qualitative published research article

Criteria for Good Qualitative Research: A Comprehensive Review

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• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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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.

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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

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Research Journals

The qualitative report guide to qualitative research journals, curated by ronald j. chenail.

The Qualitative Report Guide to Qualitative Research Journals is a unique resource for researchers, scholars, and students to explore the world of professional, scholarly, and academic journals publishing qualitative research. The number and variety of journals focusing primarily on qualitative approaches to research have steadily grown over the last forty years. From discipline- or profession-specific to trans-, cross-, and multidisciplinary missions, these journals represent a richly diverse approach to qualitative inquiry.

Acta Ethnographica Hungarica: An International Journal of Sociocultural Anthropology (First Issue: 1955)

Action Research  (First Issue: 2003)

Action Research Electronic Reader  (First Issue: 1997)

Action Research International  (First Issue: 1998)

AI Practitioner  (First Issue: 2003)

ALARA Journal  (First Issue: 1996)

American Ethnologist  (First Issue: 1974)

American Journal of Qualitative Research (First Issue: 2017)

Anthropology and Education Quarterly  (First Issue: 1970)

The Applied Anthropologist  (First Issue: 1981)

Biograf: časopis pro kvalitativní výzkum (Biograf: journal for qualitative research)  (First Issue: 1994)  (English Version )

Cadernos de Arte e Antropologia  (First Issue: 2012)

The Canadian Journal of Action Research  (First Issue: 2011; Formerly  Ontario Action Researcher

Commoning Ethnography (First Issue: 2018)

Critical Approaches to Discourse Analysis Across Disciplines  (First Issue: 2007)

Critical Discourse Studies  (First Issue: 2004)

Cultural Anthropology  (First issue: 1986)

Cultural Studies <=> Critical Methodologies  (First Issue: 2001)

Current Narratives  (First Issue: 2009)

Departures in Critical Qualitative Research (First Issue: 2012) (This journal was formally known as Qualitative Communication Research )

Discourse Analysis Online  (First Issue: 2003)

Discourse, Context and Media  (First Issue: 2012)

Discourse Processes  (First Issue: 1978)

Discourse Studies  (First Issue: 1999)

Educational Action Research  (First Issue: 1993)

Electronic Journal of Sociology  (First Issue: 1995)

Entanglements: Experiments in Multimodal Ethnography (First Issue: 2018)

Ethnographic Encounters  (First Issue: 2012)

ethnographiques.org  (First Issue: 2002)

Ethnography  (First Issue: 2000)

Ethnography and Education  (First Issue: 2006)

Ethnologia Europaea  (Journal of European Ethnology, First issue: 1967)

Etnográfica (First issue: 1997)

Etnografia e ricerca qualitativa (Ethnography and Qualitative Research) (First issue: 2008)

European Journal for Qualitative Research in Psychotherapy  (First Issue: 2006)

Feminism & Psychology (First Issue: 1991)

Field Methods  (First Issue: 1989) (Formerly Cultural Anthropology Methods CAM Journal)

Forum Qualitative Sozialforschung

(Forum: Qualitative Social Research)  (First Issue: 2000)

Gestalt Theory: An International Multidisciplinary Journal  (First Issue: 1978)

Global Ethnographic: An Online Magazine of Interpretive Anthropology  (First Issue: 2009)

Global Qualitative Nursing Research  (First Issue: 2015)

The Grounded Theory Review  (First Issue: 1999)

HAU: Journal of Ethnographic Theory  (First Issue: 2011)

The Indo-Pacific Journal of Phenomenology  (First Issue: 2001)

International Journal of Action Research  (First Issue: 2005)

International Journal of Qualitative Methods  (First Issue: 2002)

International Journal of Qualitative Research (First Issue: 2021)

International Journal of Qualitative Research in Services  (First Issue: 2013)

International Journal of Qualitative Studies in Education  (First Issue: 1988)

International Journal of Qualitative Studies on Health and Well-Being  (First Issue: 2006)

International Journal of Social Research Methodology  (First Issue: 1998)

International Review of Qualitative Research  (First Issue: 2008)

Investigación Cualitativa (First issue: 2016)

日本質的心理学会 (Japanese Journal of Qualitative Psychology) (First Issue: 2002)

Le Journal des anthropologues  (First Issue: 1990)

The Journal for Undergraduate Ethnography  (First Issue: 2011)

Journal of Autoethnography (First Issue: 2020)

Journal of Business Anthropology  (First Issue: 2011)

Journal of Contemporary Ethnography  (First Issue: 1972) (Formerly Urban Life and Culture)

Journal of Qualitative Research in Education (Eğitimde Nitel Araştırmalar Dergisi – ENAD, First Issue: 2013)

Journal of Ethnographic & Qualitative Research  (First Issue: 2007)

Journal of Mixed Methods Research  (First Issue: 2007)

Journal of Museum Ethnography  (First Issue: 1976)

Journal of Organizational Ethnography  (First Issue: 2012)

Journal of Phenomenological Psychology  (First Issue: 1970)

Journal of Qualitative Criminal Justice & Criminology  (First Issue: 2013)

تحقیقات کیفی در علوم سلامت (Journal of Qualitative Research in Health Sciences) (First Issue: 2019)

Journal of Qualitative Research in Tourism (First Issue: 2020)

Journal of Video Ethnography  (First Issue: 2014)

Kaleidoscope: A Graduate Journal of Qualitative Communication Research  (First Issue: 2002)

KWALON, tijdschrift voor kwalitatief onderzoek (JOurnal for Qualitative Research)  (First Issue: 1996)

The Malaysian Journal of Qualitative Research  (First Issue: 2005)

Medical Anthropology Quarterly  (First Issue: 1970)

Medicine Anthropology Theory (MAT) (First Issue: 2014)

Medische Antropologie (Medical Anthropology)  (First Issue: 1989)

Methodological Innovations Online  (First Issue: 2006)

Moroccan Journal of Quantitative and Qualitative Research (First Issue: 2019)

MOTRICIDADES: Revista da Sociedade de Pesquisa Qualitativa em Motricidade Humana (First Issue: 2017)

Murmurations: Journal of Transformative Systemic Practice  (First Issue: 2017)

Museum Anthropology (First Issue: 1976)

Narrative Inquiry (First Issue: 1991) (Formerly Journal of Narrative and Life History; ( Old Web Page )

Narrative Inquiry in Bioethics: A Journal of Qualitative Research  (First Issue: 2011)

Narrative Works: Issues, Investigations & Interventions  (First Issue: 2011)

New Trends in Qualitative Research (First Issue: 2021)

Nitel Sosyal Bilimler (Qualitative Social Sciences) (First Issue: 2020)

Ontario Action Researcher  (First Issue: 1998; Name changed to > The Canadian Journal of Action Research  in 2011)

PhaenEx: Journal of Existential and Phenomenological Theory and Culture  (First Issue: 2006)

Phenomenology & Practice  (First Issue: 2007)

Phenomenology and the Cognitive Sciences  (First Issue: 2001)

Poroi: An Interdisciplinary Journal of Rhetorical Analysis and Invention  (First Issue: 2001)

Pragmatic Case Studies in Psychotherapy  (First Issue: 2005)

Psychotherapie & Sozialwissenschaft (Psychotherapy & Social Science, First Issue: 2005)

QRSIG: Newsletter of the AERA Qualitative Research Interest Group  (First Issue: 2007)

QQML: Qualitative and Quantitative Methods in Libraries (First issue: 2012)

Qualitative Health Research  (First Issue: 1991)

Qualitative Inquiries in Music Therapy: A Monograph Series  (First Issue: 2004)

Qualitative Inquiry  (First Issue: 1995)

Qualitative Market Research: An International Journal  (First Issue: 1994)

Qualitative and Multi-Method Research (First Issue: 2014)

(Formerly Qualitative Methods)

Qualitative Psychology  (First Issue: 2014)

質的心理学フォーラム (Qualitative Psychology Forums) (First Issue: 2009)

The Qualitative Report  (First Issue: 1990)

Qualitative Research  (First Issue: 2001)

Qualitative Research in Accounting & Management (First issue: 2004)

Qualitative Research in Education  (First Issue: 2012)

Qualitative Research in Medicine & Healthcare (First Issue: 2017)

Qualitative Research in Organizations and Management: An International Journal  (First Issue: 2005)

Qualitative Research in Psychology  (First Issue: 2004)

Qualitative Research in Sport, Exercise, and Health  (First Issue: 2009)

Qualitative Research Journal (First issue: 2002)

Qualitative Research Reports in Communication  (First Issue: 2000)

Qualitative Researcher  (First Issue: 2005)

Qualitative Social Work: Research and Practice  (First Issue: 2002)

Qualitative Sociology  (First Issue: 1978)

Przeglądu Socjologii Jakościowej! (Qualitative Sociology Review)  (First Issue: 2005)

Qualitative Studies  (First Issue: 2009)

Quality and Quantity: International Journal of Methodology  (First Issue: 1967)

QUILT: Journal of Qualitative Health Research & Case Studies Reports (iphorr.com) (First Issue: 2021)

QuiViRR: Qualitative Video Research Reports (First Issue: 2020)

QuPuG – Journal für Qualitative Forschung in Pflege- und Gesundheitswissenschaft (Journal of Qualitative Research in Nursing and Health Sciences) (First Issue: 2014)

Recherches qualitatives  (First Issue: 1989)

Research in Phenomenology  (First Issue: 1971)

Revista Pesquisa Qualitativa (Qualitative Research Journal) (First Issue: 2005)

Revue Internationale d’Ethnographie (First Issue: 2013) (Formerly Revue Européenne d’Ethnographie de l’Education)

Sociological Research Online  (First Issue: 1996)

Social Research Update  (First Issue: 1993)

The Socjournal: A New Media Journal of Sociology and Society  (First Issue: 2010)

SSM – Qualitative Research in Health (First Issue: 2021)

Student Anthropologist  (First Issue: 2014)

Symbolic Interaction  (First Issue: 1977)

Tamara Journal for Critical Organization Inquiry  (First Issue: 2002) (Formerly Tamara Journal for Critical Post Modern Organization)

Terrain  (First Issue: 1983)

Turkish Online Journal of Qualitative Inquiry  (First Issue: 2010)

Visual Ethnography  (First Issue: 2012)

Visual Studies  (First Issue: 1986)

Vitae Scholasticae: The Journal of Educational Biography (First Issue: 1983)

The Weekly Qualitative Report  (First Issue: 2008)

ZQF – Zeitschrift für Qualitative Forschung (First issue: 1999)

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• Practical thematic...

A new dawn for qualitative research in the BMJ

Rapid response to:

Practical thematic analysis: a guide for multidisciplinary health services research teams engaging in qualitative analysis

• Related content
• Article metrics
• Rapid responses

Rapid Response:

Dear Editor

We were delighted that a qualitative research methods paper was recently published in the BMJ.[1] We wondered if the BMJ had therefore reversed its stance that:

“We have chosen to focus our efforts on quantitative research that reports outcomes that are important to patient, doctors and policy makers.” [2]

We do, however, have some minor criticisms of the paper. We note that the old-fashioned term ‘theoretical saturation’ is used. Qualitative research methods are developing very rapidly, and the communities who use these methods now more usually refer to ‘theoretical sufficiency’ or ‘information power,’[3] which recognise that it is not possible to be sure of saturation. We also note that the authors refer to ‘member checking’ and ‘triangulation,’ without acknowledging contemporary debates about the usefulness of such these stages.[4] We recognise that some of these terms stem directly from the COREQ reporting guidelines, but also note that at seven years old, these guidelines are already out of touch with current thinking. The validity of COREQ has also been brought into question due to a lack of repeatability of its development.[5]

We were surprised that the authors did not make any reference to the incorporation of existing literature. Most qualitative analytical methods aim to build on existing studies, by incorporating theory either as ‘sensitising concepts’[6] or by predefining some of the codes. In the absence of this, researchers risk producing a study which constitutes a ‘brick on the pile’[7] as opposed to meaningfully adding to research in their area of interest (a brick in the wall).

We agree that the paper provides a wonderfully clear introduction to thematic analysis for novices, and commend the authors for making a somewhat complex process more accessible to clinicians.

We also hope that this paper heralds a new dawn for qualitative research publication within the BMJ, the results of which can be equally meaningful and important to patient, healthcare practitioners and the systems in which we work.

References 1 Saunders C, Sierpe A, von Plessen C, et al. Practical thematic analysis: a guide for multidisciplinary health services research teams engaging in qualitative analysis. BMJ 2023;e074256:381. 2 Loder E, Groves T, Schroter S, et al. Qualitative research and The BMJ. Bmj. 2016;352. 3 Varpio L, Ajjawi R, Monrouxe L V, et al. Shedding the cobra effect: problematising thematic emergence, triangulation, saturation and member checking. Med Educ 2017;51:40–50. 4 Varpio L, Paradis E, Uijtdehaage S, et al. The distinctions between theory, theoretical framework, and conceptual framework. Academic Medicine 2020;95:989–94. 5 Buus N, Perron A. The quality of quality criteria: Replicating the development of the Consolidated Criteria for Reporting Qualitative Research (COREQ). Int J Nurs Stud 2020;102:103452. doi: https://doi.org/10.1016/j.ijnurstu.2019.103452 6 Blumer H. What is wrong with social theory? Am Sociol Rev 1954;19:3–10. 7 Forscher BK. Chaos in the brickyard. Science (1979) 1963;142:35–8.

Competing interests: No competing interests

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• 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.

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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.

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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 .

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• 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

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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

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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

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Use of qualitative research in World Health Organisation guidelines: a document analysis

• Melissa Taylor   ORCID: orcid.org/0009-0006-3506-0902 1 ,
• Paul Garner 1 ,
• Sandy Oliver 2 , 3 &
• Nicola Desmond 4  

Health Research Policy and Systems volume  22 , Article number:  44 ( 2024 ) Cite this article

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Guidelines depend on effect estimates, usually derived from randomised controlled trials, to inform their decisions. Qualitative research evidence may improve decisions made but where in the process and the methods to do this have not been so clearly established. We sought to describe and appraise how qualitative research has been used to inform World Heath Organization guidance since 2020.

We conducted a document analysis of WHO guidelines from 2020 to 2022. We purposely sampled guidelines on the topics of maternal and newborn health (MANH) and infectious diseases, as most of the qualitative synthesis to date has been conducted on these topics, likely representing the ‘best case’ scenario. We searched the in-built repository feature of the WHO website and used standardised search terms to identify qualitative reporting. Using deductive frameworks, we described how qualitative evidence was used to inform guidelines and appraised the standards of this use.

Of the 29 guidelines, over half used qualitative research to help guide decisions (18/29). A total of 8 of these used qualitative research to inform the guideline scope, all 18 to inform recommendations, and 1 to inform implementation considerations. All guidelines drew on qualitative evidence syntheses (QES), and five further supplemented this with primary qualitative research. Qualitative findings reported in guidelines were typically descriptive, identifying people’s perception of the benefits and harms of interventions or logistical barriers and facilitators to programme success. No guideline provided transparent reporting of how qualitative research was interpreted and weighed used alongside other evidence when informing decisions, and only one guideline reported the inclusion of qualitative methods experts on the panel. Only a few guidelines contextualised their recommendations by indicating which populations and settings qualitative findings could be applied.

Conclusions

Qualitative research frequently informed WHO guideline decisions particularly in the field of MANH. However, the process often lacked transparency. We identified unmet potential in informing implementation considerations and contextualisation of the recommendations. Use in these areas needs further methods development.

Peer Review reports

Evidence-informed guidance usually includes a critical summary of one or more systematic reviews of reliable research findings to inform the decisions. For simple clinical questions which assess the efficacy of a new drug, systematic reviews of randomised control trials may provide the most appropriate information [ 1 ]. Making recommendations about drugs, vaccines and public health interventions all require reflection on the acceptability or appropriateness of an intervention, and this requires different forms of evidence and types of research [ 2 ]. The value of qualitative methods lies in their ability to pursue systematically ‘what’, ‘why’ or ‘how’ questions that are not easily answerable by experimental methods [ 3 ].

There is an increasing recognition of the importance of the social determinants of health in policy making, given the complex nature of most public health issues [ 4 ]. Qualitative research methods are particularly adept to explore these findings from the individual, community or broader system level [ 4 , 5 ]. Qualitative research may also range from descriptive to explanatory in nature [ 6 ]. Descriptive findings address people’s views or experiences, such as the perception of personal benefits and harms of interventions, and the trade-offs between these. Descriptive findings may also identify and describe unintended consequences of the proposed intervention. Finally, they may identify logistical barriers and facilitators to programme success [ 7 , 8 ]. These aspects are particularly valuable, as they bring forth the patient and health worker voice in decision making [ 9 ].

Explanatory findings, on the other hand, link descriptive perspectives or experiences to aspects of psychological, historical, cultural, economic, social, environmental and political context [ 6 ]. In doing so, they help generate a theoretical understanding of ‘why’ perceptions and experiences occur and may have broader applications to related contexts [ 6 ]. Here qualitative findings may be used to explain how personal attributes and lifestyle impact individuals, how local context impacts group choice to access treatment or diagnosis or how broad structural and health systems can impede their ability to access, benefit or trust health interventions [ 7 , 8 ].

Guideline developers such as the World Health Organisation (WHO) are beginning to draw on qualitative research to inform their decisions [ 2 ], aided by the methodological developments of systematic reviews of qualitative research, known as qualitative evidence syntheses (QES) and their appraisal [ 10 ]. Previous research has documented examples on how qualitative research has so far informed guideline processes, including identifying relevant outcomes, evaluating evidence to produce recommendations and developing implementation considerations [ 11 , 12 , 13 ]. However, it remains unclear how often qualitative research is actually used for these purposes. Further, it is thought that qualitative research does not always fit well within the ‘summary-based and compartmentalised structure’ of the guideline framework [ 12 ], given the wide range of aims of qualitative research, from describing people’s views to explaining the impact of structural barriers to treatment access. Documenting which of these the WHO has drawn on so far will help to further refine guidance for the uptake of qualitative research by Identifying areas of unmet potential.

Furthermore, as with any guideline development, those preparing the reviews and the panels using them need to provide transparent reporting and rigorous appraisal akin to those historically practised with quantitative research in decision-making [ 12 , 14 ]. However, so far, no methodological guidance exists on how best to systematically draw on and evaluate qualitative findings during guideline processes [ 9 ], and it is unclear how often these standards are achieved [ 11 , 12 , 13 ].

Our aim is to describe how qualitative evidence has been used in existing WHO guideline development procedures and appraise the standards of this inclusion.

We used a study design of document analysis to systematically describe and appraise WHO guidelines. Document analysis is a qualitative method commonly used in health policy analysis [ 15 ], which aims to synthesise and appraise textual data to elicit meaning, gain understanding and develop empirical knowledge [ 16 ]. This necessitates a systematic approach; however, standardised methodologies are lacking [ 15 ]. To ensure rigour, we drew on Kayesa and Shung-King [ 15 ], who identified the key steps reported in document analyses: adopting clear inclusion criteria for documents and clear procedures for identifying documents, coding them and extracting data; applying a clear analytical framework to analyse the role of qualitative research cited in policy documents; and presenting the findings of each stage of the process from searching for documents to answering the research question.

Guideline retrieval

A scoping search of the Cochrane Library [ 17 ] identified that QES were most frequently conducted on MANH (6/23 QES) and infectious disease topics (7/23 QES). For this reason, we chose to focus our analysis on these topic areas, as whilst not exhaustive, they may represent the ‘best case scenario’.

We used the in-built document repository feature on WHO’s website [ 18 ] to identify guideline documents. Therefore, only documents published on this web page were eligible for inclusion. Grey literature was not included. The web page allowed for filtering by publication type and year, which was restricted to ‘guideline’ in 2020 and 2021. A 2-year period was chosen to reflect the most current practices of qualitative research at the time of the search. The lead author (M.T.) then screened the guideline titles in the search results for topics relating to Maternal and Newborn Health (MANH) and infectious disease. MANH was defined as any topic covering the health of women during pregnancy, childbirth and the post-partum period and babies’ first month of life. Infectious disease was defined as any topic covering the prevention, diagnosis and treatment of all diseases acquired through human–human or animal–human transmission, including vector-borne diseases. A table detailing the excluded guidelines and justification for this exclusion can be found in Additional file 1: Excluded studies. The final list of included and excluded guidelines was approved by the entire author team.

The unit of analysis used in this study was the section of text describing a qualitative finding within a guideline document. As a result, we performed a second search within the included guideline documents to identify any qualitative reporting. We defined a qualitative study as one that collected data using qualitative methods such as ethnographic observations, in‐depth interviews, focus group discussions and open‐ended survey questions. Appropriate analysis methods included, for example, thematic analysis, narrative analysis, framework analysis, and grounded theory. While we acknowledge that mixed methods studies may contribute qualitative findings, for the purpose of this study they were excluded, as it was not possible to identify which findings had been derived from quantitative or qualitative methods. Initial reading of a sample of three guidelines in-depth identified terms that accompanied qualitative reporting. We then performed a key-word search for the following terms in all guidelines to identify qualitative reporting: ‘qualitative’, ‘accept*’, ‘value’, ‘equit*’, ‘feasib’, ‘interview’ or ‘focus-group discussion’. Sections of text containing the keywords were checked against their corresponding citation to ensure the findings were derived from qualitative studies.

Data extraction and analysis

Data analysis occurred in three phases. First, given the broad range of potential qualitative findings, we sought to understand what ‘type’ guidelines typically drew on. To achieve this, we developed a deductive framework informed by the literature. We crossed (1) the nested individual, community and broader system ecosystems within social determinants of health theory against (2) descriptive to explanatory qualitative research methodology. Within this, we populated the matrix with qualitative research aims derived from literature and discussed in the background of this paper. This provided us with a theoretical overview of the potential contribution of qualitative research (Fig.  1 ). We then coded each qualitative finding contained within guidelines with one of these aims. The framework was validated on a selection of guidelines, which led to the inclusion of one inductive aim of qualitative research: to understand information needs.

Matrix of how qualitative research can contribute to guideline development

We next sought to describe how qualitative research was identified by the guideline and how it was used to inform the scope of the guideline, the intervention recommendation and implementation considerations. Finally, we sought to appraise how qualitative research had been used using analogous standards expected and practised for quantitative methods in decision-making processes. Table 1 guided this process. Extraction domains and questions were initially identified a priori, and any new questions that arose during analysis were shared and discussed within the team to ensure they were appropriate. If new questions were added to the data extraction tool (Table  1 ), all guidelines were re-analysed to ensure a complete dataset.

Search results

Between 2020 and 2022, the WHO published 29 guidelines on the topics MANH and infectious diseases. Seven guidelines were excluded as they did not cover the chosen topics areas. Of the 29 included guidelines, 18 (62%) incorporated qualitative research to inform either the scope, recommendation or implementation considerations. Of the 18 guidelines that used qualitative research, 15/18 guidelines were on topics of MANH, in contrast to 3/18 on infectious diseases. An overview of the search results is shown in Fig.  2 below, and a summary of all included guidelines is detailed in Table  2 .

Overview of guideline search process

Below follows a narrative summary of where the 18 guidelines used qualitative evidence in informing their scope, decisions and implementation considerations. This is followed by an appraisal of this use according to the pre-specified domains of transparency, specificity, certainty and reflexivity.

How qualitative research was used

Overall, qualitative research summarised in guidelines typically provided descriptive understanding of logistical barriers and facilitators to programme success (133 quotations across 18 guidelines) or patient perception of benefits and harms (126 quotations across 18 guidelines). Less frequently, qualitative findings explained the influence of local context of health-seeking behaviours and the influence of local context (51 quotations across 18 guidelines); described information needs (42 quotations across 10 guidelines); explained the influence of personal attributes on health seeking behaviour (42 quotations across 10 guidelines); described unintended consequences (12 quotations across 5 guidelines); or explained how systems function and their impact on individuals (5 quotations across 1 guidelines). Figure  3 provides an overview of these findings with selected example quotations derived from the guidelines presented in this study. A cross comparison of how these roles fed into each stage of the decision-making process is presented below:

Illustration of how WHO guidelines used qualitative research according to their role

Retrieving qualitative research

Guideline documents either specifically commission research to inform their process or identify existing literature. Seven guidelines commissioned QES specifically for their guideline [ 22 , 25 , 28 , 29 , 30 , 31 , 32 ], while four guidelines performed a systematic search of published literature [ 19 , 20 , 33 , 34 ]. However, seven guidelines did not include any methods for how they obtained qualitative research.

Overall, the guidelines in our analysis drew on a total of 38 primary studies and 25 systematic reviews of qualitative research (QES) to inform their recommendations. Guidelines most often drew on 2 qualitative research studies and a maximum of 33 qualitative research studies [ 27 ].

All guidelines that used qualitative research drew on systematic reviews of qualitative evidence, known as QES to inform their process. No guidelines drew exclusively on primary qualitative studies, but five did include them alongside qualitative evidence synthesis data [ 22 , 24 , 25 , 27 , 31 ].

Informing guideline scope

Seven guidelines [ 19 , 20 , 21 , 22 , 23 , 24 , 25 ] on the topic of MANH drew on the same QES [ 26 ] to inform the addition of a quantitative ‘positive postnatal experience outcome’, defined as ‘ in which women, partners, parents, caregivers and families receive information and reassurance in a consistent manner from motivated health workers. Both the women’s and babies’ health, social and developmental needs are recognized, within a resourced and flexible health system that respects their cultural context ’ [ 25 ]. The inclusion of this outcome allowed for prioritising women’s psychosocial and emotional well-being alongside physical health outcomes, such as mortality or morbidity, when evaluating an intervention. One infectious disease guideline [ 27 ] drew on qualitative research to inform the background of 6/99 recommendations. Findings here were often coded as ‘to understand why programmes succeed or fail’, suggesting that qualitative research can be used in this context to detail challenges with current approaches and provide a rationale for the consideration of new interventions and service designs.

Informing the decision to recommend an intervention

All 18 guidelines drew on qualitative research to inform the decision. The frequency of use for this purpose likely reflects the standardisation of the research-to-decision-making framework (EtD) and pre-specified domains of ‘acceptability’, ‘values and preferences’, ‘feasibility’ or ‘equity’ of a proposed intervention. Table 2 provides an overview of which of these domains included qualitative research. Regarding the feasibility of the proposed intervention, 12 guidelines drew on qualitative research. Regarding the acceptability of the proposed intervention, 13 guidelines drew on qualitative research. Regarding the values and preferences relating to the proposed intervention, 17 guidelines drew on qualitative research. Finally, regarding the equity implications of the proposed intervention, five guidelines drew on qualitative research.

Findings that described people’s perception of benefits and harms were typically used in the ‘values and preferences’ domain, which helped to understand the importance patients place on guideline outcomes. They were also used to inform acceptability and feasibility, and it was noted that typically these findings often justified that interventions were acceptable or feasible. In contrast, unacceptable or unfeasible aspects of interventions drew on findings concerned with explaining the influence of local context on health seeking behaviour, understanding how programmes succeed or fail or identifying information needs. Qualitative research was rarely used to identify unintended consequences or to understand how systems function and its impact. These two roles may have important contributions to considerations of equity, yet few guidelines drew on qualitative research to inform this domain.

Depending on the information provided, all but one [ 27 ] of the guidelines then determined a judgement of ‘probably yes’, ‘variable’ or ‘probably no’ to each domain. Judgements of the former two were frequent, and we observed only one occasion in which the acceptability was judged to be ‘probably no’ [ 25 ]. However, ‘varied’ acceptability judgements did not appear to correspond to context specific recommendations or feed into implementation considerations. We found only one example where qualitative research had influenced the overall recommendation and was directly reported in the accompanying justification [ 25 ].

Informing the implementation considerations of an intervention

We found only one guideline where qualitative research had been clearly cited in the designated implementation considerations section for 1/99 recommendations [ 27 ]. This makes it difficult to assess the extent to which qualitative research is used for this component or to delineate considerations that are derived from panel opinion or other forms of research. The qualitative research finding used here stated ‘other challenges include lack of nutrition support’ in reference to adherence support required for children and infants. The reductive nature of the quotation makes it difficult to assess the intended purpose of the use of qualitative research.

Standards of qualitative research use

All MANH guidelines reported judgements about the certainty of evidence by applying the CERQual tool to their QES findings but did not conduct any formal quality assessment on stand-alone primary studies. None of the infectious disease guidelines reported judgements about the certainty of evidence or conducted quality assessments on primary studies.

Transparency

Readers should be able to understand the justification for each recommendation from the research presented [ 12 ]. However, we found that this information was often lacking. A rationale for why the guideline panel judged there to be ‘probably yes’, ‘varied’ or ‘probably no’ acceptability, feasibility, and equity was not provided in any guideline. For some recommendations, the judgement could be easily intuited. For example, a summary of qualitative research that only describes positive viewpoints under acceptability could be reasonably judged to be ‘probably yes’. Yet, when varied viewpoints were presented, it was unclear why acceptability had been labelled ‘probably yes’ as opposed to ‘varied’. Was this due to the relative proportions of conflicting viewpoints or the relative importance of viewpoints?

Some guidelines drew on a mixture of both qualitative and quantitative studies to inform their values, acceptability, feasibility and equity domains. When this occurred, it was not clear how this research was weighed and evaluated in the decision. For example, in one guideline [ 27 ], women were less accepting of the intervention in qualitative interviews in contrast to the surveys which reported high rates of acceptability. Yet the guideline summarised acceptability as ‘high’ and cited quantitative studies to support this. As no quality assessments were performed in any guideline, it is likely that weighting was not dependant on this.

Specificity

Qualitative research can allow for more tailored recommendations that moves beyond what intervention may work in a controlled setting, to which intervention may work in real-life settings and contexts. This is often referred to as the efficacy to effectiveness gap [ 35 ]. However, for this to happen contextualising of recommendations are necessary. This requires narrative summaries of qualitative research to retain sufficient information on the context of findings [ 12 ]. A total of 11 guidelines contextualised a finding at least once. However, overall contextualisation was infrequent and reductive as considerations were labelled as: LMIC settings (54 findings), low-resource settings (2 findings), rural settings (7 findings), HIC settings (3 findings), children (1 finding) and unequal gender relations (2 findings). We acknowledge there is likely to be some crossover between these considerations but have listed them as referred to in the guideline documents. Moreover, contextualised findings did not appear to lead to more nuanced recommendations, e.g. for which populations is this intervention acceptable, or implementation considerations, e.g. how should the implementation be adapted for specific populations.

Reflexivity

Three guidelines in the field of MANH health, but no guidelines in infectious diseases, included someone experienced in qualitative research on the panel. Meanwhile, we sought to understand whether summaries of qualitative research had been produced by the guideline author team, by the guideline panel or in close collaboration, yet no guidelines reported this.

Qualitative research was frequently used in WHO guidelines between 2020 and 2022, although had a larger role in informing MANH than infectious diseases. Within healthcare, qualitative research has its roots in nursing, due to the relative importance of social interventions [ 6 ], and it is likely that the frequent use of qualitative research in MANH is linked to its longer history here, given the similarities in the two fields. This may also explain why some of the MANH guidelines included qualitative expertise, compared with none of the infectious disease guidelines.

We found that qualitative research rarely informed the scope of the guideline or the implementation considerations. Instead, qualitative research most often informed the decision. A similar study reported that 86% of WHO and UK, US and Canadian national guidelines used qualitative research to inform decisions but only 20% to identify clinical questions and 19% to inform implementation considerations [ 36 ]. This may be due to lack of clear citing, which made it difficult to assess accurately the extent of use. However, qualitative research presented in guidelines were often found to touch on issues regarding implementation, and yet this information did not appear to track to the appropriate section. Given that qualitative methods are considered an integral component in wider implementation science, it is surprising to see the lack of qualitative research here [ 37 , 38 ].

Across the different theoretical aims of qualitative research, the most frequently used was ‘describing perception of benefits and harms’ and ‘describing barriers and facilitators to programme success’. In contrast, explanatory findings were less frequently used. Similarly, In National Institute of Health and Care Excellence (NICE) guidelines between 2015 and 2019, over half of qualitative research addressed one of two types of question: “What are the barriers and/or facilitators?” and “What are the information (and support) needs?”, and they were all descriptive in nature [ 39 ]. This may indicate a limited understanding of the potential of qualitative research particularly for more explanatory findings or simply reflect that they infrequently capture these findings to begin with. However, engaging with explanatory findings may allow guideline panels to indicate to national government which findings are likely to be transferable to their context and population groups.

We found that summaries of qualitative research and the process of transforming these into ‘yes’, ‘no’ or ‘varied’ judgments were often reductive, at the expense of the original case complexity and nuance [ 8 , 40 ]. There are several ways recommendations can be contextualised from the perspectives of: geographical, epidemiological, sociocultural, socioeconomic, ethical, legal and political [ 41 ]. Qualitative research may help in understanding how proposed interventions interact with these aspects of context, but this is currently poorly conducted. One driver of this may be in how domains such as ‘acceptability’ are framed and defined. Guideline developers drew on the following definition of acceptability: ‘the extent to which that intervention is considered to be reasonable among those receiving, delivering or affected by the intervention’ [ 13 ]. However, acceptability can include affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness and self-efficacy [ 42 ].

We found that guidelines failed to address or consider quality when interpreting primary qualitative research. Similarly, national UK guidelines by the National Institute of Health and Care Excellence (NICE) between 2003 and 2019 rarely conducted quality appraisal [ 39 , 43 ]. High quality, rigorous evidence is central to the principles of evidence-based practice [ 1 ], and it is important that appropriate standards are applied to qualitative research, not only to ensure the usability of the findings but also to institutionalise the credibility of the methodology as a whole. The use of qualitative research also lacked transparency as it was often unclear how the information had been interpreted and evaluated. Aside from a transparency issue, it is possible that qualitative research was just not a key influencer in most decisions and mainly relegated to supportive roles in guideline processes [ 44 ].

Study limitations

This study has some limitations. First, we collected guideline documents from a relatively short time frame. The trends documented in this review may be an artefact of 2020–2022, specifically, and do not describe general trends in qualitative research use. Second, lack of clear and transparent reporting on the use of qualitative research does not necessarily mean that, for example, it did not directly feed into overall judgements, or implementation considerations. Document analysis is limited by the availability of public documents, and it may be that further information is contained within meeting notes, email exchanges and other private reports that we cannot access. Finally, we chose to focus on the topics of MANH and infectious disease as they account for a large portion of qualitative research, but the use of qualitative research may be different for other topic areas.

Qualitative research frequently informed WHO guideline decisions particularly in the field of MANH and was rarely used to inform guidelines relating to infectious diseases. However, the process of how qualitative evidence was used and evaluated often lacked transparency. We identified unmet potential in informing implementation considerations and contextualisation of the recommendations. Use in these areas needs further methods development.

Availability of data and materials

The coded guideline documents and data extraction tables are available from the authors upon request.

Abbreviations

Maternal and newborn health

World Health Organisation

National Institute of Health and Care Excellence

• Qualitative evidence synthesis

Low-and middle-income country

High income country

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Melissa Taylor and Sandy Oliver are supported by the Research, Evidence and Development Initiative (READ‐It) project. READ‐It (project number 300342‐104) is funded by UK aid from the UK Government; however, the views expressed do not necessarily reflect the UK Government's official policies.

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M.T. conducted data collection, analysis and interpretation in consultation with P.G., S.O. and N.D. M.T. wrote the first and subsequent drafts of the manuscript, with comments and revision from P.G., S.O. and N.D. All authors read and approved the final manuscript.

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Taylor, M., Garner, P., Oliver, S. et al. Use of qualitative research in World Health Organisation guidelines: a document analysis. Health Res Policy Sys 22 , 44 (2024). https://doi.org/10.1186/s12961-024-01120-y

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ORIGINAL RESEARCH article

This article is part of the research topic.

Exploring the Links between Social Connections, Care and Integration

"If I fall down, he will pick me up": Refugee hosts and everyday care in protracted displacement Provisionally Accepted

• 1 Centre for Development and Emergency Practice, Oxford Brookes University, United Kingdom

The final, formatted version of the article will be published soon.

Around the world, refugees share shelters and homes with other refugees. Such household-level hosting relationships play a central role in the lives of displaced individuals and families, offering support to meet basic needs, safety, and a sense of belonging. Yet, the role of displaced people as refugee hosts is often overlooked, an omission that fails to account for the active role of displaced populations in supporting one another and the dynamic social connections between refugees.Thus far, hosting relationships have often been understood through hospitality. Instead, in this paper I develop an understanding of refugee-refugee hosting as constituted through care. Drawing on qualitative research conducted with Sudanese refugee men in Amman, Jordan, I demonstrate the value of this framework in explaining the emergence and experiences of their hosting relationships. I highlight the importance of everyday interdependencies for life in displacement, alongside the challenges and ambivalences of providing and receiving care in such contexts, and show how configurations of care shift and alter throughout protracted displacement. In doing so, I centre informal and everyday acts of care among refugees in relation to external humanitarian care, arguing for a re-conceptualisation of the relationship between 'hosts' and 'humanitarians', and propose avenues for those working with displaced populations to engage with the vital support that refugeerefugee hosting provides.

Keywords: Refugees, Host families, hosting, care, Humanitarian, Jordan

Received: 24 Aug 2023; Accepted: 04 Apr 2024.

Copyright: © 2024 Jordan. 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) or licensor 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: Mx. Zoe Jordan, Centre for Development and Emergency Practice, Oxford Brookes University, Oxford, United Kingdom

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Correction: Improving the Engagement of Underrepresented People in Health Research Through Equity-Centered Design Thinking: Qualitative Study and Process Evaluation for the Development of the Grounding Health Research in Design Toolkit

Authors of this article:

Corrigenda and Addenda

• Alessandra N Bazzano 1 , MPH, PhD   ; 
• Lesley-Ann Noel 2 , PhD   ; 
• Tejal Patel 1 , MA   ; 
• C Chantel Dominique 3 , AA   ; 
• Catherine Haywood 4 , BSW   ; 
• Shenitta Moore 5 , MD   ; 
• Andrea Mantsios 6 , PhD   ; 
• Patricia A Davis 1 , BSc  

1 Department of Social, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States

2 College of Design, North Carolina State University, Raleigh, NC, United States

3 Global Impact Board, New Orleans, LA, United States

4 Louisiana Community Health Outreach Network, New Orleans, LA, United States

5 Louisiana State University Health Sciences Center, New Orleans, LA, United States

6 Public Health Innovation & Action, New York, NY, United States

Corresponding Author:

Alessandra N Bazzano, MPH, PhD

Department of Social, Behavioral, and Population Sciences

Tulane University School of Public Health and Tropical Medicine

1440 Canal St

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Email: [email protected]

Related Article Correction of: hhttps://formative.jmir.org/2023/1/e43101 JMIR Form Res 2024;8:e58397 doi:10.2196/58397

In “Improving the Engagement of Underrepresented People in Health Research Through Equity-Centered Design Thinking: Qualitative Study and Process Evaluation for the Development of the Grounding Health Research in Design Toolkit” (JMIR Form Res 2023;7:e43101) the authors noted one error.

In Reference 28, the URL:

https://pcornet.org/about/

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The correction will appear in the online version of the paper on the JMIR Publications website on April 4, 2024 together with the publication of this correction notice. Because this was made after submission to PubMed, PubMed Central, and other full-text repositories, the corrected article has also been resubmitted to those repositories.

This is a non–peer-reviewed article. submitted 14.03.24; accepted 14.03.24; published 04.04.24.

©Alessandra N Bazzano, Lesley-Ann Noel, Tejal Patel, C Chantel Dominique, Catherine Haywood, Shenitta Moore, Andrea Mantsios, Patricia A Davis. Originally published in JMIR Formative Research (https://formative.jmir.org), 04.04.2024.

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A Practical Guide to Writing Quantitative and Qualitative Research Questions and Hypotheses in Scholarly Articles

Edward barroga.

1 Department of General Education, Graduate School of Nursing Science, St. Luke’s International University, Tokyo, Japan.

Glafera Janet Matanguihan

2 Department of Biological Sciences, Messiah University, Mechanicsburg, PA, USA.

The development of research questions and the subsequent hypotheses are prerequisites to defining the main research purpose and specific objectives of a study. Consequently, these objectives determine the study design and research outcome. The development of research questions is a process based on knowledge of current trends, cutting-edge studies, and technological advances in the research field. Excellent research questions are focused and require a comprehensive literature search and in-depth understanding of the problem being investigated. Initially, research questions may be written as descriptive questions which could be developed into inferential questions. These questions must be specific and concise to provide a clear foundation for developing hypotheses. Hypotheses are more formal predictions about the research outcomes. These specify the possible results that may or may not be expected regarding the relationship between groups. Thus, research questions and hypotheses clarify the main purpose and specific objectives of the study, which in turn dictate the design of the study, its direction, and outcome. Studies developed from good research questions and hypotheses will have trustworthy outcomes with wide-ranging social and health implications.

INTRODUCTION

Scientific research is usually initiated by posing evidenced-based research questions which are then explicitly restated as hypotheses. 1 , 2 The hypotheses provide directions to guide the study, solutions, explanations, and expected results. 3 , 4 Both research questions and hypotheses are essentially formulated based on conventional theories and real-world processes, which allow the inception of novel studies and the ethical testing of ideas. 5 , 6

It is crucial to have knowledge of both quantitative and qualitative research 2 as both types of research involve writing research questions and hypotheses. 7 However, these crucial elements of research are sometimes overlooked; if not overlooked, then framed without the forethought and meticulous attention it needs. Planning and careful consideration are needed when developing quantitative or qualitative research, particularly when conceptualizing research questions and hypotheses. 4

There is a continuing need to support researchers in the creation of innovative research questions and hypotheses, as well as for journal articles that carefully review these elements. 1 When research questions and hypotheses are not carefully thought of, unethical studies and poor outcomes usually ensue. Carefully formulated research questions and hypotheses define well-founded objectives, which in turn determine the appropriate design, course, and outcome of the study. This article then aims to discuss in detail the various aspects of crafting research questions and hypotheses, with the goal of guiding researchers as they develop their own. Examples from the authors and peer-reviewed scientific articles in the healthcare field are provided to illustrate key points.

DEFINITIONS AND RELATIONSHIP OF RESEARCH QUESTIONS AND HYPOTHESES

A research question is what a study aims to answer after data analysis and interpretation. The answer is written in length in the discussion section of the paper. Thus, the research question gives a preview of the different parts and variables of the study meant to address the problem posed in the research question. 1 An excellent research question clarifies the research writing while facilitating understanding of the research topic, objective, scope, and limitations of the study. 5

On the other hand, a research hypothesis is an educated statement of an expected outcome. This statement is based on background research and current knowledge. 8 , 9 The research hypothesis makes a specific prediction about a new phenomenon 10 or a formal statement on the expected relationship between an independent variable and a dependent variable. 3 , 11 It provides a tentative answer to the research question to be tested or explored. 4

Hypotheses employ reasoning to predict a theory-based outcome. 10 These can also be developed from theories by focusing on components of theories that have not yet been observed. 10 The validity of hypotheses is often based on the testability of the prediction made in a reproducible experiment. 8

Conversely, hypotheses can also be rephrased as research questions. Several hypotheses based on existing theories and knowledge may be needed to answer a research question. Developing ethical research questions and hypotheses creates a research design that has logical relationships among variables. These relationships serve as a solid foundation for the conduct of the study. 4 , 11 Haphazardly constructed research questions can result in poorly formulated hypotheses and improper study designs, leading to unreliable results. Thus, the formulations of relevant research questions and verifiable hypotheses are crucial when beginning research. 12

CHARACTERISTICS OF GOOD RESEARCH QUESTIONS AND HYPOTHESES

Excellent research questions are specific and focused. These integrate collective data and observations to confirm or refute the subsequent hypotheses. Well-constructed hypotheses are based on previous reports and verify the research context. These are realistic, in-depth, sufficiently complex, and reproducible. More importantly, these hypotheses can be addressed and tested. 13

There are several characteristics of well-developed hypotheses. Good hypotheses are 1) empirically testable 7 , 10 , 11 , 13 ; 2) backed by preliminary evidence 9 ; 3) testable by ethical research 7 , 9 ; 4) based on original ideas 9 ; 5) have evidenced-based logical reasoning 10 ; and 6) can be predicted. 11 Good hypotheses can infer ethical and positive implications, indicating the presence of a relationship or effect relevant to the research theme. 7 , 11 These are initially developed from a general theory and branch into specific hypotheses by deductive reasoning. In the absence of a theory to base the hypotheses, inductive reasoning based on specific observations or findings form more general hypotheses. 10

TYPES OF RESEARCH QUESTIONS AND HYPOTHESES

Research questions and hypotheses are developed according to the type of research, which can be broadly classified into quantitative and qualitative research. We provide a summary of the types of research questions and hypotheses under quantitative and qualitative research categories in Table 1 .

Research questions in quantitative research

In quantitative research, research questions inquire about the relationships among variables being investigated and are usually framed at the start of the study. These are precise and typically linked to the subject population, dependent and independent variables, and research design. 1 Research questions may also attempt to describe the behavior of a population in relation to one or more variables, or describe the characteristics of variables to be measured ( descriptive research questions ). 1 , 5 , 14 These questions may also aim to discover differences between groups within the context of an outcome variable ( comparative research questions ), 1 , 5 , 14 or elucidate trends and interactions among variables ( relationship research questions ). 1 , 5 We provide examples of descriptive, comparative, and relationship research questions in quantitative research in Table 2 .

Hypotheses in quantitative research

In quantitative research, hypotheses predict the expected relationships among variables. 15 Relationships among variables that can be predicted include 1) between a single dependent variable and a single independent variable ( simple hypothesis ) or 2) between two or more independent and dependent variables ( complex hypothesis ). 4 , 11 Hypotheses may also specify the expected direction to be followed and imply an intellectual commitment to a particular outcome ( directional hypothesis ) 4 . On the other hand, hypotheses may not predict the exact direction and are used in the absence of a theory, or when findings contradict previous studies ( non-directional hypothesis ). 4 In addition, hypotheses can 1) define interdependency between variables ( associative hypothesis ), 4 2) propose an effect on the dependent variable from manipulation of the independent variable ( causal hypothesis ), 4 3) state a negative relationship between two variables ( null hypothesis ), 4 , 11 , 15 4) replace the working hypothesis if rejected ( alternative hypothesis ), 15 explain the relationship of phenomena to possibly generate a theory ( working hypothesis ), 11 5) involve quantifiable variables that can be tested statistically ( statistical hypothesis ), 11 6) or express a relationship whose interlinks can be verified logically ( logical hypothesis ). 11 We provide examples of simple, complex, directional, non-directional, associative, causal, null, alternative, working, statistical, and logical hypotheses in quantitative research, as well as the definition of quantitative hypothesis-testing research in Table 3 .

Research questions in qualitative research

Unlike research questions in quantitative research, research questions in qualitative research are usually continuously reviewed and reformulated. The central question and associated subquestions are stated more than the hypotheses. 15 The central question broadly explores a complex set of factors surrounding the central phenomenon, aiming to present the varied perspectives of participants. 15

There are varied goals for which qualitative research questions are developed. These questions can function in several ways, such as to 1) identify and describe existing conditions ( contextual research question s); 2) describe a phenomenon ( descriptive research questions ); 3) assess the effectiveness of existing methods, protocols, theories, or procedures ( evaluation research questions ); 4) examine a phenomenon or analyze the reasons or relationships between subjects or phenomena ( explanatory research questions ); or 5) focus on unknown aspects of a particular topic ( exploratory research questions ). 5 In addition, some qualitative research questions provide new ideas for the development of theories and actions ( generative research questions ) or advance specific ideologies of a position ( ideological research questions ). 1 Other qualitative research questions may build on a body of existing literature and become working guidelines ( ethnographic research questions ). Research questions may also be broadly stated without specific reference to the existing literature or a typology of questions ( phenomenological research questions ), may be directed towards generating a theory of some process ( grounded theory questions ), or may address a description of the case and the emerging themes ( qualitative case study questions ). 15 We provide examples of contextual, descriptive, evaluation, explanatory, exploratory, generative, ideological, ethnographic, phenomenological, grounded theory, and qualitative case study research questions in qualitative research in Table 4 , and the definition of qualitative hypothesis-generating research in Table 5 .

Qualitative studies usually pose at least one central research question and several subquestions starting with How or What . These research questions use exploratory verbs such as explore or describe . These also focus on one central phenomenon of interest, and may mention the participants and research site. 15

Hypotheses in qualitative research

Hypotheses in qualitative research are stated in the form of a clear statement concerning the problem to be investigated. Unlike in quantitative research where hypotheses are usually developed to be tested, qualitative research can lead to both hypothesis-testing and hypothesis-generating outcomes. 2 When studies require both quantitative and qualitative research questions, this suggests an integrative process between both research methods wherein a single mixed-methods research question can be developed. 1

FRAMEWORKS FOR DEVELOPING RESEARCH QUESTIONS AND HYPOTHESES

Research questions followed by hypotheses should be developed before the start of the study. 1 , 12 , 14 It is crucial to develop feasible research questions on a topic that is interesting to both the researcher and the scientific community. This can be achieved by a meticulous review of previous and current studies to establish a novel topic. Specific areas are subsequently focused on to generate ethical research questions. The relevance of the research questions is evaluated in terms of clarity of the resulting data, specificity of the methodology, objectivity of the outcome, depth of the research, and impact of the study. 1 , 5 These aspects constitute the FINER criteria (i.e., Feasible, Interesting, Novel, Ethical, and Relevant). 1 Clarity and effectiveness are achieved if research questions meet the FINER criteria. In addition to the FINER criteria, Ratan et al. described focus, complexity, novelty, feasibility, and measurability for evaluating the effectiveness of research questions. 14

The PICOT and PEO frameworks are also used when developing research questions. 1 The following elements are addressed in these frameworks, PICOT: P-population/patients/problem, I-intervention or indicator being studied, C-comparison group, O-outcome of interest, and T-timeframe of the study; PEO: P-population being studied, E-exposure to preexisting conditions, and O-outcome of interest. 1 Research questions are also considered good if these meet the “FINERMAPS” framework: Feasible, Interesting, Novel, Ethical, Relevant, Manageable, Appropriate, Potential value/publishable, and Systematic. 14

As we indicated earlier, research questions and hypotheses that are not carefully formulated result in unethical studies or poor outcomes. To illustrate this, we provide some examples of ambiguous research question and hypotheses that result in unclear and weak research objectives in quantitative research ( Table 6 ) 16 and qualitative research ( Table 7 ) 17 , and how to transform these ambiguous research question(s) and hypothesis(es) into clear and good statements.

a These statements were composed for comparison and illustrative purposes only.

b These statements are direct quotes from Higashihara and Horiuchi. 16

a This statement is a direct quote from Shimoda et al. 17

The other statements were composed for comparison and illustrative purposes only.

CONSTRUCTING RESEARCH QUESTIONS AND HYPOTHESES

To construct effective research questions and hypotheses, it is very important to 1) clarify the background and 2) identify the research problem at the outset of the research, within a specific timeframe. 9 Then, 3) review or conduct preliminary research to collect all available knowledge about the possible research questions by studying theories and previous studies. 18 Afterwards, 4) construct research questions to investigate the research problem. Identify variables to be accessed from the research questions 4 and make operational definitions of constructs from the research problem and questions. Thereafter, 5) construct specific deductive or inductive predictions in the form of hypotheses. 4 Finally, 6) state the study aims . This general flow for constructing effective research questions and hypotheses prior to conducting research is shown in Fig. 1 .

Research questions are used more frequently in qualitative research than objectives or hypotheses. 3 These questions seek to discover, understand, explore or describe experiences by asking “What” or “How.” The questions are open-ended to elicit a description rather than to relate variables or compare groups. The questions are continually reviewed, reformulated, and changed during the qualitative study. 3 Research questions are also used more frequently in survey projects than hypotheses in experiments in quantitative research to compare variables and their relationships.

Hypotheses are constructed based on the variables identified and as an if-then statement, following the template, ‘If a specific action is taken, then a certain outcome is expected.’ At this stage, some ideas regarding expectations from the research to be conducted must be drawn. 18 Then, the variables to be manipulated (independent) and influenced (dependent) are defined. 4 Thereafter, the hypothesis is stated and refined, and reproducible data tailored to the hypothesis are identified, collected, and analyzed. 4 The hypotheses must be testable and specific, 18 and should describe the variables and their relationships, the specific group being studied, and the predicted research outcome. 18 Hypotheses construction involves a testable proposition to be deduced from theory, and independent and dependent variables to be separated and measured separately. 3 Therefore, good hypotheses must be based on good research questions constructed at the start of a study or trial. 12

In summary, research questions are constructed after establishing the background of the study. Hypotheses are then developed based on the research questions. Thus, it is crucial to have excellent research questions to generate superior hypotheses. In turn, these would determine the research objectives and the design of the study, and ultimately, the outcome of the research. 12 Algorithms for building research questions and hypotheses are shown in Fig. 2 for quantitative research and in Fig. 3 for qualitative research.

EXAMPLES OF RESEARCH QUESTIONS FROM PUBLISHED ARTICLES

• EXAMPLE 1. Descriptive research question (quantitative research)
• - Presents research variables to be assessed (distinct phenotypes and subphenotypes)
• “BACKGROUND: Since COVID-19 was identified, its clinical and biological heterogeneity has been recognized. Identifying COVID-19 phenotypes might help guide basic, clinical, and translational research efforts.
• RESEARCH QUESTION: Does the clinical spectrum of patients with COVID-19 contain distinct phenotypes and subphenotypes? ” 19
• EXAMPLE 2. Relationship research question (quantitative research)
• - Shows interactions between dependent variable (static postural control) and independent variable (peripheral visual field loss)
• “Background: Integration of visual, vestibular, and proprioceptive sensations contributes to postural control. People with peripheral visual field loss have serious postural instability. However, the directional specificity of postural stability and sensory reweighting caused by gradual peripheral visual field loss remain unclear.
• Research question: What are the effects of peripheral visual field loss on static postural control ?” 20
• EXAMPLE 3. Comparative research question (quantitative research)
• - Clarifies the difference among groups with an outcome variable (patients enrolled in COMPERA with moderate PH or severe PH in COPD) and another group without the outcome variable (patients with idiopathic pulmonary arterial hypertension (IPAH))
• “BACKGROUND: Pulmonary hypertension (PH) in COPD is a poorly investigated clinical condition.
• RESEARCH QUESTION: Which factors determine the outcome of PH in COPD?
• STUDY DESIGN AND METHODS: We analyzed the characteristics and outcome of patients enrolled in the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) with moderate or severe PH in COPD as defined during the 6th PH World Symposium who received medical therapy for PH and compared them with patients with idiopathic pulmonary arterial hypertension (IPAH) .” 21
• EXAMPLE 4. Exploratory research question (qualitative research)
• - Explores areas that have not been fully investigated (perspectives of families and children who receive care in clinic-based child obesity treatment) to have a deeper understanding of the research problem
• “Problem: Interventions for children with obesity lead to only modest improvements in BMI and long-term outcomes, and data are limited on the perspectives of families of children with obesity in clinic-based treatment. This scoping review seeks to answer the question: What is known about the perspectives of families and children who receive care in clinic-based child obesity treatment? This review aims to explore the scope of perspectives reported by families of children with obesity who have received individualized outpatient clinic-based obesity treatment.” 22
• EXAMPLE 5. Relationship research question (quantitative research)
• - Defines interactions between dependent variable (use of ankle strategies) and independent variable (changes in muscle tone)
• “Background: To maintain an upright standing posture against external disturbances, the human body mainly employs two types of postural control strategies: “ankle strategy” and “hip strategy.” While it has been reported that the magnitude of the disturbance alters the use of postural control strategies, it has not been elucidated how the level of muscle tone, one of the crucial parameters of bodily function, determines the use of each strategy. We have previously confirmed using forward dynamics simulations of human musculoskeletal models that an increased muscle tone promotes the use of ankle strategies. The objective of the present study was to experimentally evaluate a hypothesis: an increased muscle tone promotes the use of ankle strategies. Research question: Do changes in the muscle tone affect the use of ankle strategies ?” 23

EXAMPLES OF HYPOTHESES IN PUBLISHED ARTICLES

• EXAMPLE 1. Working hypothesis (quantitative research)
• - A hypothesis that is initially accepted for further research to produce a feasible theory
• “As fever may have benefit in shortening the duration of viral illness, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response when taken during the early stages of COVID-19 illness .” 24
• “In conclusion, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response . The difference in perceived safety of these agents in COVID-19 illness could be related to the more potent efficacy to reduce fever with ibuprofen compared to acetaminophen. Compelling data on the benefit of fever warrant further research and review to determine when to treat or withhold ibuprofen for early stage fever for COVID-19 and other related viral illnesses .” 24
• EXAMPLE 2. Exploratory hypothesis (qualitative research)
• - Explores particular areas deeper to clarify subjective experience and develop a formal hypothesis potentially testable in a future quantitative approach
• “We hypothesized that when thinking about a past experience of help-seeking, a self distancing prompt would cause increased help-seeking intentions and more favorable help-seeking outcome expectations .” 25
• “Conclusion
• Although a priori hypotheses were not supported, further research is warranted as results indicate the potential for using self-distancing approaches to increasing help-seeking among some people with depressive symptomatology.” 25
• EXAMPLE 3. Hypothesis-generating research to establish a framework for hypothesis testing (qualitative research)
• “We hypothesize that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout). ” 26
• Compassionomics is the branch of knowledge and scientific study of the effects of compassionate healthcare. Our main hypotheses are that compassionate healthcare is beneficial for (1) patients, by improving clinical outcomes, (2) healthcare systems and payers, by supporting financial sustainability, and (3) HCPs, by lowering burnout and promoting resilience and well-being. The purpose of this paper is to establish a scientific framework for testing the hypotheses above . If these hypotheses are confirmed through rigorous research, compassionomics will belong in the science of evidence-based medicine, with major implications for all healthcare domains.” 26
• EXAMPLE 4. Statistical hypothesis (quantitative research)
• - An assumption is made about the relationship among several population characteristics ( gender differences in sociodemographic and clinical characteristics of adults with ADHD ). Validity is tested by statistical experiment or analysis ( chi-square test, Students t-test, and logistic regression analysis)
• “Our research investigated gender differences in sociodemographic and clinical characteristics of adults with ADHD in a Japanese clinical sample. Due to unique Japanese cultural ideals and expectations of women's behavior that are in opposition to ADHD symptoms, we hypothesized that women with ADHD experience more difficulties and present more dysfunctions than men . We tested the following hypotheses: first, women with ADHD have more comorbidities than men with ADHD; second, women with ADHD experience more social hardships than men, such as having less full-time employment and being more likely to be divorced.” 27
• “Statistical Analysis
• ( text omitted ) Between-gender comparisons were made using the chi-squared test for categorical variables and Students t-test for continuous variables…( text omitted ). A logistic regression analysis was performed for employment status, marital status, and comorbidity to evaluate the independent effects of gender on these dependent variables.” 27

EXAMPLES OF HYPOTHESIS AS WRITTEN IN PUBLISHED ARTICLES IN RELATION TO OTHER PARTS

• EXAMPLE 1. Background, hypotheses, and aims are provided
• “Pregnant women need skilled care during pregnancy and childbirth, but that skilled care is often delayed in some countries …( text omitted ). The focused antenatal care (FANC) model of WHO recommends that nurses provide information or counseling to all pregnant women …( text omitted ). Job aids are visual support materials that provide the right kind of information using graphics and words in a simple and yet effective manner. When nurses are not highly trained or have many work details to attend to, these job aids can serve as a content reminder for the nurses and can be used for educating their patients (Jennings, Yebadokpo, Affo, & Agbogbe, 2010) ( text omitted ). Importantly, additional evidence is needed to confirm how job aids can further improve the quality of ANC counseling by health workers in maternal care …( text omitted )” 28
• “ This has led us to hypothesize that the quality of ANC counseling would be better if supported by job aids. Consequently, a better quality of ANC counseling is expected to produce higher levels of awareness concerning the danger signs of pregnancy and a more favorable impression of the caring behavior of nurses .” 28
• “This study aimed to examine the differences in the responses of pregnant women to a job aid-supported intervention during ANC visit in terms of 1) their understanding of the danger signs of pregnancy and 2) their impression of the caring behaviors of nurses to pregnant women in rural Tanzania.” 28
• EXAMPLE 2. Background, hypotheses, and aims are provided
• “We conducted a two-arm randomized controlled trial (RCT) to evaluate and compare changes in salivary cortisol and oxytocin levels of first-time pregnant women between experimental and control groups. The women in the experimental group touched and held an infant for 30 min (experimental intervention protocol), whereas those in the control group watched a DVD movie of an infant (control intervention protocol). The primary outcome was salivary cortisol level and the secondary outcome was salivary oxytocin level.” 29
• “ We hypothesize that at 30 min after touching and holding an infant, the salivary cortisol level will significantly decrease and the salivary oxytocin level will increase in the experimental group compared with the control group .” 29
• EXAMPLE 3. Background, aim, and hypothesis are provided
• “In countries where the maternal mortality ratio remains high, antenatal education to increase Birth Preparedness and Complication Readiness (BPCR) is considered one of the top priorities [1]. BPCR includes birth plans during the antenatal period, such as the birthplace, birth attendant, transportation, health facility for complications, expenses, and birth materials, as well as family coordination to achieve such birth plans. In Tanzania, although increasing, only about half of all pregnant women attend an antenatal clinic more than four times [4]. Moreover, the information provided during antenatal care (ANC) is insufficient. In the resource-poor settings, antenatal group education is a potential approach because of the limited time for individual counseling at antenatal clinics.” 30
• “This study aimed to evaluate an antenatal group education program among pregnant women and their families with respect to birth-preparedness and maternal and infant outcomes in rural villages of Tanzania.” 30
• “ The study hypothesis was if Tanzanian pregnant women and their families received a family-oriented antenatal group education, they would (1) have a higher level of BPCR, (2) attend antenatal clinic four or more times, (3) give birth in a health facility, (4) have less complications of women at birth, and (5) have less complications and deaths of infants than those who did not receive the education .” 30

Research questions and hypotheses are crucial components to any type of research, whether quantitative or qualitative. These questions should be developed at the very beginning of the study. Excellent research questions lead to superior hypotheses, which, like a compass, set the direction of research, and can often determine the successful conduct of the study. Many research studies have floundered because the development of research questions and subsequent hypotheses was not given the thought and meticulous attention needed. The development of research questions and hypotheses is an iterative process based on extensive knowledge of the literature and insightful grasp of the knowledge gap. Focused, concise, and specific research questions provide a strong foundation for constructing hypotheses which serve as formal predictions about the research outcomes. Research questions and hypotheses are crucial elements of research that should not be overlooked. They should be carefully thought of and constructed when planning research. This avoids unethical studies and poor outcomes by defining well-founded objectives that determine the design, course, and outcome of the study.

Disclosure: The authors have no potential conflicts of interest to disclose.

Author Contributions:

• Conceptualization: Barroga E, Matanguihan GJ.
• Methodology: Barroga E, Matanguihan GJ.
• Writing - original draft: Barroga E, Matanguihan GJ.
• Writing - review & editing: Barroga E, Matanguihan GJ.

• Open access
• Published: 28 March 2024

Using the consolidated Framework for Implementation Research to integrate innovation recipients’ perspectives into the implementation of a digital version of the spinal cord injury health maintenance tool: a qualitative analysis

• John A Bourke 1 , 2 , 3 ,
• K. Anne Sinnott Jerram 1 , 2 ,
• Mohit Arora 1 , 2 ,
• Ashley Craig 1 , 2 &
• James W Middleton 1 , 2 , 4 , 5  

BMC Health Services Research volume  24 , Article number:  390 ( 2024 ) Cite this article

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Despite advances in managing secondary health complications after spinal cord injury (SCI), challenges remain in developing targeted community health strategies. In response, the SCI Health Maintenance Tool (SCI-HMT) was developed between 2018 and 2023 in NSW, Australia to support people with SCI and their general practitioners (GPs) to promote better community self-management. Successful implementation of innovations such as the SCI-HMT are determined by a range of contextual factors, including the perspectives of the innovation recipients for whom the innovation is intended to benefit, who are rarely included in the implementation process. During the digitizing of the booklet version of the SCI-HMT into a website and App, we used the Consolidated Framework for Implementation Research (CFIR) as a tool to guide collection and analysis of qualitative data from a range of innovation recipients to promote equity and to inform actionable findings designed to improve the implementation of the SCI-HMT.

Data from twenty-three innovation recipients in the development phase of the SCI-HMT were coded to the five CFIR domains to inform a semi-structured interview guide. This interview guide was used to prospectively explore the barriers and facilitators to planned implementation of the digital SCI-HMT with six health professionals and four people with SCI. A team including researchers and innovation recipients then interpreted these data to produce a reflective statement matched to each domain. Each reflective statement prefaced an actionable finding, defined as alterations that can be made to a program to improve its adoption into practice.

Five reflective statements synthesizing all participant data and linked to an actionable finding to improve the implementation plan were created. Using the CFIR to guide our research emphasized how partnership is the key theme connecting all implementation facilitators, for example ensuring that the tone, scope, content and presentation of the SCI-HMT balanced the needs of innovation recipients alongside the provision of evidence-based clinical information.

Conclusions

Understanding recipient perspectives is an essential contextual factor to consider when developing implementation strategies for healthcare innovations. The revised CFIR provided an effective, systematic method to understand, integrate and value recipient perspectives in the development of an implementation strategy for the SCI-HMT.

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Peer Review reports

Injury to the spinal cord can occur through traumatic causes (e.g., falls or motor vehicle accidents) or from non-traumatic disease or disorder (e.g., tumours or infections) [ 1 ]. The onset of a spinal cord injury (SCI) is often sudden, yet the consequences are lifelong. The impact of a SCI is devastating, with effects on sensory and motor function, bladder and bowel function, sexual function, level of independence, community participation and quality of life [ 2 ]. In order to maintain good health, wellbeing and productivity in society, people with SCI must develop self-management skills and behaviours to manage their newly acquired chronic health condition [ 3 ]. Given the increasing emphasis on primary health care and community management of chronic health conditions, like SCI, there is a growing responsibility on all parties to promote good health practices and minimize the risks of common health complications in their communities.

To address this need, the Spinal Cord Injury Health Maintenance Tool (SCI-HMT) was co-designed between 2018 and 2023 with people living with SCI and their General Practitioners (GPs) in NSW, Australia [ 4 ] The aim of the SCI-HMT is to support self-management of the most common and arguably avoidable potentially life-threatening complications associated with SCI, such as mental health crises, autonomic dysreflexia, kidney infections and pressure injuries. The SCI-HMT provides comprehensible information with resources about the six highest priority health areas related to SCI (as indicated by people with SCI and GPs) and was developed over two phases. Phase 1 focused on developing a booklet version and Phase 2 focused on digitizing this content into a website and smartphone app [ 4 , 5 ].

Enabling the successful implementation of evidence-based innovations such as the SCI-HMT is inevitably influenced by contextual factors: those dynamic and diverse array of forces within real-world settings working for or against implementation efforts [ 6 ]. Contextual factors often include background environmental elements in which an intervention is situated, for example (but not limited to) demographics, clinical environments, organisational culture, legislation, and cultural norms [ 7 ]. Understanding the wider context is necessary to identify and potentially mitigate various challenges to the successful implementation of those innovations. Such work is the focus of determinant frameworks, which focus on categorising or classing groups of contextual determinants that are thought to predict or demonstrate an effect on implementation effectiveness to better understand factors that might influence implementation outcomes [ 8 ].

One of the most highly cited determinant frameworks is the Consolidated Framework for Implementation Research (CFIR) [ 9 ], which is often posited as an ideal framework for pre-implementation preparation. Originally published in 2009, the CFIR has recently been subject to an update by its original authors, which included a literature review, survey of users, and the creation of an outcome addendum [ 10 , 11 ]. A key contribution from this revision was the need for a greater focus on the place of innovation recipients, defined as the constituency for whom the innovation is being designed to benefit; for example, patients receiving treatment, students receiving a learning activity. Traditionally, innovation recipients are rarely positioned as key decision-makers or innovation implementers [ 8 ], and as a consequence, have not often been included in the application of research using frameworks, such as the CFIR [ 11 ].

Such power imbalances within the intersection of healthcare and research, particularly between those receiving and delivering such services and those designing such services, have been widely reported [ 12 , 13 ]. There are concerted efforts within health service development, health research and health research funding, to rectify this power imbalance [ 14 , 15 ]. Importantly, such efforts to promote increased equitable population impact are now being explicitly discussed within the implementation science literature. For example, Damschroder et al. [ 11 ] has recently argued for researchers to use the CFIR to collect data from innovation recipients, and that, ultimately, “equitable population impact is only possible when recipients are integrally involved in implementation and all key constituencies share power and make decisions together” (p. 7). Indeed, increased equity between key constituencies and partnering with innovation recipients promotes the likelihood of sustainable adoption of an innovation [ 4 , 12 , 14 ].

There is a paucity of work using the updated CFIR to include and understand innovation recipients’ perspectives. To address this gap, this paper reports on a process of using the CFIR to guide the collection of qualitative data from a range of innovation recipients within a wider co-design mixed methods study examining the development and implementation of SCI-HMT. The innovation recipients in our research are people living with SCI and GPs. Guided by the CFIR domains (shown in the supplementary material), we used reflexive thematic analysis [ 16 ]to summarize data into reflective summaries, which served to inform actionable findings designed to improve implementation of the SCI-HMT.

The procedure for this research is multi-stepped and is summarized in Fig.  1 . First, we mapped retrospective qualitative data collected during the development of the SCI-HMT [ 4 ] against the five domains of the CFIR in order to create a semi-structured interview guide (Step 1). Then, we used this interview guide to collect prospective data from health professionals and people with SCI during the development of the digital version of the SCI-HMT (Step 2) to identify implementation barriers and facilitators. This enabled us to interpret a reflective summary statement for each CFIR domain. Lastly, we developed an actionable finding for each domain summary. The first (RESP/18/212) and second phase (2019/ETH13961) of the project received ethical approval from The Northern Sydney Local Health District Human Research Ethics Committee. The reporting of this study was conducted in line with the consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [ 17 ]. All methods were performed in accordance with the relevant guidelines and regulations.

Procedure of synthesising datasets to inform reflective statements and actionable findings. a Two health professionals had a SCI (one being JAB); b Two co-design researchers had a SCI (one being JAB)

Step one: retrospective data collection and analysis

We began by retrospectively analyzing the data set (interview and focus group transcripts) from the previously reported qualitative study from the development phase of the SCI-HMT [ 4 ]. This analysis was undertaken by two team members (KASJ and MA). KASJ has a background in co-design research. Transcript data were uploaded into NVivo software (Version 12: QSR International Pty Ltd) and a directed content analysis approach [ 18 ] was applied to analyze categorized data a priori according to the original 2009 CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process of implementation) described by Damschroder et al. [ 9 ]. This categorized data were summarized and informed the specific questions of a semi-structured interview guide. The final output of step one was an interview guide with context-specific questions arranged according to the CFIR domains (see supplementary file 1). The interview was tested with two people with SCI and one health professional.

Step two: prospective data collection and analysis

In the second step, semi-structured interviews were conducted by KASJ (with MA as observer) with consenting healthcare professionals who had previously contributed to the development of the SCI-HMT. Healthcare professionals included GPs, Nurse Consultants, Specialist Physiotherapists, along with Health Researchers (one being JAB). In addition, a focus group was conducted with consenting individuals with SCI who had contributed to the SCI-HMT design and development phase. The interview schedule designed in step one above guided data collection in all interviews and the focus group.

The focus group and interviews were conducted online, audio recorded, transcribed verbatim and uploaded to NVivo software (Version 12: QSR International Pty Ltd). All data were subject to reflexive, inductive and deductive thematic analysis [ 16 , 19 ] to better understand participants’ perspectives regarding the potential implementation of the SCI-HMT. First, one team member (KASJ) read transcripts and began a deductive analysis whereby data were organized into CFIR domains-specific dataset. Second, KASJ and JAB analyzed this domain-specific dataset to inductively interpret a reflective statement which served to summarise all participant responses to each domain. The final output of step two was a reflective summary statement for each CFIR domain.

Step three: data synthesis

In the third step we aimed to co-create an actionable finding (defined as tangible alteration that can be made to a program, in this case the SCI-HMT [ 20 ]) based on each domain-specific reflective statement. To achieve this, three codesign researchers (KAS and JAB with one person with SCI from Step 2 (deidentified)) focused on operationalising each reflective statement into a recommended modification for the digital version of the SCI-HMT. This was an iterative process guided by the specific CFIR domain and construct definitions, which we deemed salient and relevant to each reflective statement (see Table  2 for example). Data synthesis involved line by line analysis, group discussion, and repeated refinement of actionable findings. A draft synthesis was shared with SCI-HMT developers (JWM and MA) and refinement continued until consensus was agreed on. The final outputs of step three were an actionable finding related to each reflective statement for each CFIR domain.

The characteristics of both the retrospective and prospective study participants are shown in Table  1 . The retrospective data included data from a total of 23 people: 19 people with SCI and four GPs. Of the 19 people with SCI, 12 participated in semi-structured interviews, seven participated in the first focus group, and four returned to the second focus group. In step 2, four people with SCI participated in a focus group and six healthcare professionals participated in one-on-one semi-structured interviews. Two of the healthcare professionals (a GP and a registrar) had lived experience of SCI, as did one researcher (JAB). All interviews and focus groups were conducted either online or in-person and ranged in length between 60 and 120 min.

In our overall synthesis, we actively interpreted five reflective statements based on the updated CFIR domain and construct definitions by Damschroder et al. [ 11 ]. Table  2 provides a summary of how we linked the updated CFIR domain and construct definitions to the reflective statements. We demonstrate this process of co-creation below, including illustrative quotes from participants. Importantly, we guide readers to the actionable findings related to each reflective statement in Table  2 . Each actionable statement represents an alteration that can be made to a program to improve its adoption into practice.

Participants acknowledged that self-management is a major undertaking and very demanding, as one person with SCI said, “ we need to be informed without being terrified and overwhelmed”. Participants felt the HMT could indeed be adapted, tailored, refined, or reinvented to meet local needs. For example, another person with SCI remarked:

“Education needs to be from the get-go but in bite sized pieces from all quarters when readiness is most apparent… at all time points , [not just as a] a newbie tool or for people with [long-term impairment] ” (person with SCI_02).

Therefore, the SCI-HMT had to balance complexity of content while still being accessible and engaging, and required input from both experts in the field and those with lived experience of SCI, for example, a clinical nurse specialist suggested:

“it’s essential [the SCI-HMT] is written by experts in the field as well as with collaboration with people who have had a, you know, the lived experience of SCI” (healthcare professional_03).

Furthermore, the points of contact with healthcare for a person with SCI can be challenging to navigate and the SCI-HMT has the potential to facilitate a smoother engagement process and improve communication between people with SCI and healthcare services. As a GP suggested:

“we need a tool like this to link to that pathway model in primary health care , [the SCI-HMT] it’s a great tool, something that everyone can read and everyone’s reading the same thing” (healthcare professional_05).

Participants highlighted that the ability of the SCI-HMT to facilitate effective communication was very much dependent on the delivery format. The idea of digitizing the SCI-HMT garnered equal support from people with SCI and health care professionals, with one participant with SCI deeming it to be “ essential” ( person with SCI_01) and a health professional suggesting a “digitalized version will be an advantage for most people” (healthcare professional_02).

Outer setting

There was strong interest expressed by both people with SCI and healthcare professionals in using the SCI-HMT. The fundamental premise was that knowledge is power and the SCI-HMT would have strong utility in post-acute rehabilitation services, as well as primary care. As a person with SCI said,

“ we need to leave the [spinal unit] to return to the community with sufficient knowledge, and to know the value of that knowledge and then need to ensure primary healthcare provider [s] are best informed” (person with SCI_04).

The value of the SCI-HMT in facilitating clear and effective communication and shared decision-making between healthcare professionals and people with SCI was also highlighted, as shown by the remarks of an acute nurse specialist:

“I think this tool is really helpful for the consumer and the GP to work together to prioritize particular tests that a patient might need and what the regularity of that is” (healthcare professional_03).

Engaging with SCI peer support networks to promote the SCI-HMT was considered crucial, as one person with SCI emphasized when asked how the SCI-HMT might be best executed in the community, “…peers, peers and peers” (person with SCI_01). Furthermore, the layering of content made possible in the digitalized version will allow for the issue of approachability in terms of readiness for change, as another person with SCI said:

“[putting content into a digital format] is essential and required and there is a need to put summarized content in an App with links to further web-based information… it’s not likely to be accessed otherwise” (person with SCI_02).

Inner setting

Participants acknowledged that self-management of health and well-being is substantial and demanding. It was suggested that the scope, tone, and complexity of the SCI-HMT, while necessary, could potentially be resisted by people with SCI if they felt overwhelmed, as one person with SCI described:

“a manual that is really long and wordy, like, it’s [a] health metric… they maybe lack the health literacy to, to consume the content then yes, it would impede their readiness for [self-management]” (person with SCI_02).

Having support from their GPs was considered essential, and the HMT could enable GP’s, who are under time pressure, to provide more effective health and advice to their patients, as one GP said:

“We GP’s are time poor, if you realize then when you’re time poor you look quickly to say oh this is a patient tool - how can I best use this?” (healthcare professional_05).

Furthermore, health professional skills may be best used with the synthesis of self-reported symptoms, behaviors, or observations. A particular strength of a digitized version would be its ability to facilitate more streamlined communication between a person with SCI and their primary healthcare providers developing healthcare plans, as an acute nurse specialist reflected, “ I think that a digitalized version is essential with links to primary healthcare plans” (healthcare professional_03).

Efficient communication with thorough assessment is essential to ensure serious health issues are not missed, as findings reinforce that the SCI-HMT is an educational tool, not a replacement for healthcare services, as a clinical nurse specialist commented, “ remember, things will go wrong– people end up very sick and in acute care “ (healthcare professional_02).

The SCI-HMT has the potential to provide a pathway to a ‘hope for better than now’ , a hope to ‘remain well’ and a hope to ‘be happy’ , as the informant with SCI (04) declared, “self-management is a long game, if you’re keeping well, you’ve got that possibility of a good life… of happiness”. Participants with SCI felt the tool needed to be genuine and

“acknowledge the huge amount of adjustment required, recognizing that dealing with SCI issues is required to survive and live a good life” (person with SCI_04).

However, there is a risk that an individual is completely overwhelmed by the scale of the SCI-HMT content and the requirement for lifelong vigilance. Careful attention and planning were paid to layering the information accordingly to support self-management as a ‘long game’, which one person with SCI reflected in following:

“the first 2–3 year [period] is probably the toughest to get your head around the learning stuff, because you’ve got to a stage where you’re levelling out, and you’ve kind of made these promises to yourself and then you realize that there’s no quick fix” (person with SCI_01).

It was decided that this could be achieved by providing concrete examples and anecdotes from people with SCI illustrating that a meaningful, healthy life is possible, and that good health is the bedrock of a good life with SCI.

There was universal agreement that the SCI-HMT is aspirational and that it has the potential to improve knowledge and understanding for people with SCI, their families, community workers/carers and primary healthcare professionals, as a GP remarked:

“[different groups] could just read it and realize, ‘Ahh, OK that’s what that means… when you’re doing catheters. That’s what you mean when you’re talking about bladder and bowel function or skin care” (healthcare professional_04).

Despite the SCI-HMT providing an abundance of information and resources to support self-management, participants identified four gaps: (i) the priority issue of sexuality, including pleasure and identity, as one person with SCI remarked:

“ sexuality is one of the biggest issues that people with SCI often might not speak about that often cause you know it’s awkward for them. So yeah, I think that’s a that’s a serious issue” (person with SCI_03).

(ii) consideration of the taboo nature of bladder and bowel topics for indigenous people, (iii) urgent need to ensure links for SCI-HMT care plans are compatible with patient management systems, and (iv) exercise and leisure as a standalone topic taking account of effects of physical activity, including impact on mental health and wellbeing but more especially for fun.

To ensure longevity of the SCI-HMT, maintaining a partnership between people with SCI, SCI community groups and both primary and tertiary health services is required for liaison with the relevant professional bodies, care agencies, funders, policy makers and tertiary care settings to ensure ongoing education and promotion of SCI-HMT is maintained. For example, delivery of ongoing training of healthcare professionals to both increase the knowledge base of primary healthcare providers in relation to SCI, and to promote use of the tools and resources through health communities. As a community nurse specialist suggested:

“ improving knowledge in the health community… would require digital links to clinical/health management platforms” (healthcare professional_02).

In a similar vein, a GP suggested:

“ our common GP body would have continuing education requirements… especially if it’s online, in particular for the rural, rural doctors who you know, might find it hard to get into the city” (healthcare professional_04).

The successful implementation of evidence-based innovations into practice is dependent on a wide array of dynamic and active contextual factors, including the perspectives of the recipients who are destined to use such innovations. Indeed, the recently updated CFIR has called for innovation recipient perspectives to be a priority when considering contextual factors [ 10 , 11 ]. Understanding and including the perspectives of those the innovation is being designed to benefit can promote increased equity and validation of recipient populations, and potentially increase the adoption and sustainability of innovations.

In this paper, we have presented research using the recently updated CFIR to guide the collection of innovation recipients’ perspectives (including people with SCI and GPs working in the community) regarding the potential implementation barriers and facilitators of the digital version of the SCI-HMT. Collected data were synthesized to inform actionable findings– tangible ways in which the SCI-HMT could be modified according of the domains of the CFIR (e.g., see Keith et al. [ 20 ]). It is important to note that we conducted this research using the original domains of the CFIR [ 9 ] prior to Damschroder et al. publishing the updated CFIR [ 11 ]. However, in our analysis we were able to align our findings to the revised CFIR domains and constructs, as Damschroder [ 11 ] suggests, constructs can “be mapped back to the original CFIR to ensure longitudinal consistency” (p. 13).

One of the most poignant findings from our analyses was the need to ensure the content of the SCI-HMT balanced scientific evidence and clinical expertise with lived experience knowledge. This balance of clinical and experiential knowledge demonstrated genuine regard for lived experience knowledge, and created a more accessible, engaging, useable platform. For example, in the innovation and individual domains, the need to include lived experience quotes was immediately apparent once the perspective of people with SCI was included. It was highlighted that while the SCI-HMT will prove useful to many parties at various stages along the continuum of care following onset of SCI, there will be those individuals that are overwhelmed by the scale of the content. That said, the layering of information facilitated by the digitalized version is intended to provide an ease of navigation through the SCI-HMT and enable a far greater sense of control over personal health and wellbeing. Further, despite concerns regarding e-literacy the digitalized version of the SCI-HMT is seen as imperative for accessibility given the wide geographic diversity and recent COVID pandemic [ 21 ]. While there will be people who are challenged by the technology, the universally acceptable use of the internet is seen as less of a barrier than printed material.

The concept of partnership was also apparent within the data analysis focusing on the outer and inner setting domains. In the outer setting domain, our findings emphasized the importance of engaging with SCI community groups, as well as primary and tertiary care providers to maximize uptake at all points in time from the phase of subacute rehabilitation onwards. While the SCI-HMT is intended for use across the continuum of care from post-acute rehabilitation onwards, it may be that certain modules are more relevant at different times, and could serve as key resources during the hand over between acute care, inpatient rehabilitation and community reintegration.

Likewise, findings regarding the inner setting highlighted the necessity of a productive partnership between GPs and individuals with SCI to address the substantial demands of long-term self-management of health and well-being following SCI. Indeed, support is crucial, especially when self-management is the focus. This is particularly so in individuals living with complex disability following survival after illness or injury [ 22 ], where health literacy has been found to be a primary determinant of successful health and wellbeing outcomes [ 23 ]. For people with SCI, this tool potentially holds the most appeal when an individual is ready and has strong partnerships and supportive communication. This can enable potential red flags to be recognized earlier allowing timely intervention to avert health crises, promoting individual well-being, and reducing unnecessary demands on health services.

While the SCI-HMT is an educational tool and not meant to replace health services, findings suggest the current structure would lead nicely to having the conversation with a range of likely support people, including SCI peers, friends and family, GP, community nurses, carers or via on-line support services. The findings within the process domain underscored the importance of ongoing partnership between innovation implementers and a broad array of innovation recipients (e.g., individuals with SCI, healthcare professionals, family, funding agencies and policy-makers). This emphasis on partnership also addresses recent discussions regarding equity and the CFIR. For example, Damschroder et al. [ 11 ] suggests that innovation recipients are too often not included in the CFIR process, as the CFIR is primarily seen as a tool intended “to collect data from individuals who have power and/or influence over implementation outcomes” (p. 5).

Finally, we feel that our inclusion of innovation recipients’ perspectives presented in this article begins to address the notion of equity in implementation, whereby the inclusion of recipient perspectives in research using the CFIR both validates, and increases, the likelihood of sustainable adoption of evidence-based innovations, such as the SCI-HMT. We have used the CFIR in a pragmatic way with an emphasis on meaningful engagement between the innovation recipients and the research team, heeding the call from Damschroder et al. [ 11 ], who recently argued for researchers to use the CFIR to collect data from innovation recipients. Adopting this approach enabled us to give voice to innovation recipient perspectives and subsequently ensure that the tone, scope, content and presentation of the SCI-HMT balanced the needs of innovation recipients alongside the provision of evidence-based clinical information.

Our research is not without limitations. While our study was successful in identifying a number of potential barriers and facilitators to the implementation of the SCI-HMT, we did not test any implementation strategies to impact determinants, mechanisms, or outcomes. This will be the focus of future research on this project, which will investigate the impact of implementation strategies on outcomes. Focus will be given to the context-mechanism configurations which give rise to particular outcomes for different groups in certain circumstances [ 7 , 24 ]. A second potential concern is the relatively small sample size of participants that may not allow for saturation and generalizability of the findings. However, both the significant impact of secondary health complications for people with SCI and the desire for a health maintenance tool have been established in Australia [ 2 , 4 ]. The aim our study reported in this article was to achieve context-specific knowledge of a small sample that shares a particular mutual experience and represents a perspective, rather than a population [ 25 , 26 ]. We feel our findings can stimulate discussion and debate regarding participant-informed approaches to implementation of the SCI-HMT, which can then be subject to larger-sample studies to determine their generalisability, that is, their external validity. Notably, future research could examine the interaction between certain demographic differences (e.g., gender) of people with SCI and potential barriers and facilitators to the implementation of the SCI-HMT. Future research could also include the perspectives of other allied health professionals working in the community, such as occupational therapists. Lastly, while our research gave significant priority to recipient viewpoints, research in this space would benefit for ensuring innovation recipients are engaged as genuine partners throughout the entire research process from conceptualization to implementation.

Employing the CFIR provided an effective, systematic method for identifying recipient perspectives regarding the implementation of a digital health maintenance tool for people living with SCI. Findings emphasized the need to balance clinical and lived experience perspectives when designing an implementation strategy and facilitating strong partnerships with necessary stakeholders to maximise the uptake of SCI-HMT into practice. Ongoing testing will monitor the uptake and implementation of this innovation, specifically focusing on how the SCI-HMT works for different users, in different contexts, at different stages and times of the rehabilitation journey.

Data availability

The datasets supporting the conclusions of this article are available available upon request and with permission gained from the project Steering Committee.

Abbreviations

spinal cord injury

HMT-Spinal Cord Injury Health Maintenance Tool

Consolidated Framework for Implementation Research

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Acknowledgements

Authors of this study would like to thank all the consumers with SCI and healthcare professionals for their invaluable contribution to this project. Their participation and insights have been instrumental in shaping the development of the SCI-HMT. The team also acknowledges the support and guidance provided by the members of the Project Steering Committee, as well as the partner organisations, including NSW Agency for Clinical Innovation, and icare NSW. Author would also like to acknowledge the informant group with lived experience, whose perspectives have enriched our understanding and informed the development of SCI-HMT.

The SCI Wellness project was a collaborative project between John Walsh Centre for Rehabilitation Research at The University of Sydney and Royal Rehab. Both organizations provided in-kind support to the project. Additionally, the University of Sydney and Royal Rehab received research funding from Insurance and Care NSW (icare NSW) to undertake the SCI Wellness Project. icare NSW do not take direct responsibility for any of the following: study design, data collection, drafting of the manuscript, or decision to publish.

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John A Bourke, K. Anne Sinnott Jerram, Mohit Arora, Ashley Craig & James W Middleton

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Contributions

Project conceptualization: KASJ, MA, JWM; project methodology: JWM, MA, KASJ, JAB; data collection: KASJ and MA; data analysis: KASJ, JAB, MA, JWM; writing—original draft preparation: JAB; writing—review and editing: JAB, KASJ, JWM, MA, AC; funding acquisition: JWM, MA. All authors contributed to the revision of the paper and approved the final submitted version.

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Correspondence to John A Bourke .

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The first (RESP/18/212) and second phase (2019/ETH13961) of the project received ethical approval from The Northern Sydney Local Health District Human Research Ethics Committee. All participants provided informed, written consent. All data were to be retained for 7 years (23rd May 2030).

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Competing interests

MA part salary (from Dec 2018 to Dec 2023), KASJ part salary (July 2021 to Dec 2023) and JAB part salary (Jan 2022 to Aug 2022) was paid from the grant monies. Other authors declare no conflicts of interest.

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Bourke, J.A., Jerram, K.A.S., Arora, M. et al. Using the consolidated Framework for Implementation Research to integrate innovation recipients’ perspectives into the implementation of a digital version of the spinal cord injury health maintenance tool: a qualitative analysis. BMC Health Serv Res 24 , 390 (2024). https://doi.org/10.1186/s12913-024-10847-x

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Received : 14 August 2023

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DOI : https://doi.org/10.1186/s12913-024-10847-x

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