below.

The pre-set inclusion criteria included willingness to consent and to participate in the study, and good knowledge or understanding of the areas of inquiry. We employed purposeful participant selection to include diverse demographic characteristics, experiences, and perspectives in relation to the research topic.

Data collection

Data collection took place in November 2022 and in March 2023. Participants were recruited from the antenatal, delivery and post-natal clinics in Lumakanda and Malava sub-County hospitals. We conducted key informant interviews, in-depth interviews, small group interviews and focus group discussions with pregnant women attending Antenatal clinics, women who had delivered, women attending post-natal clinics, and men using guides with questions developed in English and then translated into Swahili.

The interviews covered three broad topics of interest (1) factors that affect women’s autonomy and decision-making power in the household, (2) the process of decision-making at the family level in seeking maternal health care during pregnancy, delivery, and the postpartum period, and (3) how the decision-making process affects women’s ability to access and use maternal health services. Interviews were audio-recorded for participants who consented. During the interviews, detailed descriptive field notes were written covering interactions between the interviewer and respondent, non-verbal communication, environment, and reflections from interview content. All interviews were transcribed verbatim in Swahili and translated to English then cross-checked to ensure appropriate data and its quality before data analysis. Interviews were conducted to the point of theoretical saturation through iterative data analysis of emerging themes which was done alongside data collection. Iterating between data collection and analysis enabled the research team to be mindful of their own biases and actively worked to mitigate them, thus contributing to the robust representation of opinions. A total of 27 interviews including the IDIs, KIIs and FGDs lasting 30-60 min were conducted sequentially.

Data analysis

A thematic analysis approach was adopted. The English transcripts were read several times to develop familiarity with the raw data. Open coding was done to identify women’s expressions highlighting their autonomy; axial coding then followed to relate and label codes with shared concepts, dimension, and properties. Finally selective coding was done to delimit coding to the identified core concepts from the data [ 32 ]. See Table  2 below. E.O independently coded the data in the first phase of analysis. This was then followed by discussions between E.O and J.N, comparing emerging codes and developing a consensus on a final coding framework that was used to code and analyze the data in NVIVO 12.

This section presents the findings from an in-depth exploration of women’s agency and autonomy. Several key themes and sub-themes emerged, providing valuable insights into the complex dynamics surrounding women’s agency and autonomy. These findings contribute to a deeper understanding of the challenges and opportunities women face in asserting their rights, making choices, and navigating their social and cultural environments. The results further reveal the multifaceted nature of women’s agency and autonomy, encompassing individual, immediate relational, and distance relational factors and shed light on the interplay between these factors and uptake and utilization of maternal and child health services.

Individual agency

Independent women with strong self-trust were more likely to exercise their agency with greater adaptability and confidence in decision-making. Such strong inherent trust mediated power within which consequently shaped women’s individual agency and their ability to make decisions regarding maternal care.

“In my life, I’ve always been very independent and doing things on my own. I’ve never really encountered those challenges where I was told that someone else had to speak for me. Most of the time, I just do my own thing.”-ANC2

Conversely, the perception of shame, and insignificance among young pregnant girls diminished their agency in seeking services.

“For some, some are just afraid, especially those of young age. They are scared of coming to the clinic, so they try to hide the pregnancy because it brings them shame.” FGD men

The power within was also influenced by other factors including social support and past experiences. Supportive social networks provided women with the necessary resources, information, and support to develop their power within and exercise agency. Our findings indicate that social networks played a crucial role in shaping women’s individual agency in maternal healthcare decisions as they provided women with information, knowledge, and resources that enhanced their agency. Women sought input from their social networks including, family members, friends, community health volunteers (CHVs), and birth companions. Some elements such as finances, relational trust, and experiences of people were considered before a social network was chosen to aid with the decision-making.

“At times, the husband will help in decision making because it could be a place that is far and needs transport, he will be the one to decide whether I will go to Malava or not. The decision comes from him.”-PNC 1

The contacts drawn from social networks also shared their previous birthing experience with women fostering a sense of agency. Negative birth experiences raised awareness of potential challenges and helped women make more informed decisions while choosing the best options for the next birthing experience. In such instances, while the objective was to look for quality, the previous experiences of others as well as social relationships with health workers constituted the yardstick in making the final choice as the experiences of some participants revealed:

“That time I heard negative views about this place, and I didn’t feel the need to come. I heard that in Lumakanda they are very harsh and I told myself that “let me get used to Turbo”, I never set foot here. But in 2014, I said no, let me try the local facility.”-PNC 3

“Number one, etiquette of these nurses towards these pregnant women. You know you can go somewhere else, and the nurse just shouts at you. It’s like she carries all her stress to the hospital. But here in Lumakanda, I have not faced anything. So, that’s why I decided to come all the way.”-ANC 2

Additionally, health literacy had a great influence on women’s individual agency through the knowledge, attitudes, and beliefs acquired through health education and media exposure. Collectively, we saw how health education, media exposure, and health-seeking behavior significantly impacted women’s individual agency and decision-making for maternal care. With improved knowledge, women were more empowered to actively participate in decision-making processes, assert their preferences, and access appropriate healthcare services. Of note, is how health and financial literacy empowered women by increasing their understanding and enabling them to actively participate in decision-making processes.

“Maybe the media can broadcast that, mothers with children, and pregnant women, need to go to the hospital to get health services. They need to understand that they will benefit from going there. They need to hear it for themselves.”-PNC 3

Additionally, m edia exposure had a substantial impact on shaping women’s perceptions and attitudes toward maternal care. Our findings show that access to accurate and reliable information through various media channels can contribute to informed decision-making and empower women to seek appropriate maternal care. The respondents identified and recognized the value of health literacy in gaining autonomy and control over their health and well-being as corroborated in the quote below.

“Through media, newspapers, radios, councils, through these open places, many mothers have now discovered their rights and they have power now”-CHV.

Immediate relational agency

We found that women’s immediate relationships were also linked to household decision-making and freedom of movement. Our findings demonstrated that when women had their own source of income, it often led to increased empowerment and decision-making power within the household. Conversely, women who did not participate in income generation could hardly participate in decision-making in the house as recounted by this respondent.

“The only thing affecting my ability to make decisions, it’s because I’m not working. I do see those who are working, have the ability to decide, they can do their own things, as they wish. Even if there are obstacles from the husband, she can decide, let me do this. But for someone like me, it’s difficult.”-PNC 3

Health-related decisions, including seeking medical treatment, had financial implications. The costs associated with treatment impacted decision-making, particularly if they were substantial or necessitated long-term financial obligations. In such cases, decisions were made, considering the financial impact and available resources.

“Our clients depend on their husbands and their mothers-in-law as decision-makers. Since they depend on them especially the husbands to give them transport to go to the facility, they (husbands) are the key decision makers on where they seek their service.”-NO-IC

Spousal communication allowed for open dialogue, negotiation, and compromise, leading to decisions that consider the needs and preferences of both partners. Couples who trusted each other navigated power over each other by considering each other and providing a morale boost that facilitated decision-making in the household.

“It’s my husband whom I confide in the most. I feel comfortable talking to him, especially during my pregnancy, when I had a lot of complications like high blood pressure, and even had to undergo an operation. He’s my husband, so I talk to him, and he’s the one who helps me.”-PNC 3

Freedom of movement also influenced women’s immediate rational agency. Household structures were mostly patriarchal, where men held dominant roles and women’s mobility and decision-making power was limited. The traditional role of men as heads of households mandated a restricted life for women as they were expected to be submissive and show respect towards male partners.

“You find in some cultures a woman cannot say anything in front of the husband. The man is the one who speaks. In some areas, you are told “When you get here you follow what the husband, the mother or the father says”. -ANC 1

In contrast, single/separated women had complete freedom of movement and were able to decide alone. This was evidenced by one of the respondents, who shared that.

“When it comes to decision-making, I don’t think anyone can influence me because I make decisions myself. Even if someone discourages me, I know what I’m doing and what I’m looking for.”-ANC 2

Engaging in domestic tasks restricted women’s mobility outside the home. The demands of household chores meant that women could not move freely. Their social functioning was largely restricted to the household, the fields, and tending to children.

“Well, there are hindrances, at times I am alone at home without a house help, and I need to go somewhere. There are cows to take care of and children who may have gone to school waiting for me to make lunch. You see, there are hindrances, and you cannot just leave like that until you plan yourself.”-PNC 3

Mistrust within the household also undermined women’s freedom of movement and decision-making. These restrictions were reinforced by societal expectations and gender norms that prescribe women’s roles as primarily confined to the private sphere. Women’s ability to move about was sometimes constrained due to trust issues between spouses.

“You know, sometimes I come here in the morning and leave at two or three. He thinks it’s not just the hospital, he doesn’t understand, but I only come to the hospital. That’s one of the things he considers that and regulates my time out.”-PNC 3

Distance relational agency

Finally, social-cultural, and health systems factors presented various influences and circumstances that affected women’s ability to exercise agency and make choices in their lives. In this context, religious norms limited women’s access to evidence-based maternal care. Some respondents acknowledged that some religions challenged the idea of seeking healthcare in health facilities.

“In terms of decision-making, the church does not hinder anyone, but our church believes in not taking medication. We believe that if I am sick and you come to pray for me, I will be healed. However, it also says that if you know that your faith is not strong enough, you can go and seek medical treatment. But after you have received treatment, don’t come back to the church until you have finished whatever you need to do. Then, you can call on the elders to come and pray for you before returning to the church.”-CHV

Patriarchal structures including male dominance also limited women’s ability to exercise agency and make decisions independently. Most respondents emphasized men’s cultural role in decision-making regarding seeking MCH care. They acknowledged that increasing the engagement of men would yield considerable health benefits and provide an important avenue for giving men information which would also foster trust between spouses.

“Well, I would really wish to bring him along so he can see for himself how busy it is, from here to there. If he doesn’t see it for himself, he won’t understand.”-PNC 3

However, there were instances where male involvement was recognized as enabler for agency, as evidenced by men accompanying their spouses for clinics.

“You see, for instance, today my husband accompanied me, and he needed to go to work, so he brought me and went to work, and he finished what he was doing, and now he is calling me because we have been waiting here for a long time.”-PNC 1

Additionally, gender norms affected women’s ability to make decisions at the household level. Several women had partial control of their households’ finances but also kept financial secrets from their partners. This could be attributed to the feeling of being disempowered and the belief that financial secrets would give them a sense of autonomy. Interestingly, even after saving this money secretly, some women still needed their spouse’s approval to spend.

“They (women) also fear, even after saving they still can’t use the money without getting approval from the husband because they cannot do anything. It is mandatory, the husband has to know.”-MCH in charge

Women also stressed the need for securing the buy-in of the decision makers through community units, the nyumba kumi initiative, counselors, and healthcare providers.

“If we can find partners like you, we can go to the assistant chief’s council through the community health volunteers (CHVs). We can invite men to attend, and even if not all of them will come, we can create a network by telling a friend who tells another friend. This is like politics, but if we can use this network to spread the importance of maternal healthcare, it will be beneficial.”-CHV.

Health system factors such as facility workload, wait times, staff availability, and distance to health facilities also impacted women’s agency. The healthcare facilities were often overwhelmed with a high patient load, leading to longer waiting times, and delays in receiving care which can reduce women’s agency in seeking timely healthcare and may force them to delay or forgo necessary care. Women’s ability to make decisions about their own health was compromised when they had limited choices or faced barriers to accessing services. It also created a burden on women who had additional responsibilities, such as caregiving or work, as they struggled to find time to visit busy healthcare facilities.

“The health workers here are often overworked and have many patients to attend to. This leads to longer waiting times, which can sometimes make the patients frustrated.”-CHV

“Because of the staff shortage, we have only 2 staff in the ANC area. So, if one goes on leave, the one who is there serves both sides, the ANC and the other clients, the immunization side. So, the long queues and the long waiting time affect them, they don’t like it. I think that demotivates them even just to come to seek the services” -NO IC.

The distance between women’s residences and healthcare facilities also impacted their agency due to challenges related to transportation, time constraints, and financial resources required for travel.

“Most of them I’ve seen prefer the rural facilities, that is health centers or dispensaries instead of coming back to Lumakanda. I think the issue affecting them is transport.”-MS.

“At night, for a car, you’ll spend Ksh. 2,000 and if it’s a motorcycle, you’ll give him Ksh.800 shilling.”-FGD-BC

In some cases, where improved road networks existed, there were reports of women being able to access hospitals easily without difficulties.

“They come to Lumakanda because the road is tarmacked, so, if it’s a pregnant woman, she will not be spun in potholes.”-FGD Men

Our results indicate that individual agency, immediate relational agency, and distance relational agency influence women’s agency and autonomy. In terms of individual agency, factors such as self-stigma, trust in oneself, social networks, and previous birthing experiences emerged as important determinants of women’s decision-making power and control over their lives. Immediate relational agency, on the other hand, highlighted the significance of household decision-making dynamics, including aspects like control of household finances, respect between couples, and spousal communication. These factors played a crucial role in shaping women’s ability to exercise agency within their immediate relationships. Furthermore, distance relational agency demonstrated the impact of health system factors and socio-cultural norms on women’s agency and autonomy. Factors such as facility workload, staff availability, and religious norms were found to significantly influence women’s decision-making power and freedom of movement. Overall, these findings underscore the importance of recognizing and addressing various dimensions of agency and autonomy in order to empower women and promote gender equality.

Our work highlights a myriad of factors that influenced decision-making among women attending ANC, delivery, and PNC clinics during the early days of implementing a service delivery reform aimed at shifting all delivery to hospitals in a rural county in Kenya. Women’s autonomy and agency is still limited despite it being a crucial determinant of the use of maternal healthcare services. In our case, literacy was a pointer when analyzing women’s individual agency and decision-making capacity in engaging with MCH interventions and reforms. Our work revealed how, women with limited health literacy were unaware of their options in regarding participation in decision-making over their own reproductive health. Respondents reported the positive contribution of mass media in enhancing the household decision-making capacity. Similarly, Seidu et al. [ 33 ] demonstrated that women who watched television almost every day had a higher capacity to take household decisions, compared to those who did not watch television at [ 33 ] all. Mass media influences women empowerment, including their ability to take household decisions [ 34 ] by changing some socio-cultural norms such as gender stereotyping [ 35 ] suggesting that interventions to promote shared decision-making may be particularly important for patients with limited health literacy.

When women had individual agency, they reported having informed and better financial choices for themselves, and their families. Thus, individual agency elevated perceived self-efficacy in their decision making. Choices about individual women’s reproductive pathways and decision-making for care seeking therefore depended their perception of self; the self in relation to social environment and reflection on risks associated with the decision to seek care or not [ 36 ]. Social identity influences decision-making practices of individuals emphasizing the importance of deliberately embracing diversity and promoting inclusion future in the design of interventions and reforms with a focus on. This involves acknowledging and valuing different social identities, creating spaces that are safe and accessible for all individuals, and actively involving them in decision-making processes [ 37 ].

Women’s autonomy can also be better understood from a relational perspective since individual autonomy often fails to incorporate social reality. Relational autonomy posits that persons are socially embedded and that their identities are formed within the context of social relationships and shaped by a complex of intersecting social determinants and health system determinants [ 38 ]. We found that in both joint and nuclear families, women who have better spousal communication with their husbands have greater agency. The role of immediate relational agency is therefore mediated through the family context and the quality of relationships the women have which consequently influences their agency. Male heads of households were central in health decisions, and in some instances discussing health issues with their wives before final decisions were made [ 39 , 40 ]. While joint and constructive communication leads to psychological well-being and protect against stressors during pregnancy [ 41 ] the process for decision-making often becomes delayed, consequently mothers’ ability to receive professional health care and other obstetric interventions on time.

Freedom of movement is also an important determinant of immediate relational agency, as the household structure affects women’s freedom of movement, since women residing in joint households are less likely to have decision-making power and need permission more often from other household members to execute some routine household activities [ 42 ]. Women require the permission of a husband or another male to pursue activities outside the home due to trust issues, social norms, and religious norm. This subsequently limited women’s ability to access and use skilled maternal health services including attending antenatal clinics or giving birth at a health facility. However, women who worked outside the home were more mobile, and women who were independent in the social sphere were also confident in their ability to negotiate independent mobility [ 40 ]. Additionally, it has been shown that husbands’ out-migration promotes women’s freedom of movement [ 43 ].

In summary, there is need for deliberate efforts towards empowering women’s autonomy in reproductive matters. Men might also benefit in the empowerment process through enlightenment and through effective implementation of male engagement interventions that leverage men’s power within households and promote women’s autonomy in decision making. Notably, women who receive male engagement education report making joint decisions (such as contraceptive choices, purchases of daily needs, and whether or not to work out of the home) compared to those who do not received such education [ 44 ].

The strength of this study includes the comprehensive exploration of agency across multiple dimensions, providing insights into the influence of factors such as previous birthing experiences, self-esteem, social support, financial control, respectful communication, and health system barriers on women’s agency. Although the challenge of establishing causality between the identified factors and women’s agency pose a challenge, the findings offer compelling descriptive explorations of the often undermined voice of women in shaping maternal and child health interventions policies and practices.

The study findings underscore the limited autonomy of women in Kakamega County, emphasizing the importance of considering women’s decision-making in the successful implementation of the SDR. Moving forward, it is crucial for SDR implementation strategies to recognize and promote women’s autonomy, engaging decision-makers to understand the significance of women’s choices regarding delivery in higher-level facilities. This calls for a concerted effort to enhance women’s autonomy in reproductive healthcare through initiatives such as male involvement, women’s empowerment programs, access to resources, and institutional support. Additionally, MCH programs should prioritize health and financial literacy, freedom of movement, gender equality, and media access to counter cultural and religious barriers to women’s autonomy.

Availability of data and materials

The data that supports the findings of this study are available in the article and its supplementary material.

Abbreviations

Antenatal clinics

Community Health Volunteers

Emergency obstetric and newborn care

Facility Improvement Fund

Focus Group Discussions

International Centre for Research on Women

In-depth interviews

Key Informant Interviews

Newborn Unit

National Health Insurance Fund

Sustainable Development Goal

Service Delivery Redesign

Crossing the quality chasm: a new health system for the 21st century - PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/25057539/ . Cited 2020 Jul 25.

Epstein RM, Street RL. The values and value of patient-centered care. Ann Fam Med. 2011;9:100–3.

Article   PubMed   PubMed Central   Google Scholar  

Ells C, Hunt MR, Chambers-Evans J. Relational autonomy as an essential component of patient-centered care. IJFAB. 2011;4(2):79–101.

Google Scholar  

Prata N, Tavrow P, Upadhyay U. Women’s empowerment related to pregnancy and childbirth: introduction to special issue. BMC Pregnancy Childbirth. 2017;17(2):1–5.

Imo CK. Influence of women’s decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria: evidence from the Nigeria Demographic and Health Survey 2018. BMC Pregnancy Childbirth. 2022;22(1):141.

Bloom SS, Wypij D, Das GM. Dimensions of women’s autonomy and the influence on maternal health care utilization in a north Indian city. Demography. 2001;38:67–78.

Article   CAS   PubMed   Google Scholar  

Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: implications for maternal health service utilization in developing countries. PLoS One. 2010;5(6):e11190.

Article   ADS   PubMed   PubMed Central   Google Scholar  

Mistry R, Galal O, Lu M. Women’s autonomy and pregnancy care in rural India: a contextual analysis. Soc Sci Med. 2009;69(6):926–33.

Article   PubMed   Google Scholar  

Thapa NR. Women’s autonomy and antenatal care utilization in Nepal: a study from Nepal demographic and health survey 2016. MOJ Women’s Heal. 2019;8(4):1–7.

MathSciNet   Google Scholar  

Vedam S, Stoll K, McRae DN, Korchinski M, Velasquez R, Wang J, et al. Patient-led decision making: measuring autonomy and respect in Canadian maternity care. Patient Educ Couns. 2019;102(3):586–94.

Gagliardi AR, Dunn S, Foster A, Grace SL, Green CR, Khanlou N, et al. How is patient-centred care addressed in women’s health? A theoretical rapid review. BMJ Open. 2019;9(2):e026121.

Sadiq UA. Women autonomy and the use of antenatal and delivery services in Nigeria. MOJ Public Heal. 2017;6(2):273–7.

Prata N, Fraser A, Huchko MJ, Gipson JD, Withers M, Lewis S, et al. Women’s empowerment and family planning: a review of the literature. J Biosoc Sci. 2017;49(6):713–43.

Corroon M, Speizer IS, Fotso J-C, Akiode A, Saad A, Calhoun L, et al. The role of gender empowerment on reproductive health outcomes in urban Nigeria. Matern Child Health J. 2014;18:307–15.

Do M, Kurimoto N. Women’s empowerment and choice of contraceptive methods in selected African countries. Int Perspect Sex Reprod Health. 2012;38(1):23–33.

Adhikari R. Effect of women’s autonomy on maternal health service utilization in Nepal: a cross sectional study. BMC Womens Health. 2016;16(1):1–7.

Article   Google Scholar  

Rominski SD, Gupta M, Aborigo R, Adongo P, Engman C, Hodgson A, et al. Female autonomy and reported abortion-seeking in Ghana, West Africa. Int J Gynecol Obstet. 2014;126(3):217–22.

Jejeebhoy SJ. Women’s autonomy in rural India: its dimensions. In: Determinants and the influence of context, IUSSP seminar paper on Female Empowerment and Demograpi, ic c’roce. 2000.

SDG Indicators. SDG indicators. Available from: https://unstats.un.org/sdgs/metadata/ . Cited 2023 Jan 6.

Crissman HP, Adanu RM, Harlow SD. Women’s sexual empowerment and contraceptive use in Ghana. Stud Fam Plann. 2012;43(3):201–12.

Burkitt I. Relational agency: relational sociology, agency and interaction. Eur J Soc Theory. 2016;19(3):322–39.

Ahinkorah BO, Dickson KS, Seidu A-A. Women decision-making capacity and intimate partner violence among women in sub-Saharan Africa. Arch Public Health. 2018;76(1):1–10.

Tesha J, Fabian A, Mkuwa S, Misungwi G, Ngalesoni F. The role of gender inequities in women’s access to reproductive health services: a population-level study of Simiyu Region Tanzania. BMC Public Health. 2023;23(1):1–9.

Fernando P, Porter G. Bridging the gap between gender and transport. In: Balanc load women, Gend Transp. 2002. pp. 1–14.

Bandura A. Human agency in social cognitive theory. Am Psychol. 1989;44(9):1175.

Merrell LK, Blackstone SR. Women’s empowerment as a mitigating factor for improved antenatal care quality despite impact of 2014 Ebola Outbreak in Guinea. Int J Environ Res Public Health. 2020;17(21):8172.

Mirghafourvand M, Bagherinia M. Relationship between maternal self-efficacy and functional status four months after delivery in Iranian primiparous women. J Psychosom Obstet Gynecol. 2018;39(4):321–8.

Kadengye DT, Atahigwa C, Kampire P, Mucunguzi S, Kemigisha E, Nyakato VN, et al. Effect of women’s intra-household bargaining power on postnatal and infant healthcare in rural Uganda-results from a cross sectional survey in Kyenjojo district. Midwifery. 2020;84:102665.

Field E, Pande R, Rigol N, Schaner S, Moore CT. On her account: Can strengthening women’s financial control boost female labor supply? Growth labour markes low income. In: Ctries Program Work Pap. 2016(32).

Heath R, Tan X. Intrahousehold bargaining, female autonomy, and labor supply: theory and evidence from India. J Eur Econ Assoc. 2020;18(4):1928–68.

Croke K, Gage A, Fulcher I, Opondo K, Nzinga J, Tsofa B, et al. Service delivery reform for maternal and newborn health in Kakamega County, Kenya: study protocol for a prospective impact evaluation and implementation science study. BMC Public Health. 2022;22(1):1727.

Strauss A, Corbin J. Basics of qualitative research techniques. 1998.

Seidu A-A, Ahinkorah BO, Hagan JE Jr, Ameyaw EK, Abodey E, Odoi A, et al. Mass media exposure and women’s household decision-making capacity in 30 sub-Saharan African countries: analysis of demographic and health surveys. Front Psychol. 2020;11:581614.

Jensen R, Oster E. The power of TV: cable television and women’s status in India. Q J Econ. 2009;124(3):1057–94.

Dasgupta S. Impact of exposure to mass media on female empowerment: evidence from India. Int J Dev Issues. 2019;18(2):243–58.

SolnesMiltenburg A, van Pelt S, Lindskog B, Sundby J, Meguid T. Understanding women’s decision-making process for birth location in Tanzania based on individual women’s reproductive pathways: a life-course perspective. Glob Health Action. 2022;15(1):2040149.

Scott J, Onyango MA, Burkhardt G, Mullen C, Rouhani S, Haider S, et al. A qualitative analysis of decision-making among women with sexual violence-related pregnancies in conflict-affected eastern Democratic Republic of the Congo. BMC Pregnancy Childbirth. 2018;18(1):1–9.

Osamor PE, Grady C. Autonomy and couples’ joint decision-making in healthcare. BMC Med Ethics. 2018;19:1–8.

Chace Dwyer S, Mathur S, Kirk K, Dadi C, Dougherty L. “When you live in good health with your husband, then your children are in good health….” A qualitative exploration of how households make healthcare decisions in Maradi and Zinder Regions, Niger. BMC Public Health. 2022;22(1):1–9.

Raman S, Srinivasan K, Kurpad A, Ritchie J, Razee H. “We have to ask and only then do”: unpacking agency and autonomy in women’s reproductive health in urban India. Health Care Women Int. 2016;37(10):1119–37.

Dakura J, Yidana A, Kuganab-lem R. Spousal communication in decision making during pregnancy in Northern Ghana. Public Health Res. 2022;12(3):69–77.

Debnath S. The impact of household structure on female autonomy in developing countries. J Dev Stud. 2015;51(5):485–502.

Ghimire D, Zhang Y, Williams N. Husbands’ migration: increased burden on or more autonomy for wives left behind? J Ethn Migr Stud. 2021;47(1):227–48.

Japhet P, Maluka S. Effects of male engagement interventions on women’s autonomy in decision making in Iringa Region, Tanzania. Tanzania J Dev Stud. 2021;19(1).

Download references

Acknowledgements

We would like to express our gratitude to the Kakamega County Government for granting us permission to conduct the study and for providing the essential preliminary information that facilitated our research. Furthermore, we would like to convey our sincere appreciation to the study participants for their invaluable cooperation throughout the course of this study.

This study is funded by the Bill and Mellinda Gates Foundation grant number # 263771.5119872. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Author information

Authors and affiliations.

KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya

Easter Olwanda, Dorothy Oluoch, Justinah Maluni, Joyline Jepkosgei & Jacinta Nzinga

Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA

Kennedy Opondo & Kevin Croke

You can also search for this author in PubMed   Google Scholar

Contributions

JN conceptualized the study, EO conducted the interviews, JN and EO undertook the analysis, EO developed the first draft of the manuscript. KO, KC, DO, JM, and JJ contributed to subsequent drafts and all authors approved this version of the manuscript for publication.

Corresponding author

Correspondence to Jacinta Nzinga .

Ethics declarations

Ethics approval and consent to participate.

Ethics approval was granted by the Kenya Medical Research Institute (KEMRI), Centre for Geographic Medical Research, Coast (CGMR-C) (KEMRI/SERU/CGMR-C/4226). All participants were provided information sheets and participants provided informed, written consent prior to any data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Supplementary material 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Olwanda, E., Opondo, K., Oluoch, D. et al. Women’s autonomy and maternal health decision making in Kenya: implications for service delivery reform - a qualitative study. BMC Women's Health 24 , 181 (2024). https://doi.org/10.1186/s12905-024-02965-9

Download citation

Received : 08 November 2023

Accepted : 11 February 2024

Published : 19 March 2024

DOI : https://doi.org/10.1186/s12905-024-02965-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Empowerment

BMC Women's Health

ISSN: 1472-6874

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 41, Issue 4
• Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0003-3067-9416 Jo Daniels 1 , 2 ,
• http://orcid.org/0000-0002-8013-3297 Emilia Robinson 1 ,
• http://orcid.org/0000-0001-5686-5132 Elizabeth Jenkinson 3 ,
• http://orcid.org/0000-0002-2064-4618 Edward Carlton 4 , 5
• 1 Department of Psychology , University of Bath , Bath , UK
• 2 Psychology , North Bristol NHS Trust , Westbury on Trym , Bristol , UK
• 3 Department of Health and Social Sciences , University of the West of England , Bristol , UK
• 4 Emergency Department, Southmead Hospital , North Bristol NHS Trust , Westbury on Trym , UK
• 5 Bristol Medical School , University of Bristol , Bristol , UK
• Correspondence to Dr Jo Daniels, Department of Psychology, University of Bath, Bath, UK; j.daniels{at}bath.ac.uk

Background Staff retention in Emergency Medicine (EM) is at crisis level and could be attributed in some part to adverse working conditions. This study aimed to better understand current concerns relating to working conditions and working practices in Emergency Departments (EDs).

Methods A qualitative approach was taken, using focus groups with ED staff (doctors, nurses, advanced care practitioners) of all grades, seniority and professional backgrounds from across the UK. Snowball recruitment was undertaken using social media and Royal College of Emergency Medicine communication channels. Focus group interviews were conducted online and organised by profession. A semi-structured topic guide was used to explore difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Data were analysed using a directive content analysis to identify common themes.

Results Of the 116 clinical staff who completed the eligibility and consent forms, 46 met criteria and consented, of those, 33 participants took part. Participants were predominantly white British (85%), females (73%) and doctors (61%). Four key themes were generated: ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’. Data pertaining to barriers and opportunities for change were identified as sub-themes. In particular, strong leadership emerged as a key driver of change across all aspects of working practices.

Conclusion This study identified four key themes related to workplace concerns and their associated barriers and opportunities for change. Culture, working environment and need for support echoed current narratives across healthcare settings. Leadership emerged more prominently than in prior studies as both a barrier and opportunity for well-being and retention in the EM workplace. Further work is needed to develop leadership skills early on in clinical training, ensure protected time to deliver the role, ongoing opportunities to refine leadership skills and a clear pathway to address higher levels of management.

• qualitative research
• staff support

Data availability statement

Data are available upon reasonable request. Requests go to the corresponding author - Jo Daniels ([email protected], University of Bath, UK). De-identified participant data can be made available upon reasonable request.

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/emermed-2023-213189

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

WHAT IS ALREADY KNOWN ON THIS TOPIC

Retention of staff in emergency medicine is at crisis level and has been a high priority area for over a decade.

Multiple guidelines have been published to outline improvements that need to be made to retain staff; however, little improvement has been seen on the ground in EDs.

Key factors such as staff burnout and poor working conditions are known to influence intention to leave; however, it is unclear why change has not taken place despite knowledge of these problems and existing guidelines seeking to address these issues.

WHAT THIS STUDY ADDS

This qualitative study assessed perceived barriers that may be inhibiting the implementation to working conditions and working practices in EDs.

Leadership is identified as an important driver of change in working practices and can play an important role in workplace well-being and retention.

Key recommendations for avenues of improvement are made, identifying key actions at government, professional, organisational and personal level.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

This study identifies leadership as a key opportunity for change and as a result makes specific recommendations for policy and practice regarding leadership in emergency medicine.

Introduction

Emergency Medicine (EM) is facing a global staffing crisis. 1 Record numbers of staff continue to leave the UK NHS with EM the most affected specialty. 2 EM reports the highest work intensity of all medical specialties, 3 with ‘intensity’ recognised as one of the leading factors in job dissatisfaction, attrition and career burnout. 3–5 These factors are amplified in an already stretched workforce. 2 Psychological well-being of the EM workforce is compromised, with working conditions recognised as playing a key role. 6 7 Staff attrition has a systemic impact: lower staff ratios lead to higher workloads, reduced quality of care, 8 higher levels of medical errors 9 and poorer staff well-being, 10 all factors associated with staff absence and intention to leave. 11 The landscape of EM has also changed; increased prevalence of high patient acuity, multimorbidity and an ageing population all bear considerable impact.

Key sector stakeholder initiatives and policy recommendations relating to retention and well-being 12–14 are largely generic and forfeit relevance to the specialty due to the lack of specificity to the clinical context within which these guidelines need to be implemented. Retention improvement programmes suggest approaches should be tailored per organisation, 12 however, this assumes that the challenges faced by staff across specialities and disciplines are homogeneous. In a specialty which reports the highest pressured environment, highest attrition and rates of burnout, 15 considerations of workplace context and specificity of policy recommendations are likely to be crucial. Interventions or initiatives must take account of the unique demands of the EM working environment, and how feasible it is to implement recommendations.

The James Lind Alliance (JLA) priority setting partnership in EM 16 identified initiatives to improve staff retention as research priorities in 2017 and again in the 2022 JLA refresh, 17 signalling the need for further research in this area due to a deepening workforce crisis. Current guidelines and initiatives target working conditions which are known to be associated with retention; however, these initiatives have been poorly implemented or enforced, with few formal evaluations of such interventions. 5 Moreover, current research is limited to the perspectives of specific professional groups and most are survey-based studies. 18

In order to better address current working conditions, with a view to improving retention, this research was aimed at determining practical barriers and opportunities for change in the ED working environment as perceived by professional staff working in this environment. This will tooffer insight into the shared experiences, constraints and priorities of those working within the ED.

Enhanced understanding of these issues can provide a firm basis from which to shape, inform and underpin future policies and workplace initiatives, ensuring that practical barriers and opportunities for change are embedded in a way that optimises relevance and feasibility of implementation in the ED working environment.

Study aims and objectives

This study sought to engage three core professional groups (doctors, nurses, advanced care practitioners; ACPs) who work within an EM context to better understand (a) primary concerns relating to working conditions; (b) perceived barriers to implementing change and (c) perceived opportunities and targets for change. Findings will be used to underpin key recommendations that are tailored to the needs of an over-burdened and under-resourced ED.

This qualitative study forms part of a larger collaborative project between the University of Bath and the Royal College of Emergency Medicine (RCEM), funded by a UKRI Policy Fund. The full recommendations relating to the four core themes are available on the RCEM website (Psychologically Informed Practice and Policy (PIPP) | RCEM).

Methodology

This study uses a qualitative approach involving online focus groups in order to gain a rich and detailed understanding of participant perspectives and views, unrestricted by closed question responses. Focus groups offer the opportunity to gain an understanding of shared experiences and narratives, using a dynamic approach to the subject matter, allowing further probing for clarification and participant interaction for deeper insights. The COVID Clinicians Cohort (CoCCo) study 19 was used to organise data into key categories; this model mirrors Maslow’s Hierarchy of Needs 20 from a workplace perspective.

Participants

To be eligible for participation, ED staff must have been currently employed in a UK NHS ED as either a doctor, nurse or ACP.

ACPs are a recently developed workforce of accredited clinicians who have received advanced training to expand the scope of their usual role (eg, paramedic, nurse), permitting them to take on additional clinical responsibility in the ED.

These three groups are core affiliates of the RCEM and represent the majority of the workforce in the ED. The ED setting was used as the focus (rather than all acute care settings) as this represents the core and central setting for EM.

Recruitment and procedure

Online adverts and qualtrics survey links were distributed through social media (ie, Twitter) and RCEM communication channels using snowball recruitment methods. Profession-specific focus group interviews were conducted online using MS teams by two study researchers (JD, ER) using a semi-structured topic guide (see online supplemental materials ). The guide was shaped by the scope of study aims and the current evidence base and explored difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Focus groups were 60–90 min in duration and were recorded using encrypted audio recorders, transcribed and stored securely. Participants were given debrief information sheets following the focus group. Transcripts were not returned to participants and no repeat focus groups were carried out.

Supplemental material

Directive content analysis was applied to the data. 21 This analysis strategy was used to identify common themes from participant responses, using deductive codes by identifying key concepts from existing theory 19 and prior research. Two researchers (ER, JD) read through each transcript, highlighting passages that could be categorised in the pre-determined codes. Any passages that could not be categorised within the initial coding theme were given new codes. Further coding was then conducted and this iteration was reviewed and updated. After coding was completed, initial notes from the focus groups were revisited to ensure all reflective notes were incorporated where relevant. Final themes were refined through an iterative process between JD, ER and EJ (qualitative analysis expert), with all stages of analysis reaching consensus agreement with regard to the content and labelling of codes and themes.

Patient and public involvement

As this study focused on staff experiences in an EM workplace, a Clinical Advisory Group (CAG) was used in place of patient or public involvement. The CAG comprised of five clinicians working in the ED who advised on the scope and priorities of the study. This included two medical consultants, one charge nurse, one trainee and one specialty grade doctor. Of those, three were males and two were females. All CAG members were offered renumeration for their time.

Of the 117 total responses to the study advert, 16 respondents were eligible but not available to attend focus groups and 55 either did not consent or were not eligible based on their role and/or department. From the remaining 46 respondents, 13 of these could not attend or cancelled, leaving a final sample of N=33 (28% of total responses). Due to higher response rates from doctors, these focus groups were further grouped by grade; nurses and ACPs were grouped by profession only and were organised base on availability. There were 11 groups in total (see table 1 ). Participants were mostly female, and from a white British background. Ages were spread fairly evenly across the categories, except ages 35–44 which included substantially fewer participants.

• View inline

Participant and focus group characteristics

Following analysis of the qualitative data, four key themes were generated. These were termed: ‘culture of blame and negativity’, ‘untenable working environments’, ‘compromised leadership’ and ‘striving for support’. Data within these themes that were identified as ‘barriers’ or ‘opportunities’ for change were extracted ( table 2 ). Illustrative participant quotes are identified by researcher codes, which reflect the profession and a recoded group number, to preserve anonymity.

Primary concerns, barriers and opportunities for change

Culture of blame and negativity

When asked about the most difficult aspects of their working conditions, participants commonly reported a culture of blame and negativity in the ED. The work culture not only felt unsupportive and ‘toxic’ but had a marked effect on well-being. Participants described a culture which was quick to blame rather than support:

You worry about making a mistake, and if you did make a mistake who would have your back. (ACP, G7) You very rarely get anyone saying that was a good job. (SAS doctor, G8)

This was particularly felt top-down, where those in management position were perceived to take an unsympathetic view of extended waiting times and unmet targets, despite the tangible constraints of operating at overcapacity and ‘exit block’, problems that participants perceived to be out of their control. Participants in all groups indicated that the negative culture instils anxiety over how they might be perceived by peers, but particularly by senior colleagues:

That’s a classic example… she’s a senior member of the team, really knows her job…. She was quite critical really, in a very negative way about how you managed that patient. (Nurse, G11)

Some participants reported senior colleagues having unrealistic expectations of the more junior staff, with little consideration of the increased pressures that have arisen in recent years:

It’s ridiculous to compare the needs, even for our senior colleagues who were registrars five years ago, the reality of running the department overnight is not the same as it was then. (SAS doctor, G1)

Existing structures and working practices of the NHS were described as ‘archaic’ and ‘old fashioned’, leading staff to feel blamed if they could not cope with the pressures and disempowered to seek support due to the expectation that they should be ‘unbreakable’ (Trainee, G9). Participants also voiced that they were unclear on lines of accountability, who to approach for what problem. This barrier to escalating their concerns was further compounded by the belief that both clinical leadership and higher management were generally overburdened and unreceptive to discussions on workplace concerns.

Increasing pressure and longer waiting times were described as driving antisocial behaviour from patients, exposing staff to risks to physical and psychological well-being:

So the long wait causes verbal or physical violence and aggression, which has a massive impact on staff well-being. (Nurse, G11)

Participants highlighted the desire to be supported to learn from difficult experiences and develop in light of them, suggesting that a simple checking in on how individual staff members are progressing would be well received and beneficial to well-being:

We have intermittent debriefs… but it’s not every time. It doesn’t necessarily need to be every time, but it’s not as frequent as it should be. Even if it is just ask are you okay? (Trainee, G5)

Interprofessional respect and development of a more empathic culture of shared responsibility were flagged as key opportunities for change that would support better team cohesion:

We need to change how we speak and respect each group, and we need to try and understand each other’s point of view, and if we could get better ways of working, but just talking to each other about what are my problems, what are your problems, why is this stressing you, what’s stressing us, how can we work together to do that. (ACP, G2)

Findings suggest that EM professionals are confronted with outdated perceptions of clinical demand from within teams and systems, with unrealistic expectations which compound a blame and shame culture when expectations are not met. Operating within this chronically under-resourced system was framed as compromising workforce well-being and risking burnout, yet participants indicated that simple interventions such as check-ins, clearer lines of accountability and a more civil and respectful culture would offer key opportunities for growth and sustainability even in the face of a staffing crisis.

Untenable work environments

The complex work environment within the ED was described as being of significant concern, compromising care and leaving staff feeling undervalued due to basic needs being unmet. Participants frequently reported poor quality or inadequate facilities, such as provision of toilets, lockers and changing rooms, hot food only available within limited hours, poorly functioning IT systems and rest spaces being in a different building.

So you’re just basically sharing (toilets) with the patients. In the urgent care centre there’s two toilets for the whole of the department in there, often one of those is broken…and not enough lockers for every member of staff. (ACP, G2) Stuff like working computers, a consistently working POD system… those little things I think make a bigger impact on your life than how many people come in through the front door. (Trainee, G5)

A lack of physical space for administrative tasks was highlighted by many clinical staff, being described as ‘woefully inadequate’ (ACP, G2). Wards were described as ‘unfit for purpose ’ (Nurse, G11), which was attributed, in part, to higher management lacking understanding of the needs and practices of the ED. One example highlighted the long-term impact of ED workspace changes that were not fit for purpose:

…it was clear that no clinical staff had been involved. Doors were in the wrong space, no sinks in the right place, not enough storage, poor flow, poor layout (ACP, G2)

Existing rest spaces or staff rooms were reported to be taken over to provide more clinical room, limiting the space for staff to change, rest and decompress.

The nurses were getting changed in a corridor, now they seem to have a cubicle they can get changed in. But the facilities for the same trust are really very different. (Nurse, G10)

This was perceived to be particularly important due to working in the high-pressure environments of a crowded ED, where staff voiced concerns regarding the sustainability of working with a high workload safely without private spaces.

EDs were perceived to be more busy, for reasons associated with shifts in societal expectations and perceptions of the scope and role of ED:

Go back ten years ago in the emergency department and people would try their best at home, would take painkillers, will see how it goes, not wanting to trouble A&E, but seems like now it seems like A&E is the open door for everybody just to come in with everything. (ACP, G7)

Participants used emotionally laden language when describing the intensity of the workload itself, with parallels drawn between being at war and working on the NHS frontline, where staff worked under similar levels of intensity but longer term and without rest.

…when people are deployed (in the forces) they are deployed for 6 months…because that 6 months is intense, it’s intense on your body, it’s intense on your mind, it’s intense on your family, it’s intense on everything about you, and that’s while you were deployed for 6 months, and then there’s some recovery time coming back. (Consultant, G4)

Comparisons were also made to the sinking of ‘the Titanic’:

There is the jollying everybody along, being the redcoat on the shift, cheering everybody up, saying everything is going to be okay, but feeling like you’re just rearranging the deckchairs on the Titanic (Nurse, G10)

The impact of a consistently high workload was described as being compacted by a lack of agency and autonomy over working patterns, which was perceived to be related to non-clinical staff making decisions about shifts without understanding the inherent pressures:

The people who control our rotas are… her job is a rota co-ordinator, she works in an office, she is administrative, and the person who signs that off is the manager for the department, again non-clinical, and getting leave is a nightmare, it’s awful. (Trainee doctor, G5)

Consultants identified that there were limited options to reduce workload when approaching retirement, and they did not necessarily feel well-equipped to continue operating under high pressure and for long hours. Those in training posts reported insufficient time to meet requirements or study due to workload, influencing both career progression and confidence in the role.

You are getting no progression because you’re not getting your training, and I know that personally in the last year I made my decision that I will not continue to work clinically, I will step back in the next few years because there’s… why would I stay doing something that there’s no reward for? (Nurse, G11)

Participants agreed that there was both a need and an opportunity for the ED to be a ‘nicer place to work’ (ACP, G2). Specific suggestions included a full staffing quota, ensuring staff are adequately rested to return to work and the opportunity for peer support:

My top three things would be coming on with a full staffing quote so you know there’s no gaps in the rota, so you’re all there. Everyone is well rested and ready for the shift, just being able to talk to each other on the shop floor and being quite open with each other on how everyone is feeling. (ACP, G7)

Many of the suggested changes directed at making working conditions in the ED more sustainable related to basic needs such as being able to take breaks, access healthy food and functioning IT when needed:

…having those opportunities to go off and have a five minutes when you need to, to be able to continue your shift. (ACP, G7) It would be really nice to be able to have some healthy nice food in the department. (Nurse, G11) As more and more of our job goes electronic, electronic notes, electronic prescribing, actually having IT systems that are fit for purpose, everyone has access to (Trainee doctor, G9)

Self-rostering was frequently mentioned as a positive experience for participants and a useful avenue to help participants to deliver better care and improve well-being:

One day off between a set of shifts is not enough to decompress and be re-energised to start back on your next set of shifts. So I think the rota, we have moved to a more self-rostering method now, and I think that’s helping with staff well-being, especially in our team. (A7)

Overall, working in existing ED environments was described as ‘untenable’ and ‘unsustainable’ in terms of both the working environment and the lack of agency and autonomy over high-intensity workloads. Many of the problems and solutions relate to provision of resources to meet basic needs, many of which are subject to professional and NHS regulations; however, due to pressures this is not being implemented.

Compromised leadership

Clinical leads in the ED were perceived to hold responsibility for setting the tone for culture and behaviour in the ED, leading by example:

And you lead by example as well, so if your consultant in charge is not taking a break you feel like you can’t ask to take a break. It’s the same with the nurses, if the nurse in charge is not taking a break then a lot of the junior nurses won’t come and ask for a break because again you’re guided by the leadership aren’t you? (A7)

The clinical lead in the ED is a key conduit for change, from a cultural and environmental perspective especially. However, participants expressed frustration about feeling that their voices were not heard or valued outside of the department, in part due to clinical leads being reluctant to escalate their concerns due to the discrepancies between clinical priorities within the ED and the priorities expressed by trust level executive management:

You’ve got the clinical side, and we are to one degree or another worried about the patients, and then you have got the management side and they are worried about figures, times or money, and those two things don’t really mesh together (ACP, G2)

Yet, within the EDs, leadership was described as being poorly supported in terms of protected time to train and deliver the role fully. Consultants voiced reluctance to take on a leadership role due to lack of ‘visible leaders’ to provide inspiration or exemplar: ‘There is no one for us to look up to, to lead us’ (Consultant, G4), ‘We need compassionate leadership’ (SAS doctor, G1).

A lack of definition or clear understanding of what the clinical role entailed was reported to make it difficult for clinical leads to be effective in their role:

People tell you that you’re there to lead, and you’re like I know but what does that mean? And then you don’t know if you’ve got to go to all these meetings, which ones you really need to go to, which ones can I not go to, also for me I do the job on my own. (Clinical lead, G6)

Participants emphasised they need a ‘clear definition of what the college would see the role to be, and how much time they would expect it to take of your job ’ (Clinical lead, G6). Any possibility for growth was hampered by a lack of training or support from colleagues to help with even the practicalities of the role (such as recruitment and personnel management):

I have literally started last week on a leadership course that’s been for other clinical leads in the organisation. But I feel a bit could have done with this maybe earlier. But that’s more about your leadership qualities and conflict resolution, it’s all that side of it as opposed to the actual practicalities of the job. (Clinical Lead, G6)

When considering possible solutions to these difficulties, participants suggested that an accessible time to do the job and an online repository may offer an opportunity to share resources, learn from one another and foster development:

I think sharing all the stuff we shared on the WhatsApp, trying to share stuff, so how to write a business case, what you need to do. (Clinical lead, G6) I should be doing work at a time I am getting paid, so you need to give me that time. (Trainee doctor, G9)

Mentorship was also deemed to be important for successful delivery of the role:

I think personally as leads and stuff we should all have some kind of mentoring type…Supervision, that’s the thing, we don’t get any. (Nurses, G10)

Participants described having difficulties feeding into emerging issues to address unmet need, blocked from communication with leaders by ‘layers of bureaucratic sediment’. This was compounded by the career trajectory of NHS management, where often those in post would swiftly move on for promotion.

Overall, clinical leadership within the ED was described as compromised, unsupported and, ultimately, a key barrier or missed opportunity for change in culture and working practices in the ED. However, there were clear indications of opportunities for growth and change, including a need for compassionate leadership, shared resources, time to do the job and mentorship.

Striving for support

This final theme encompasses the concerns raised by participants regarding well-being and staff support, specifically the barriers to accessing well-being support and their preferences in relation to what changes are likely to improve their well-being. Common barriers included having to attend support or well-being services during time off, with the scheduling of support geared to a ‘nine to five’ non-clinical workforce (ACP, G2). Mental health stigma in the ED was also cited as a key barrier.

I think for me it still feels like a bit of a stigma about saying I am struggling what should I do next. (Nurses, G11) There’s nowhere that I can express how I am feeling or even understand how I am feeling. (Consultant, G4)

This was reinforced by well-being not being viewed as a priority, with team check-ins or formal appraisals described as having ‘nothing in there about wellbeing’ (Clinical lead, G6), despite suggestions that simple well-being check-ins would suffice.

Participants suggested that support should not be purely accessed after the fact but something that should be prioritised and routinely available to staff to safeguard mental health:

… psychological support…it shouldn’t be something that we access when there is a problem, it should be something where we go well every month on a Friday at this time I go and talk to someone about what I have seen. (Trainee, G9)

Participants’ lack of understanding about which services were being offered was raised by many, with participants often able to list services available, or where the staff support centre was based, but not how or when one might access them. This offers a key opportunity for collaboration between staff support services and the ED to develop clearer pathways or a clear role for a departmental well-being lead.

Peer support was consistently highlighted as a highly valued resource that should be considered part of supportive culture ‘gives you somebody else to share the load with, and not be that single voice’ (Trainee doctor, G9). However, limited physical space and time to engage in peer activities were cited as barriers:

Well yeah it would be lovely to sit down and chat with my peers, apart from the fact that 1) we’re constantly busy, 2) we don’t have anywhere where we can sit and have a confidential gas. (SAS doctor, G8)

Overall, accounts suggested that existing support was largely unfit for purpose, and where it was easy to access (such as peer support) and available, it was often incompatible with ED working practices and within a culture where seeking support was often stigmatised.

Some participants expressed that having a psychologist embedded within the department was highly valued as a resource, particularly the different levels of support dependent on need:

…(during the pandemic) we setup weekly drop-in sessions with the psychologist… and it was really great for a lot of people to be able to drop-in, and then that led on to having one to one for people who felt they needed that, and also within ED we had a psychologist come round to our supervision when we needed them. (ACP, G7)

Participants reflected that psychological input introduced in response to the impact of the COVID-19 pandemic was highly valued. While many were open to discussion about their mental health and well-being, for many, stigma still permeates the ED culture and is further compounded by poor understanding and communication of available resources. Appointment of well-being leads, more value placed on well-being (including informal peer support) and routine access to psychology are suggested as opportunities to make strides towards improved well-being.

This study identified four key themes describing the difficulties in the ED work place. Working culture, physical working environment, pathways to care and leadership represent the core workplace concerns within our sample. These issues were perceived to play an instrumental role in their ability to sustain good working practices, well-being and, importantly, their intention to leave. Participants identified key barriers and opportunities within their work contexts which resonate with existing research and policy and can be used to shape the future policy and research development. 22 , 2 5 These findings act as a basis for the development of specialty-specific targets for change that are aligned with the views and voices of those working in this working environment and also take account the barriers and opportunities faced in the fast-paced unique environment of the ED. For a full set of EM-specific recommendations to underpin change across all of these four areas, see the Psychologically Informed Practice and Policy (PIPP) recommendations ( https://rcem.ac.uk/workforce/psychologically-informed-practice-and-policy-pipp/ )

Several of our findings have been noted in previous studies, particularly the role of culture, environment and access to support. 22 Most of the research examining factors associated with working conditions and retention in EM are profession specific 3 6 18 19 and are not readily generalisable to other professional groups in the ED. However, our study included doctors, nurses and ACPs from which emerged common cross-cutting themes affecting all of these professions working in the ED, themes which are consistent with the broader literature 9 10 but specific to the EM working environment.

As reflected in the work by Darbyshire et al , 5 the nature of the problems described were systemic; the workplace challenges were interrelated and appeared reciprocal in influence, arguably maintaining one another. The cyclical nature itself proves a key barrier to change, which raises the question: which is the primary target to effect most change? Leadership has a pivotal influence across these themes and is unequivocally vital to workforce transformation; however, this is an area that has been largely neglected in EM, with very little research seeking to develop or evaluate leadership interventions in this environment. Indeed, there is an assumption that leadership naturally develops over time and is fully formed on appointment to the role. 23 However, leadership within the ED is particularly complex and demanding due to the range of competencies required (clinical, managerial and administrative) 23 and the high-pressured environment within which this role needs to be delivered. This warrants tailored training and support to fully succeed. In settings where the nature of the work is unpredictable and at times clinically critical, leadership is pivotal to patient outcomes and team functioning, 23 24 which are particularly crucial in the ED setting. Leadership has the potential to be a powerful driver in workforce transformation, cultural change 25 and team functioning within these highly skilled, professionally interdependent teams. 26 To fully harness the capacity of leaders as agents of change, those in leadership positions must be sufficiently skilled, 27 feel supported to act on important issues 27 and have time to do the job. Yet, participants in this study reported poor role definition, lack of training and absence of protected time to deliver the role. This was compounded by blurred lines of accountability that led to impotence to effect change.

Implications

The development of leadership in EM should now be a primary focus. There are clear steps that can be taken to begin to mobilise and maximise the pivotal influence of leadership in effecting change, across government, professional, organisational and individual levels.

On a public policy level, there has been a rapid growth of government level publications and resources to recognise the role of leadership as a conduit to better patient and team health. 28 However, recommended leadership training is often generic and never mandated. This is surprising given the clear links with patient safety and team functioning. 23 24 Leadership training in healthcare should be mandated by government bodies, not least due to links with patient safety. 29

Significant work has been undertaken by RCEM to integrate and embed mandatory leadership training into the training curriculum for EM trainees, without which they cannot progress. While this demonstrates forward thinking and some future-proofing for the medical profession, it cannot cease at this point, it must be supported with continuing professional development post-training. The relevant professional bodies provide access to good quality leadership training such as the RCEM EM Leaders Programme and the RCN Leadership Programme, however, this is largely online without protected time to access or support development. More work is needed to ensure leadership training is visible, supported as part of a workplan, and a priority area championed by all relevant professional bodies.

Further work is needed to ensure that leadership competencies are introduced at an early stage of training 23 so the necessary skills are embedded and cultivated on the pathway towards and within leadership roles, rather than ad hoc when necessity dictates. This falls to both training and professional bodies to work together to ensure that theory-driven leadership is a core part of the teaching curriculum, with mentorship and practical resources (such as role definition, a personal development plan, human resource support) to complement and facilitate the necessary continuing professional development throughout a clinical career. Responsibility then moves to the employing local NHS trusts to support the development of those individuals within leadership positions. It is at this level that ED clinical leads and their teams can harness their influence; local NHS trust policies are driven by guidance from government and professional bodies, however, they have the power to shape local policy and mandate change in view of the needs of a service. We summarise key recommendations to underpin change at a local NHS level in Box 1 .

Key leadership recommendations for local NHS trust level commissioning

Those in leadership positions should be supported to attend leadership training as part of their workplan, within their workplace hours. This would include top-up training and training assignments.

Support to engage with a leadership mentorship or coaching programme as part of their workplan, with a view to continuing professional leadership development and creating safe spaces to problem-solve, reflect and seek support.

Access to the consultation service within the local NHS staff support services.

Appointment of a designated ‘Wellbeing Lead’ with protected time and support to deliver the role.

Clear description of roles and responsibilities, to include protected time dedicated to undertaking additional responsibilities associated with a leadership role and a professional development plan that is reviewed annually.

Support to engage with the EM clinical lead network in order to access resources to support the delivery of the role and access peer support when necessary.

Clear lines of accountability at an NHS organisational level with identified pathways to escalate concerns.

EM, emergency medicine.

Appointment of well-being leads within the ED, as outlined in the RCEM PIPP recommendations 30 and other key documents, 22 is also a key step towards workplace transformation through leadership; however, it is imperative this role is also supported with protected time and development. A well-being lead with a clearly defined remit and role would play a pivotal gatekeeper role in encouraging attitudes towards well-being in the ED by delivering ‘warm handovers’ and well-being initiatives, such as informal check-ins, staff team activities (ie, safety huddles), and well-being surveys.

On an individual level, those in leadership positions are more likely to succeed by harnessing the influence and opportunity that accompanies the role, identifying and taking inventory of challenges and barriers, clarifying lines of accountability to drive forward change and advocating for the needs of their team. Two mechanisms by which leadership bears the greatest influence include leading and prioritising a continuous cycle of quality improvement (eg, autonomy over work patterns, access to rest spaces, patient flow, taking steps to address the diversity gap) and role modelling of positive professional behaviours. 26 The latter includes compassionate and inclusive attributes but also speaks to the necessity to meet basic needs: taking breaks, adhering to annual leave, destigmatising views on mental health and openness to learning and change. Those in leadership roles should be encouraged to engage with the leadership networks, broadened to encompass a platform or virtual environment (ie, repository) to share and access resources and be granted access to leadership consultation with the well-being team as and when necessary. Those in leadership positions should also be provided with clear referral processes and internal professional standards to help address any incivility, including bullying, harassment and issues of inclusion. This would help promote a culture of care and interprofessional valuing and respect, improving team cohesion.

Finally, it is imperative that lines of accountability are clear for those in a leadership position. While many NHS trusts differ in their management structures, each trust will have communication pathways to divisional and executive management leadership teams. In order to drive the full potential of leaders to action change through these mechanisms, it is fundamental that pathways from ‘shop floor’ to the chief executive are clear and opinions and concerns of ED leadership are welcomed.

Flow through the ED, staff ratios, pay and pension structures are of course prime targets for change and where the current high-profile focus lies. However, leadership is a key conduit to change and those with mandatory powers must now move to recognise this in order to unlock the full potential of this role.

Limitations and future directions

There are inherent limitations in the small size of some of the participant groups, and as such the views and opinions expressed cannot be considered transferable across their respective professions. While many prospective participants did not proceed to focus group meetings due to last minute requests to cover shifts, the participant pool was comfortably within the bounds of what is acceptable for a qualitative study.

Findings should be interpreted in light of the sample consisting mainly of white women, therefore the views of males and minority groups may not be fully represented. Doctors made up a higher proportion of the final sample; this may be a consequence of using RCEM communication channels as a primary recruitment method, which has more members registered as doctors than nurses. As not all professions working in ED were included (eg, physiotherapy, psychology) it is possible that additional themes or differences might have been missed.

The geographical spread reflects a broad reach; however, there was a preponderance towards the South West, where the research was conducted. While none of the interviewees were known to the research team, those in the South West may have been more exposed to recruitment drives through mutual connections.

The development and testing of leadership training and packages should be a priority for professional bodies and at organisational level. This should take account of the overlapping and competing competencies required of ED leadership, including managerial, administrative and clinical components and the high-pressured context within which these skills are required.

This study identified key themes in understanding workplace concerns in the ED, and their associated barriers and opportunities for change. Leadership in EM should now be a primary focus, with further investment and support to target the development of leadership skills early on in training and provide protected time to refine these leadership skills and qualities across the working lifetime. This will serve to harness the pivotal influence of leadership in EM, which, if properly supported, holds the potential to act as a conduit for change across all areas of focus.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by University of Bath Psychology Research Ethics Committee (22-039). The Health Research Authority toolkit confirmed further approval was not required. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The study authors would like to extend thanks to all who contributed to this project including participants and the clinical advisory group. The authors would also like to acknowledge and thank RCEM President (AB) and policy advisor (SMcI) who advised on the policy priorities of RCEM and wellbeing clinical leads (Dr Jo Poitier, Consultant Clinical Psychologist at Alder Hey Children's NHS Foundation Trust; Dr Olivia Donnelly, Consultant Clinical Psychologist at North Bristol NHS Trust) who were consulted on their respective areas of expertise. They also thank Rita De Nicola for help in preparing the manuscript.

• World Health Organisation
• Royal College of Emergency Medicine
• General Medical Council
• Darbyshire D ,
• Brewster L ,
• Isba R , et al
• Fitzgerald K ,
• Benger J , et al
• Roberts T ,
• Daniels J ,
• Hulme W , et al
• Kanavaki AM ,
• Lightfoot CJ ,
• Palmer J , et al
• Johnson J ,
• Watt I , et al
• Hofmeyer A ,
• National Health Service
• Royal College of Nursing
• Chen CC , et al
• James Lind Alliance
• McDermid F ,
• Pease A , et al
• Health Education England
• Husebø SE ,
• Thomas CS ,
• Tersigni A , et al
• Poorkavoos M
• Chaudry J ,
• McKenzie S , et al
• Brittain AC ,
• Carrington JM
• Robinson E ,
• Jenkinson E , et al

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

Handling editor Caroline Leech

Twitter @drjodaniels

Contributors The original concept for the paper was developed by JD and shaped in consultation with EC and the RCEM President AB. JD was the primary contributor, guarantor and lead for the content and refinement of the paper. EJ gave expert methodological advice and contributed to the reporting and refinement of results. ER and JD performed the analysis, both contributing to the reporting of the results. ER prepared the manuscript for publication. EC gave expert advice on all aspects of the study from an Emergency Medicine standpoint and also contributed to the write-up of the paper. All authors contributed to the final version of the paper and approved for publication.

Funding This research has been carried out through funding from the UK Research and Innovation Policy (UKRI) Support Fund. The funder did not provide a grant number for this project, it is part of block 'UKRI Policy Support' funding from UKRI directly to Universities who distribute within their institutions. The funders had no role in considering the study design or in the collection, analysis or interpretation of data; the writing of the report or the decision to submit the article for publication.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

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.

Read the full text or download the PDF:

• Open supplemental data
• Reference Manager
• Simple TEXT file

People also looked at

Original research article, exploring primary care physicians’ challenges in using home blood pressure monitoring to manage hypertension in singapore: a qualitative study.

• 1 SingHealth Polyclinics, Singapore, Singapore
• 2 SingHealth Duke-NUS Family Medicine Academic Clinical Programme, Singapore, Singapore

Objective: Hypertension guidelines recommend using home blood pressure (HBP) to diagnose, treat and monitor hypertension. This study aimed to explore the challenges primary care physicians (PCPs) face in using HBP to manage patients with hypertension.

Method: A qualitative study was conducted in 2022 at five primary care clinics in Singapore. An experienced qualitative researcher conducted individual in-depth interviews with 17 PCPs using a semi-structured interview guide. PCPs were purposively recruited based on their clinical roles and seniority until data saturation. The interviews were audio-recorded, transcribed verbatim and managed using NVivo qualitative data management software. Analysis was performed using thematic analysis.

Results: PCPs identified variations in patients’ HBP monitoring practices and inconsistencies in recording them. Access to HBP records relied on patients bringing their records to the clinic visit. A lack of seamless transfer of HBP records to the EMR resulted in an inconsistency in documentation and additional workload for PCPs. PCPs struggled to interpret the HBP readings, especially when there were BP fluctuations; this made treatment decisions difficult.

Conclusion: Despite strong recommendations to use HBP to inform hypertension management, PCPs still faced challenges accessing and interpreting HBP readings; this makes clinical decision-making difficult. Future research should explore effective ways to enhance patient self-efficacy in HBP monitoring and support healthcare providers in documenting and interpreting HBP.

Introduction

Treatment of hypertension relies heavily on accurate BP measurement. However, office BP alone is inadequate to assess BP control accurately due to BP variability and the existence of various hypertension phenotypes such as whitecoat uncontrolled hypertension and masked hypertension ( 1 – 3 ). Increasingly, out-of-office BP measurements, including ambulatory BP and home BP (HBP), are being recommended in the diagnosis and monitoring of hypertension ( 4 ). Additionally, high ambulatory BP and HBP have been associated with increased cardiovascular morbidity and mortality independent of office BP measurements ( 5 , 6 ). HBP monitoring is superior to ambulatory BP monitoring in cost, accessibility and usability ( 7 , 8 ). Globally, HBP device ownership varies between 30 and 70% ( 9 – 15 ). As a population known for embracing technology in a local study, more than 80% of Singaporean physicians recommended HBP monitoring to their patients and utilized these measurements to monitor the effects of anti-hypertensive therapy and make informed clinical decisions ( 16 ).

However, despite the increasing reliance on using HBP to diagnose, monitor and treat hypertension, studies have reported that PCPs face challenges in using HBP to manage patients with hypertension ( 17 , 18 ). These included inconsistency in HBP measurement, high out-of-pocket costs of home BP devices, and time needed to instruct patients on home BP monitoring procedures. A more recent study among American PCPs reported difficulty accessing patients’ HBP records and a lack of workflow to support patients using HBP devices ( 19 ). A local cross-sectional survey of 60 physicians (30 PCPs, 20 cardiologists and 10 nephrologists) identified patient inertia, poor patient adherence, short medical consultation time, and poor patient access to a BP machine as the barriers to implementing HBP monitoring in both hospital and primary care settings ( 16 ).

In primary care, where the majority of patients with hypertension are managed, the importance of HBP to inform prompt and accurate clinical decisions is even more pertinent, given the time constraints. Therefore, this study aimed to explore the challenges faced by PCPs when using HBP to manage patients with hypertension in their daily clinical practice. The findings of this study will help in the design of effective interventions in supporting healthcare providers to make informed decisions based on HBP. This study is part of a larger study to explore the challenges faced by doctors, nurses and pharmacists in managing patients with hypertension in a primary care setting.

Materials and methods

Study design.

A qualitative methodology using the descriptive-interpretive approach ( 20 ) explored the challenges in managing patients with hypertension, particularly on HBP.

Individual in-depth interviews (IDIs) of PCPs were conducted across five public primary care clinics located in the south and eastern region of Singapore (Bukit Merah, Marine Parade, Eunos, Sengkang and Pasir Ris). These primary care clinics provided hypertension care for a multi-ethnic Asian population; in 2022, there were over 200,000 patient-visits for hypertension with 850 attendances daily (based on the institution’s electronic medical record (EMR) system and business database).

Period of study

The field work was conducted between April 2022 and March 2023.

Research team

The research team comprised one female (ASM) and two male (PO, CJN) PCPs who worked in the institution where the study was conducted; they managed patients with hypertension in their routine clinical practice. All researchers are trained in qualitative research.

Study population and recruitment

The target study population was PCPs actively practicing in an urban public primary care setting. The eligible participants were PCPs aged 21 years and older who had been actively involved in managing patients with hypertension for the past 6 months. An email invitation containing the study purpose were sent by the senior author (CJN) to the PCPs to solicit participant interest. They were informed that participation was voluntary. Those who expressed interest were approached by a research coordinator to schedule a face-to-face interview and obtain informed consent. PCPs were recruited purposively based on their seniority and roles with an attempt to achieve maximal variation; the recruitment continued until no new themes emerged from the field notes and analysis (data saturation).

Study instruments

Participant demographic data collection form.

Participant demographic data collection forms were used to collect information about PCPs’ age, gender, clinical experience, qualification and designation.

Topic guide

The researcher used a semi-structured topic guide to guide the IDIs. The topic guide was developed based on Theory of Planned Behavior ( 21 ), literature review and discussion with the team members. The questions included PCP’s experiences, barriers and facilitators, and their needs when managing patients with hypertension in general and specifically on HBP monitoring. The topic guide was pilot-tested and iteratively modified based on data that emerged during both pilot and subsequent interviews.

Data collection

After obtaining the written consent, the participant completed the demographic data collection form, followed by the individual IDIs. The interviews were conducted face-to-face in a private room in the PCP’s practicing clinic. NCJ conducted all the interviews using the interview topic guide. Each interview lasted 45–60 min and all were audio-recorded. All participants were reimbursed with a grocery voucher of SGD20 (estimated USD15) to compensate for their time and effort.

Data analysis

All interviews were audio-recorded, transcribed verbatim and checked for accuracy. Three researchers (ASM, OP, CJN) read and reread three transcripts independently and repeatedly to familiarize themselves with the data. Each researcher coded the transcript line-by-line to generate a list of initial codes (open coding). The research team met regularly to discuss the codes; any coding discrepancies were resolved via consensus. Codes with similar content were grouped into categories; these categories were further rearranged to create an Initial coding frame (axial coding). Based on the coding frame, the rest of the transcripts were divided and analysed individually by the three researchers (ASM, OP, CJN) using the NVivo© (QRS Pty Ltd., Australia) qualitative data management software. The researchers performed constant comparison of the content of each code, which were reviewed, revised, refined, and re-named through discussion and consensus. Finally, a report of the themes generated, including the challenges faced by PCPs when using HBP to manage patients, was written with representative quotes to illustrate the key findings. No new challenges emerged after 12 interviews; further five PCPs were interviewed to ensure the data has reached saturation ( 22 , 23 ).

For the data collection, a senior researcher conducted all the interview; this helped to maintain the quality and consistency of the interviews. During the analysis, the research team met regularly to share, discuss and ‘challenge’ their data interpretations. The team adopted an open approach during the meetings and constantly reflected and debated potential biases they might carry due to their background as PCPs. The demographic data collection forms, audio recordings, transcripts, field notes, coding frame and codes were maintained in secure archives to establish a clear audit trail.

A total of 19 PCPs were approached, and 17 agreed and participated in the IDIs (response rate 89%). They were aged between 29 years and 80 years and had between 8 months and 40 years of clinical experience in primary care. The details of their demographic characteristics are presented in Table 1 .

Table 1 . Characteristics of participating primary care physicians ( n  = 17).

PCPs faced five main challenges when using HBP to manage patients with hypertension during their daily practice. They were: variations in patients’ home BP monitoring practices, inconsistent home BP recordings, reliance on patient to access the HBP records, laborious process of transferring patient HBP records to EMR, and difficulty in interpreting HBP records ( Figure 1 ).

Figure 1 . Challenges faced by primary care physicians on managing patients based on home blood pressure.

Variations in patients’ HBP monitoring practices

PCPs reported a variation in patient adherence to HBP monitoring and how they measured BP. PCPs encountered patients who declined to monitor their HBP despite owning a BP set; they perceived this was due to a lack of patient motivation.

“it’s very varied practice, some say they own a set but they do not use it because nobody told them to use it or they do not feel the need to use it or they use it occasionally when they do not feel well.,” P08 (47-year-old, Consultant, 17 years of practice).

“Some of them (patients) will just dismiss and say, “I really do not have the time, I’m too tired.” For these patients, I feel that they do not really have the motivation...” P07 (36-year-old, Associate Consultant, 11 years of practice).

“I was told that he has a machine, but just too lazy, not motivated to check. So, this time he admitted, “Actually, I’m not even (checking), do not know where the machine is actually.” P17 (32-year-old, Family Physician, 4 years of practice).

PCPs were also concerned that patients might not be measuring the HBP correctly or the HBP monitoring devices might not be calibrated; this made them doubt the accuracy of the HBP readings.

“… because a lot of times if they do it wrongly or the machine is faulty then of course you are going to get very erroneous numbers. Sometimes, the artery marker is placed on the other side that is one thing. Sometimes it could be the position of their arm whether it’s at the heart level or not.” P14 (35-year-old, Family Physician, 8 years of practice).

Inconsistency in HBP documentation by patients

PCPs also reported a wide variation in how patients document their HBP readings. PCPs struggled to make treatment decisions when patients did not document their BP or bring their BP records during their clinic visit.

“And they may or may not, in fact more of them do not record their blood pressure. So, that is a challenge because when they come in and their blood pressure is high and you ask them, “Oh, what is your blood pressure?.” Some will say, “Oh, at home it’s normal” and you ask them, “What is that number?” and they say, “I do not know but it’s normal.” So, how do you know it’s normal when you do not have a number, right?,” P08 (47-year-old, Consultant, 17 years of practice). “A lot of times they thought that it’s (recording and bringing BP records) a hassle. Some will feel like it’s not going to change anything. “Anyway, I am only here to collect medicine,” but they do not understand the point that the BP reading, they are actually so valuable because they (make) me decide what to do with their medication.,” P11 (34-year-old, Family Physician, 3 years of practice).

Reliance on patient to access the HBP records

PCPs relied on their patients to bring their HBP records to the clinic. Despite the availability of institution-based digital HBP diaries (Health Buddy), the adoption of these digital tools was low especially among the older, less tech-savvy patient populations.

“In general, we got a fairly healthy home BP ownership rate. But the problem lies more with patients forgetting to bring the home BP readings. “, P16 (40-year-old, Consultant, 12 years of practice). “… I would say the take up rate or the use of these digital blood pressure diaries is still very low. Our population, most patients with hypertension are probably in the middle to elderly age group. Many of them are not that tech-savvy.” P08 (47-year-old, Consultant, 17 years of practice).

Laborious process of transferring patient HBP records to electronic medical record (EMR)

Currently, PCPs had to manually key in patients HBP records into the EMR during the consultation. They had limited time to review stacks of HBP records brought by patients and to document them in the EMR. Without proper documentation, PCPs would not be able to assess patients’ “BP trend” over time.

“Even for the digital BP platform itself, the information goes to a separate platform but it’s not linked to the EMR, which means you need to open up another system. That is an inconvenience for the doctors,” P16 (40-year-old, Consultant, 12 years of practice). “Sometimes my patient’s hypertension is not very well-controlled. Then, I will need to flip back (his old BP records). Some of them, bring the whole stack, then I will flip back the past few months to see where it went wrong. But some patients will just throw (the past BP records) away. There is no good way to store this information which the patient has spent so much effort providing you with,” P07 (36-year-oild, Associate Consultant, 11 years of practice).

Difficulty in interpreting home blood pressure

Some PCPs struggled to interpret the HBP readings, particularly when the HBP readings fluctuated significantly, or were at the borderline. PCPs were hesitant to use these BP measurements to make treatment decisions.

“And then, they bring along a set of readings that looks high, sometimes low, sometimes you just do not know what to do.” P07 (36-year-oild, Associate Consultant, 11 years of practice). “…I mean for those HBP readings that were a bit borderline, you cannot say with confidence whether they have hypertension or not. I mean they are some which are clear-cut but those like borderline, you cannot say for sure. I do not like to just put a label on the person if the evidence is not very strong.” P15 (36-year-old, Family Physician, 6 years of practice).

There was a wide practice variation in how PCPs interpret the HBP readings; most would interpret the HBP by ‘eyeballing’ the BP readings. PCPs recognized this practice gap and attributed it to the lack of guidelines on HBP monitoring and interpretation.

“And I would circle every reading that is above the clinical target. And after I’ve done that, I will look at the sheet of paper and ask myself, ‘Do I see more circled readings or non-circled readings?’ This is a very crude, rough way of doing it. Of course, the best way is to actually get the average but what is the practical way to do this very quickly in a 10-min consultation,” P08 (47 year-old, Consultant, 17 years of practice).

“Ya. I guess okay looking at the home readings… it’s like I have my own internal thing, I guess. If maybe less than 20% of the readings are too high then I’ll consider it as okay overall.’ P12 (37-year-old, Consultant, 9 years or practice). “Sometimes they will come with a paper. And then I would like review the readings to see the rough range of the readings, whether it is morning or at night and whether there is a dip in the nocturnal blood pressure or not. And then look at the majority average of the readings and see whether they are optimal or suboptimal. I do not think we have a guide on how it should be reviewed or assessed. So it might be doctor-specific.” P05 (29-year-old, Family Physician, 3 years of practice).

Our study highlights practical challenges PCPs encountered when using HBP to manage patients with hypertension. While most of the identified challenges related to patient behavior, including variations in HBP measurement and documentation, the study also surfaced important gaps in PCP competency and a system in transferring and integrating HBP data. The PCPs in this study did not perceive cost and access to HBP monitoring devices as major challenges in using HBP to manage patients with hypertension.

Similar to our study, inconsistencies in HBP measurement and recording pose a barrier to using these records to manage patients with hypertension ( 24 , 25 ). In a survey among 643 hypertensive patients, more than two-thirds (71%) reported incorrect home BP measuring techniques ( 18 ). In a qualitative study, PCPs believed that patients failed to follow correct protocols for rest and body positioning during HBP measurements ( 26 ). A local study by Setia et al. ( 16 ) found that PCPs perceived patient inertia and poor patient compliance as the most common barriers to implementing out-of-office BP monitoring. In addition, Al-rousan et al. ( 27 ) reported patients’ willingness to monitor HBP but had concerns about their ability to do so. While patient education by clinicians and nurses can improve HBP technique ( 25 , 28 ), the time needed to instruct patients on HBP measuring protocols may not be feasible or available in busy clinical settings ( 18 ). Remote patient education through videos and online platforms could help improve HBP practices and techniques while working within the existing time constraints ( 29 ).

Lack of integration of HBP records into the EMR limited PCPs’ access to patient’s records. A systematic review of 12 studies identified similar challenges, including manually transferring patient-reported HBP data from multiple sources and devices and comparing them with office BP ( 30 ). This process was also considered laborious in busy primary care clinics ( 30 ). While integrating HBP into clinical care is an important goal, achieving integration is complex ( 31 , 32 ). Teo et al. ( 32 ) reported local PCPs’ and patients’ appreciation of the convenience of an integrated platform where HBP was automatically captured and transferred to a dashboard for PCPs to review and manage patients’ HBP promptly; patients were reassured they were being monitored by the care team and PCPs perceived their time was better utilized. Nevertheless, the participants highlighted the challenges with the usability of the equipment, management portal and data access ( 32 ). Thus, while integrating HBP records into the EMR can improve the workflow for PCPs and improve patient clinical outcomes, the perspectives of PCP and patients need to be incorporated into designing such a system to enhance its long-term adoption ( 33 ).

Similar to our study findings, studies by Teo et al., Setia et al., and Fletcher et al. also reported uncertainty among clinicians in interpreting HBP readings, particularly in patients with borderline BP and BP variability ( 16 , 30 , 32 ). Global hypertension guidelines recommend target HBP for therapy to the level below the threshold used to diagnose hypertension. However, a variation in these diagnostic thresholds results in variation in therapeutic HBP targets. While American College of Cardiology/American Heart Association 2017 guidelines specify a daytime (awake) average ≥ 130 mmHg systolic or ≥ 80 mmHg diastolic BP ( 4 ), European Society of Cardiology /European Society of Hypertension, International Society of Hypertension and National Institute for Health Care Excellence define hypertension as an average HBP of ≥135 mmHg systolic or ≥ 85 mmHg diastolic BP ( 24 , 34 , 35 ). Discrepancy also exists in HBP interpretation across the guidelines. These differences include the required number and timing of readings, averaging methods, and controversy over the omission of first readings ( 36 , 37 ). The lack of updated local clinical guidelines and PCP awareness of existing global guidelines creates practice variations in hypertension management among local PCPs ( 16 ). Local updated practice guidelines and frequent refreshers can help standardize clinicians’ management practices and keep them abreast of the current best clinical evidence ( 38 ).

PCPs in our study attributed challenges in HBP interpretation to insufficient time to calculate the average BP, which can result in clinical inertia and suboptimum BP control ( 30 ). A lack of clinical decision-support system can also create difficulty in interpreting HBP data in a timely and accurate manner. Manually going through patients’ HBP records is time-consuming and may not be practical in a busy primary care setting ( 30 ). Clinical decision support integrated into the clinician workflow could facilitate data interpretation and prompt decision-making ( 39 ).

Unlike previous studies on HBP monitoring, the PCPs in this study did not perceive out-of-pocket cost and access to HBP monitors as major challenges ( 13 , 14 ). This could be due to the Singapore government’s active promotion of using technology for health management ( 40 ). Additionally, various government and philanthropic programs actively support patients with chronic conditions like hypertension afford and utilize digital health tools. Locally, a philanthropic-sponsored program offers self-monitoring devices, including HBP devices, to “needy” patients at half the original price ( 41 ). Since its launch in 2020, more than 400 patients per year have benefited from it ( 41 ). Thus, introducing reimbursement and financial assistance enhance the use of HBP among patients, particularly those from low socio-economic stratum.

Limitations

The study has several limitations. Firstly, PCPs in this study were from a single primary care cluster in Singapore. To improve the transferability of the study findings, primary care clinics serving a diverse patient population were included, and PCPs with differing clinical roles and levels of experience were recruited. Future studies may be conducted in the private primary care sector in Singapore; this would uncover challenges unique to the PCPs and patients in the private sector. Secondly, this study focused on the challenges faced by PCPs and did not capture the challenges patients face in performing HBP monitoring. We are currently embarking on a study to explore patients’ experiences and challenges in HBP monitoring in primary care setting.

Despite international guidelines recommending HBP to inform the diagnosis, treatment and monitoring of hypertension, PCPs face significant challenges in accessing adequate and accurately measured HBP readings; they also struggle to document and interpret them consistently in their busy clinical practice. Future studies should identify effective ways to use HBP to support patient self-care and facilitate improved care for patients with hypertension by developing practical guidelines and clinical decision-support systems on HBP monitoring.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by SingHealth Centralised Institutional Review Board (CIRB No: 2022/2517). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

AM: Conceptualization, Formal analysis, Investigation, Writing – original draft, Writing – review & editing, Data curation. PO: Conceptualization, Formal analysis, Investigation, Writing – review & editing, Data curation. CN: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Supervision, Writing – review & editing, Data curation.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. The study is supported by SingHealth AM General Fund (14/FY2021/G2/01-A167), SingHealth Polyclinics and Duke-NUS Medical School.

Acknowledgments

The authors would like to express their gratitude to the SingHealth Polyclinics and primary care physicians who participated in the study.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmed.2024.1343387/full#supplementary-material

Abbreviations

HBP, Home blood pressure; PCP, Primary care physician; IDI, In-depth interview; EMR, Electronic Medical Record.

1. Setia, S, Subramaniam, K, Tay, JC, and Teo, BW. Hypertension and blood pressure variability management practices among physicians in Singapore. Vasc Health Risk Manag . (2017) 13:275–85. doi: 10.2147/VHRM.S138694

PubMed Abstract | Crossref Full Text | Google Scholar

2. Pioli, MR, Ritter, AMV, de Faria, AP, and Modolo, R. White coat syndrome and its variations: differences and clinical impact. Integr Blood Press Control . (2018) 11:73–9. doi: 10.2147/IBPC.S152761

3. Carretero, OA, and Oparil, S. Essential hypertension. Part I: definition and etiology. Circulation . (2000) 101:329–35. doi: 10.1161/01.CIR.101.3.329

Crossref Full Text | Google Scholar

4. Cepeda, M, Pham, P, and Shimbo, D. Status of ambulatory blood pressure monitoring and home blood pressure monitoring for the diagnosis and management of hypertension in the US: an up-to-date review. Hypertens Res . (2023) 46:620–9. doi: 10.1038/s41440-022-01137-2

5. Piper, MA, Evans, CV, Burda, BU, Margolis, KL, O’Connor, E, and Whitlock, EP. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. preventive services task force. Ann Intern Med . (2015) 162:192–204. doi: 10.7326/M14-1539

6. Ward, AM, Takahashi, O, Stevens, R, and Heneghan, C. Home measurement of blood pressure and cardiovascular disease: systematic review and meta-analysis of prospective studies. J Hypertens . (2012) 30:449–56. doi: 10.1097/HJH.0b013e32834e4aed

7. Parati, G, Omboni, S, and Bilo, G. Why is out-of-office blood pressure measurement needed? Hypertension . (2009) 54:181–7. doi: 10.1161/HYPERTENSIONAHA.108.122853

8. Arrieta, A, Woods, JR, Qiao, N, and Jay, SJ. Cost-benefit analysis of home blood pressure monitoring in hypertension diagnosis and treatment: an insurer perspective. Hypertension . (2014) 64:891–6. doi: 10.1161/HYPERTENSIONAHA.114.03780

9. Devaraj, NK, Ching, SM, Tan, SL, Ramzdan, SN, Chia, YC, and Devaraj, NK. A14814 ownership of home blood pressure devices among patients with hypertension in primary care. J Hypertens . (2018) 36:e172. doi: 10.1097/01.hjh.0000548699.65798.18

10. McManus, RJ, Wood, S, Bray, EP, Glasziou, P, Hayen, A, Heneghan, C, et al. Self-monitoring in hypertension: a web-based survey of primary care physicians. J Hum Hypertens . (2014) 28:123–7. doi: 10.1038/jhh.2013.54

11. Bancej, CM, Campbell, N, McKay, DW, Nichol, M, Walker, RL, and Kaczorowski, J. Home blood pressure monitoring among Canadian adults with hypertension: results from the 2009 survey on living with chronic diseases in Canada. Can J Cardiol . (2010) 26:e152–7. doi: 10.1016/S0828-282X(10)70382-2

12. Cuspidi, C, Meani, S, Lonati, L, Fusi, V, Magnaghi, G, Garavelli, G, et al. Prevalence of home blood pressure measurement among selected hypertensive patients: results of a multicenter survey from six hospital outpatient hypertension clinics in Italy. Blood Press . (2005) 14:251–6. doi: 10.1080/08037050500210765

13. Zahid, H, Amin, A, Amin, E, Waheed, S, Asad, A, and Faheem, A. et al, Prevalence and Predictors of Use of Home Sphygmomanometers Among Hypertensive Patients. Cureus . (2017) 9:e1155. doi: 10.7759/cureus.1155

14. Anbarasan, T, Rogers, A, Rorie, DA, Grieve, K, Robert, JW, Flynn, WV, et al. Factors influencing home blood pressure monitor ownership in a large clinical trial. J Hum Hypertens . (2022) 36:325–32. doi: 10.1038/s41371-021-00511-w

15. Baral-Grant, S, Haque, MS, Nouwen, A, Greenfield, SM, and Mcmanus, RJ. Self-monitoring of blood pressure in hypertension: a UK primary care survey. Int J Hypertens . (2012) 2012:1–4. doi: 10.1155/2012/582068

16. Setia, S, Subramaniam, K, Teo, BW, and Tay, JC. Ambulatory and home blood pressure monitoring: gaps between clinical guidelines and clinical practice in Singapore. Int J Gen Med . (2017) 10:189–97. doi: 10.2147/IJGM.S138789

17. Shimbo, D, Abdalla, M, Falzon, L, Townsend, RR, and Muntner, P. Role of ambulatory and home blood pressure monitoring in clinical practice: a narrative review. Ann Intern Med . (2015) 163:691–700. doi: 10.7326/M15-1270

18. Kronish, IM, Kent, S, Moise, N, Shimbo, D, Safford, MM, Kynerd, RE, et al. Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States. J Am Soc Hypertens . (2017) 11:573–80. doi: 10.1016/j.jash.2017.06.012

19. Gondi, S, Ellis, S, Gupta, M, Ellerbeck, E, Richter, K, Burns, J, et al. Physician perceived barriers and facilitators for self-measured blood pressure monitoring-a qualitative study. PLoS One . (2021) 16:e0255578. doi: 10.1371/journal.pone.0255578

20. Elliott, R, and Timulak, L. 'Descriptive and interpretive approaches to qualitative research In: J Miles and P Gilbert, editors. A Handbook of Research Methods for Clinical and Health Psychology . Oxford: Oxford Academic (2005)

Google Scholar

21. Ajzen, I . The theory of planned behavior. Organ Behav Hum Decis Process . (1991) 50:179–211. doi: 10.1016/0749-5978(91)90020-T

22. Guest, G, Namey, E, and Chen, M. A simple method to assess and report thematic saturation in qualitative research. PLoS One . (2020) 15:e0232076–17. doi: 10.1371/journal.pone.0232076

23. Hennink, MM, Kaiser, BN, and Marconi, VC. Code saturation versus meaning saturation: how many interviews are enough? Qual Health Res . (2017) 27:591–608. doi: 10.1177/1049732316665344

24. Stergiou, GS, Palatini, P, Parati, G, O’Brien, E, Januszewicz, A, Lurbe, E, et al. 2021 European Society of Hypertension practice guidelines for office and out-of-office blood pressure measurement. J Hypertens . (2021) 39:1293–302. doi: 10.1097/HJH.0000000000002843

25. Mancusi, C, Bisogni, V, Maloberti, A, Manzi, MV, Visco, V, Biolcati, M, et al. Accuracy of home blood pressure measurement: the ACCURAPRESS study - a proposal of young Investigator Group of the Italian hypertension society (Società Italiana dell’Ipertensione arteriosa). Blood Press . (2022) 31:297–304. doi: 10.1080/08037051.2022.2137461

26. Hsu, C, Hansell, L, Ehrlich, K, Munson, S, Anderson, M, Margolis, KL, et al. Primary care physician beliefs and practices regarding blood pressure measurement: results from BP-CHECK qualitative interviews. BMC Prim Care . (2023) 24:30–10. doi: 10.1186/s12875-022-01950-1

27. Al-Rousan, T, Pesantes, MA, Dadabhai, S, Kandula, NR, Huffman, MD, Miranda, JJ, et al. Patients’ perceptions of self-management of high blood pressure in three low-and middle-income countries: findings from the BPMONITOR study. Glob Heal Epidemiol Genomics . (2020) 5:e4. doi: 10.1017/gheg.2020.5

28. Fu, SN, Dao, MC, Wong, CKH, and Cheung, BMY. Knowledge and practice of home blood pressure monitoring 6 months after the risk and assessment management programme: does health literacy matter? Postgrad Med J . (2022) 98:610–6. doi: 10.1136/postgradmedj-2020-139329

29. Muldoon, MF, Einhorn, J, Yabes, JG, Burton, D, Irizarry, T, Basse, J, et al. Randomized feasibility trial of a digital intervention for hypertension self-management. J Hum Hypertens . (2022) 36:718–25. doi: 10.1038/s41371-021-00574-9

30. Fletcher, BR, Hinton, L, Hartmann-Boyce, J, Roberts, NW, Bobrovitz, N, and McManus, RJ. Self-monitoring blood pressure in hypertension, patient and provider perspectives: a systematic review and thematic synthesis. Patient Educ Couns . (2016) 99:210–9. doi: 10.1016/j.pec.2015.08.026

31. Koopman, RJ, Wakefield, BJ, Johanning, JL, Keplinger, LE, Kruse, RL, Bomar, M, et al. Implementing home blood glucose and blood pressure telemonitoring in primary care practices for patients with diabetes: lessons learned. Telemed J E Health . (2014) 20:253–60. doi: 10.1089/tmj.2013.0188

32. Teo, SH, Chew, EAL, Ng, DWL, Tang, WE, Koh, GCH, and Teo, VHY. Implementation and use of technology-enabled blood pressure monitoring and teleconsultation in Singapore’s primary care: a qualitative evaluation using the socio-technical systems approach. BMC Prim Care . (2023) 24:71–15. doi: 10.1186/s12875-023-02014-8

33. Rodriguez, S, Hwang, K, and Wang, J. Connecting home-based self-monitoring of blood pressure data into electronic health records for hypertension care: a qualitative inquiry with primary care providers. JMIR Form Res . (2019) 3:e10388. doi: 10.2196/10388

34. Unger, T, Borghi, C, Charchar, F, Khan, NA, Poulter, NR, Prabhakaran, D, et al. International Society of Hypertension Global Hypertension Practice Guidelines. Hypertens . (2020) 75:1334–57. doi: 10.1161/HYPERTENSIONAHA.120.15026

35. NICE . Hypertension in adults: diagnosis and management NICE guideline(2019), 1–41. Available at: www.nice.org.uk/guidance/ng136

36. Parati, G, Stergiou, GS, Bilo, G, Kollias, A, Pengo, M, Ochoa, JE, et al. Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the working group on blood pressure monitoring and cardiovascular variability of the European Society of Hypertension. J Hypertens . (2021) 39:1742–67. doi: 10.1097/HJH.0000000000002922

37. Kario, K . Home blood pressure monitoring: current status and new developments. Am J Hypertens . (2021) 34:783–94. doi: 10.1093/ajh/hpab017

38. Lewinski, AA, Jazowski, SA, Goldstein, KM, Whitney, C, Bosworth, HB, and Zullig, LL. Intensifying approaches to address clinical inertia among cardiovascular disease risk factors: a narrative review. Patient Educ Couns . (2022) 105:3381–8. doi: 10.1016/j.pec.2022.08.005

39. Koopman, RJ, Canfield, SM, Belden, JL, Wegier, P, Shaffer, VA, Valentine, KD, et al. Home blood pressure data visualization for the management of hypertension: designing for patient and physician information needs. BMC Med Inform Decis Mak . (2020) 20. doi: 10.1186/s12911-020-01194-y

40. Smart Nation Singapore , National Steps Challenge™ & Healthy 365 App (2022). Available at: https://www.smartnation.gov.sg/initiatives/health/national-steps-challenge

41. SingHealth Group , Empowering patients to help themselves, (2023); Available at: https://www.singhealth.com.sg/rhs/news/giving-philanthropy/empowering-patients-to-help-themselves

Keywords: home blood pressure, hypertension management, primary care, family medicine, self-monitored, uncontrolled hypertension

Citation: Moosa AS, Oka P and Ng CJ (2024) Exploring primary care physicians’ challenges in using home blood pressure monitoring to manage hypertension in Singapore: a qualitative study. Front. Med . 11:1343387. doi: 10.3389/fmed.2024.1343387

Received: 23 November 2023; Accepted: 13 March 2024; Published: 25 March 2024.

Reviewed by:

Copyright © 2024 Moosa, Oka and Ng. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Aminath Shiwaza Moosa, [email protected]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• J Grad Med Educ
• v.7(4); 2015 Dec

Choosing a Qualitative Research Approach

Associated data.

Editor's Note: The online version of this article contains a list of further reading resources and the authors' professional information .

The Challenge

Educators often pose questions about qualitative research. For example, a program director might say: “I collect data from my residents about their learning experiences in a new longitudinal clinical rotation. If I want to know about their learning experiences, should I use qualitative methods? I have been told that there are many approaches from which to choose. Someone suggested that I use grounded theory, but how do I know this is the best approach? Are there others?”

What Is Known

Qualitative research is the systematic inquiry into social phenomena in natural settings. These phenomena can include, but are not limited to, how people experience aspects of their lives, how individuals and/or groups behave, how organizations function, and how interactions shape relationships. In qualitative research, the researcher is the main data collection instrument. The researcher examines why events occur, what happens, and what those events mean to the participants studied. 1 , 2

Qualitative research starts from a fundamentally different set of beliefs—or paradigms—than those that underpin quantitative research. Quantitative research is based on positivist beliefs that there is a singular reality that can be discovered with the appropriate experimental methods. Post-positivist researchers agree with the positivist paradigm, but believe that environmental and individual differences, such as the learning culture or the learners' capacity to learn, influence this reality, and that these differences are important. Constructivist researchers believe that there is no single reality, but that the researcher elicits participants' views of reality. 3 Qualitative research generally draws on post-positivist or constructivist beliefs.

Qualitative scholars develop their work from these beliefs—usually post-positivist or constructivist—using different approaches to conduct their research. In this Rip Out, we describe 3 different qualitative research approaches commonly used in medical education: grounded theory, ethnography, and phenomenology. Each acts as a pivotal frame that shapes the research question(s), the method(s) of data collection, and how data are analyzed. 4 , 5

Choosing a Qualitative Approach

Before engaging in any qualitative study, consider how your views about what is possible to study will affect your approach. Then select an appropriate approach within which to work. Alignment between the belief system underpinning the research approach, the research question, and the research approach itself is a prerequisite for rigorous qualitative research. To enhance the understanding of how different approaches frame qualitative research, we use this introductory challenge as an illustrative example.

The clinic rotation in a program director's training program was recently redesigned as a longitudinal clinical experience. Resident satisfaction with this rotation improved significantly following implementation of the new longitudinal experience. The program director wants to understand how the changes made in the clinic rotation translated into changes in learning experiences for the residents.

Qualitative research can support this program director's efforts. Qualitative research focuses on the events that transpire and on outcomes of those events from the perspectives of those involved. In this case, the program director can use qualitative research to understand the impact of the new clinic rotation on the learning experiences of residents. The next step is to decide which approach to use as a frame for the study.

The table lists the purpose of 3 commonly used approaches to frame qualitative research. For each frame, we provide an example of a research question that could direct the study and delineate what outcomes might be gained by using that particular approach.

Methodology Overview

How You Can Start TODAY

• 1 Examine the foundations of the existing literature: As part of the literature review, make note of what is known about the topic and which approaches have been used in prior studies. A decision should be made to determine the extent to which the new study is exploratory and the extent to which findings will advance what is already known about the topic.
• 2 Find a qualitatively skilled collaborator: If you are interested in doing qualitative research, you should consult with a qualitative expert. Be prepared to talk to the qualitative scholar about what you would like to study and why . Furthermore, be ready to describe the literature to date on the topic (remember, you are asking for this person's expertise regarding qualitative approaches—he or she won't necessarily have content expertise). Qualitative research must be designed and conducted with rigor (rigor will be discussed in Rip Out No. 8 of this series). Input from a qualitative expert will ensure that rigor is employed from the study's inception.
• 3 Consider the approach: With a literature review completed and a qualitatively skilled collaborator secured, it is time to decide which approach would be best suited to answering the research question. Questions to consider when weighing approaches might include the following:
• • Will my findings contribute to the creation of a theoretical model to better understand the area of study? ( grounded theory )
• • Will I need to spend an extended amount of time trying to understand the culture and process of a particular group of learners in their natural context? ( ethnography )
• • Is there a particular phenomenon I want to better understand/describe? ( phenomenology )

What You Can Do LONG TERM

• 1 Develop your qualitative research knowledge and skills : A basic qualitative research textbook is a valuable investment to learn about qualitative research (further reading is provided as online supplemental material). A novice qualitative researcher will also benefit from participating in a massive online open course or a mini-course (often offered by professional organizations or conferences) that provides an introduction to qualitative research. Most of all, collaborating with a qualitative researcher can provide the support necessary to design, execute, and report on the study.
• 2 Undertake a pilot study: After learning about qualitative methodology, the next best way to gain expertise in qualitative research is to try it in a small scale pilot study with the support of a qualitative expert. Such application provides an appreciation for the thought processes that go into designing a study, analyzing the data, and reporting on the findings. Alternatively, if you have the opportunity to work on a study led by a qualitative expert, take it! The experience will provide invaluable opportunities for learning how to engage in qualitative research.

Supplementary Material

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of the Navy, the Department of Defense, or the US government.

References and Resources for Further Reading