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Qualitative research & evaluation methods: integrating theory and practice

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The fourth edition of Michael Quinn Patton's Qualitative Research & Evaluation Methods Integrating Theory and Practice, published by Sage Publications, analyses and provides clear guidance and advice for using a range of different qualitative methods for evaluation.

Module 1. How qualitative inquiry contributes to our understanding of the world
Module 2. What makes qualitative data qualitative
Module 3. Making methods decisions
Module 4. The fruit of qualitative methods: Chapter summary and conclusion
Module 5. Strategic design principles for qualitative inquiry
Module 6. Strategic principles guiding data collection and fieldwork
Module 7. Strategic principles for qualitative analysis and reporting findings
Module 8: Integrating the 12 strategic qualitative principles in practice
Module 9. Understanding the Paradigms Debate: Quants versus Quals
Module 10. Introduction to Qualitative Inquiry Frameworks
Module 11. Ethnography and Autoethnography
Module 12. Positivism, Postpositivism, Empiricism and Foundationalist Epistemologies
Module 13. Grounded Theory and Realism
Module 14 Phenomenology and Heuristic Inquiry
Module 15 Social Constructionism, Constructivism, Postmodernism, and Narrative Inquiry
Module 16. Ethnomethodology, Semiotics, and Symbolic Interaction, Hermeneutics and Ecological Psychology
Module 17 Systems Theory and Complexity Theory
Module 18. Pragmatism, Generic Qualitative Inquiry, and Utilization-Focused Evaluation
Module 19 Patterns and themes across inquiry frameworks: Chapter summary and conclusions
Module 20. Practical purposes, concrete questions, and actionable answers: Illuminating and enhancing quality
Module 21. Program evaluation applications: Focus on outcomes
Module 22 Specialized qualitative evaluation applications
Module 23 Evaluating program models and theories of change, and evaluation models especially aligned with qualitative methods
Module 24 Interactive and participatory qualitative applications
Module 25 Democratic evaluation, indigenous research and evaluation, capacity building, and cultural competence
Module 26 Special methodological applications
Module 27 A vision of the utility of qualitative methods: Chapter summary and conclusion
Module 28 Design thinking: Questions derive from purpose, design answers questions
Module 29 Date Collection Decisions
Module 30 Purposeful sampling and case selection: Overview of strategies and options
Module 31 Single-significant-case sampling as a design strategy
Module 32 Comparison-focused sampling options
Module 33 Group characteristics sampling strategies and options
Module 34 Concept and theoretical sampling strategies and options
Module 35. Instrumental-use multiple-case sampling
Module 36 Sequential and emergence-driven sampling strategies and options
Module 37 Analytically focused sampling
Module 38 Mixed, stratified, and nested purposeful sampling strategies
Module 39 Information-rich cases
Module 40 Sample size for qualitative designs
Module 41 Mixed methods designs
Module 42 Qualitative design chapter summary and conclusion: Methods choices and decisions
Module 43 The Power of direct observation
Module 44. Variations in observational methods
Module 45. Variations in duration of observations and site visits: From rapid reconnaissance to longitudinal studies over years
Module 46. Variations in observational focus and summary of dimensions along which fieldwork varies
Module 47. What to observe: Sensitizing concepts
Module 48. Integrating what to observe with how to observe
Module 49. Unobtrusive observations and indicators, and documents and archival fieldwork
Module 50. Observing oneself: Reflexivity and Creativity, and Review of Fieldwork Dimensions
Module 51. Doing Fieldwork: The Data Gathering Process
Module 52. Stages of fieldwork: Entry into the field
Module 53. Routinization of fieldwork: The dynamics of the second stage
Module 54. Bringing fieldwork to a close
Module 55. The observer and what is observed: Unity, separation, and reactivity
Module 56. Chapter summary and conclusion: Guidelines for fieldwork
Module 57 The Interview Society: Diversity of applications
Module 58 Distinguishing interview approaches and types of interviews
Module 59 Question options and skilled question formulation
Module 60 Rapport, neutrality, and the interview relationship
Module 61 Interviewing groups and cross-cultural interviewing
Module 62. Creative modes of qualitative inquiry
Module 63. Ethical issues and challenges in qualitative interviewing
Module 64. Personal reflections on interviewing, and chapter summary and conclusion
Module 65. Setting the Context for Qualitative Analysis: Challenge, Purpose, and Focus
Module 66. Thick description and case studies: The bedrock of qualitative analysis
Module 67. Qualitative Analysis Approaches: Identifying Patterns and Themes
Module 68. The intellectual and operational work of analysis
Module 69. Logical and matrix analyses, and synthesizing qualitative studies
Module 70. Interpreting findings, determining substantive significance, phenomenological essence, and hermeneutic interpretation
Module 71. Causal explanation thorough qualitative analysis
Module 72. New analysis directions: Contribution analysis, participatory analysis, and qualitative counterfactuals
Module 73. Writing up and reporting findings, including using visuals
Module 74. Special analysis and reporting issues: Mixed methods, focused communications, and principles-focused report exemplar.
Module 75 Chapter summary and conclusion, plus case study exhibits
Module 76. Analytical processes for enhancing credibility: systematically engaging and questioning the data
Module 77. Four triangulation processes for enhancing credibility
Part 1, universal criteria, and traditional scientific research versus constructivist criteria
Part 2: artistic, participatory, critical change, systems, pragmatic, and mixed criteria
Module 80 Credibility of the inquirer
Module 81 Generalizations, Extrapolations, Transferability, Principles, and Lessons learned
Module 82 Enhancing the credibility and utility of qualitative inquiry by addressing philosophy of science issues

Patton, M. Q. (2014). Qualitative Research & Evaluation Methods: Integrative Theory and Practice . SAGE Publications.

'Qualitative research & evaluation methods: integrating theory and practice' is referenced in:

Week 47: Rumination #3: Fools' gold: the widely touted methodological "gold standard" is neither golden nor a standard

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Rainbow Framework : Sample

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Qualitative Research & Evaluation Methods: Integrating Theory and Practice

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Qualitative Research & Evaluation Methods: Integrating Theory and Practice Hardcover – 6 Jan. 2015

Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied research and evaluation, this Fourth Edition illuminates all aspects of qualitative inquiry through new examples, stories, and cartoons; more than a hundred new summarizing and synthesizing exhibits; and a wide range of new highlight sections/sidebars that elaborate on important and emergent issues. For the first time, full case studies are included to illustrate extended research and evaluation examples. In addition, each chapter features an extended "rumination," written in a voice and style more emphatic and engaging than traditional textbook style, about a core issue of persistent debate and controversy.

ISBN-10 9781412972123
ISBN-13 978-1412972123
Edition Fourth
Publisher SAGE Publications, Inc
Publication date 6 Jan. 2015
Language English
Dimensions 22.23 x 3.81 x 28.58 cm
Print length 832 pages
See all details

Product description

"The content itself, based in years of thinking, reading, doing, conversing, is a huge strength. Reading the chapters is like sitting at the feet of one of the masters."

"I can’t emphasize enough the quality, detail, and depth of the presentation of research design and methods… Students and experienced researchers will appreciate the depth of presentation of potential qualitative paradigms, theoretical orientations and frameworks as well as special methodological applications that are often not covered in other qualitative texts."

"It is refreshing to see a text that engages the multiple philosophical and historical trajectories within a qualitative research tradition while integrating this discussion so well with the practice of research design, fieldwork strategies, and data analysis."

From the Back Cover

About the author.

Michael Quinn Patton is author of more than a dozen books on evaluation including Qualitative Research & Evaluation Methods, 4th ed (2015), Blue Marble Evaluation (2020), Principles-Focused Evaluation (2018), Facilitating Evaluation (2018) and Developmental Evaluation (2011). Based in Minnesota, he was on the faculty of the University of Minnesota for 18 years and is a former president of the American Evaluation Association (AEA). Michael is a recipient of the Alva and Gunnar Myrdal Evaluation Practice Award, the Paul F. Lazarsfeld Evaluation Theory Award, and the Research on Evaluation Award, all from AEA He has also received the Lester F. Ward Distinguished Contribution to Applied and Clinical Sociology Award from the Association for Applied and Clinical Sociology. In 2021 he received the first Transformative Evaluator Award from EvalYouth. He is an active speaker, trainer, and workshop presenter who has conducted applied research and evaluation on a broad range of issues and has worked with organizations and programs at the international, national, state, provincial, and local levels. Michael has three children―a musician, an engineer, and an evaluator―and four grandchildren. When not evaluating, he enjoys exploring the woods and rivers of Minnesota, where he lives.

Product details

Publisher ‏ : ‎ SAGE Publications, Inc; Fourth edition (6 Jan. 2015)
Language ‏ : ‎ English
Hardcover ‏ : ‎ 832 pages
ISBN-10 ‏ : ‎ 9781412972123
ISBN-13 ‏ : ‎ 978-1412972123
Dimensions ‏ : ‎ 22.23 x 3.81 x 28.58 cm
459 in Scientific Equipment & Techniques
5,430 in Anthropology & Sociology Biographies

About the author

Michael quinn patton.

Michael Quinn Patton lives in Minnesota where, according to the state's poet laureate, Garrison Keillor, "all the women are strong, all the men are good looking, and all the children are above average." It was this lack of interesting statistical variation in Minnesota that led him to qualitative inquiry despite the strong quantitative orientation of his doctoral studies in sociology at the University of Wisconsin. He serves on the graduate faculty of The Union Institute, a nontraditional, interdisciplinary, nonresidential and individually designed doctoral program.

He was on the faculty of the University of Minnesota for 18 years, including five years as Director of the Minnesota Center for Social Research, where he was awarded the Morse-Amoco Award for innovative teaching. He won the University of Minnesota storytelling competition and has authored several other books which include Utilization-Focused Evaluation, Creative Evaluation, Practical Evaluation, How to Use Qualitative Methods in Evaluation, and Family Sexual Abuse: Frontline Research and Evaluation.

He edited Culture and Evaluation for the journal New Direction in Program Evaluation. His creative nonfiction book, Grand Canyon Celebration: A Father-Son Journey of Discovery, was a finalist for 1999 Minnesota Book of the Year.He is former President of the American Evaluation Association and the only recipient of both the Alva and Gunner Myrdal Award for Outstanding Contributions to Useful and Practical Evaluation from the Evaluation Research Society and the Paul F. Lazarsfeld Award for Lifelong Contributions to Evaluation Theory from the American Evaluation Association. The Society for Applied Sociology awarded him the 2001 Lester F. Ward Award for Outstanding Contributions to Applied Sociology.

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Qualitative Research & Evaluation Methods: Integrating Theory and Practice Hardcover – Nov. 11 2014

Purchase options and add-ons.

Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied research and evaluation, this Fourth Edition of Qualitative Research & Evaluation Methods illuminates all aspects of qualitative inquiry through new examples, stories, and cartoons; more than a hundred new summarizing and synthesizing exhibits; and a wide range of new highlight sections/sidebars that elaborate on important and emergent issues. For the first time, full case studies are included to illustrate extended research and evaluation examples. In addition, each chapter features an extended "rumination," written in a voice and style more emphatic and engaging than traditional textbook style, about a core issue of persistent debate and controversy.

ISBN-10 9781412972123
ISBN-13 978-1412972123
Edition 4th
Publisher Sage Publications
Publication date Nov. 11 2014
Language English
Dimensions 22.23 x 3.81 x 28.58 cm
Print length 832 pages
See all details

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Product description

“The content itself, based in years of thinking, reading, doing, conversing, is a huge strength. Reading the chapters is like sitting at the feet of one of the masters.”

“I can’t emphasize enough the quality, detail, and depth of the presentation of research design and methods… Students and experienced researchers will appreciate the depth of presentation of potential qualitative paradigms, theoretical orientations and frameworks as well as special methodological applications that are often not covered in other qualitative texts.”

“It is refreshing to see a text that engages the multiple philosophical and historical trajectories within a qualitative research tradition while integrating this discussion so well with the practice of research design, fieldwork strategies, and data analysis.”

About the Author

Michael Quinn Patton is an independent consultant with more than 40 years’ experience conducting applied research and program evaluations. He lives in Minnesota, where, according to the state’s poet laureate, Garrison Keillor, “all the women are strong, all the men are good-looking, and all the children are above average.” It was this interesting lack of statistical variation in Minnesota that led him to qualitative inquiry despite the strong quantitative orientation of his doctoral studies in sociology at the University of Wisconsin. He was on the faculty of the University of Minnesota for 18 years, including 5 years as director of the Minnesota Center for Social Research, where he was awarded the Morse-Amoco Award for innovative teaching. Readers of this book will not be surprised to learn that he has also won the University of Minnesota storytelling competition. He has authored six other SAGE books: Utilization-Focused Evaluation, Creative Evaluation, Practical Evaluation, How to Use Qualitative Methods for Evaluation, Essentials of Utilization-Focused Evaluation, and Family Sexual Abuse: Frontline Research and Evaluation . He has edited or contributed articles to numerous books and journals, including several volumes of New Directions in Program Evaluation, on subjects as diverse as culture and evaluation, how and why language matters, HIV/AIDS research and evaluation systems, extension methods, feminist evaluation, teaching using the case method, evaluating strategy, utilization of evaluation, and valuing. He is the author of Developmental Evaluation: Applying Complexity Concepts to Enhance Innovation and Use and coauthor of Getting to Maybe: How the World Is Changed, a book that applies complexity science to social innovation. His creative nonfiction book, Grand Canyon Celebration: A Father–Son Journey of Discovery, was a finalist for Minnesota Book of the Year. He is a former president of the American Evaluation Association and recipient of both the Alva and Gunnar Myrdal Award for Outstanding Contributions to Useful and Practical Evaluation and the Paul F. Lazarsfeld Award for Lifelong Contributions to Evaluation Theory from the American Evaluation Association. The Society for Applied Sociology presented him the Lester F. Ward Award for Outstanding Contributions to Applied Sociology. He is on the faculty of The Evaluators’ Institute and teaches workshops for the American Evaluation Association’s professional development courses and Claremont University’s Summer Institute. He is a founding trainer for the International Program for Development Evaluation Training, sponsored by The World Bank and other international development agencies each summer in Ottawa, Ontario. He has conducted applied research and evaluation on a broad range of issues, including antipoverty initiatives, leadership development, education at all levels, human services, the environment, public health, medical education, employment training, agricultural extension, arts, criminal justice, mental health, transportation, diversity initiatives, international development, community development, systems change, policy effectiveness, managing for results, performance indicators, and effective governance. He has worked with organizations and programs at the international, national, state, provincial, and local levels and with philanthropic, not-for-profit, private sector, international agency, and government programs. He has worked with people from many different cultures and perspectives. He has three children―a musician, an engineer, and a nonprofit organization development and evaluation specialist―and one granddaughter. When not evaluating, he enjoys exploring the woods and rivers of Minnesota with his partner, Jean―kayaking, cross-country skiing, and snowshoeing―and occasionally hiking in the Grand Canyon. He enjoys watching the seasons change from his office overlooking the Mississippi River in Saint

Product details

ASIN ‏ : ‎ 1412972124
Publisher ‏ : ‎ Sage Publications; 4th edition (Nov. 11 2014)
Language ‏ : ‎ English
Hardcover ‏ : ‎ 832 pages
ISBN-10 ‏ : ‎ 9781412972123
ISBN-13 ‏ : ‎ 978-1412972123
Item weight ‏ : ‎ 1.97 kg
Dimensions ‏ : ‎ 22.23 x 3.81 x 28.58 cm
#165 in Social Sciences Methodology
#188 in Methodology & Statistics
#189 in Education Research (Books)

About the author

Michael quinn patton.

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Qualitative Research & Evaluation Methods Integrating Theory and Practice

Michael Quinn Patton - Utilization-Focused Evaluation, Saint Paul, MN
Description

Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied research and evaluation, t his Fourth Edition illuminates all aspects of qualitative inquiry through new examples, stories, and cartoons; more than a hundred new summarizing and synthesizing exhibits; and a wide range of new highlight sections/sidebars that elaborate on important and emergent issues . For the first time, full case studies are included to illustrate extended research and evaluation examples. In addition, each chapter features an extended "rumination," written in a voice and style more emphatic and engaging than traditional textbook style, about a core issue of persistent debate and controversy.

ISBN: 9781412972123	Hardcover	Suggested Retail Price: $179.00	Bookstore Price: $143.20
ISBN: 9781483376059	Electronic Version	Suggested Retail Price: $117.00	Bookstore Price: $93.60

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

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Supplements

"Very thoughtful and thorough coverage of qualitative design and study."

“The content itself, based in years of thinking, reading, doing, conversing, is a huge strength. Reading the chapters is like sitting at the feet of one of the masters.”

I have used Patton for this course historically; I will continue to use him for this course. I have used previous editions as well.

Great book - not currently teaching a course in evaluation - will definitely consider this text when I do next teach such a course.

Mae’r llyfr yma yn wych, yn enwedig y bennod ar fframweithiau damcaniaethol ac athroniaeth. Rwyf wedi ei argymell i nifer o fyfyrwyr ôl-radd sydd wrthi’n cynllunio traethodau hir - trwy gwrs ‘Yr ymchwilydd ansoddol’ y Coleg Cymraeg Cenedlaethol (CCC) a hefyd myfyrwyr Bangor (Cymraeg a Saesneg ei hiaith). Rwyf hefyd wedi gofyn i’r llyfrgellydd gwyddorau cymdeithasol archebu un neu ddau o gopïau i’r llyfrgell.

Adopted Creswell 3rd ed (Sage)

Good resource for students looking to develop their qualitative research skills.

Will use as a secondary text in the Qualitative Research Methods course I teach

NEW TO THIS EDITION:

A new organization that creatively groups content into individual modules within nine chapters offers instructors the ability to easily customize course content and readers the ability to quickly navigate and reference specific topics by choosing across a range of over 80 modules.
New examples of the contributions of qualitative inquiry to our understanding of patterns in the world have been added, including advances in theory, practice, and both classic and innovative methods.
New and major in-depth discussions explore systems thinking , complexity theory , pragmatic framing , and generic qualitative inquiry.
More than half of this edition consists of new, extended research and evaluation examples with full case studies as exemplars.
The number of qualitative (purposeful) sampling options has been expanded from 16 to 40 to provide readers with the most innovative and comprehensive case selection framework ever assembled and explained.
The book offers the most comprehensive, rigorous, and assertive discussion of methods and analysis techniques for drawing causal inferences available today.
Techniques for high-quality observational fieldwork and in-depth interviewing are covered, along with emergent approaches and alternative frameworks for inquiry .
Principles-focused qualitative evaluation is premiered in this edition.
Detailed analysis guidelines and diverse examples include innovative approaches to data visualization.
The number of qualitative frameworks for judging quality has been expanded from five to seven.
Over a hundred new exhibits —essential for teaching—summarize and synthesize key information.
New sidebars throughout the text elaborate on important and emergent issues.
Hundreds of new references make the book up to date and comprehensive.
New cartoons and graphic comics specially commissioned and created for this edition illustrate key concepts in a unique and memorable way.
An Instructor Resource and Student Study Site filled with helpful supplemental resources, including access to carefully selected SAGE journal articles, are available at no additional charge.

KEY FEATURES:

Qualitative inquiry’s seven major contributions to understanding the world are presented.
Twelve primary strategic themes of qualitative inquiry illuminate the unique niche of qualitative inquiry in research and evaluation studies.
Seven distinct, criteria-based frameworks for presenting and judging qualitative findings are provided.
Sixteen different theoretical and philosophical approaches to qualitative inquiry are identified, compared, contrasted, and discussed.
Variations in observational methods are covered, including historical perspectives, case studies and their layers, and cross-case analysis.
Alternative interviewing strategies and approaches are linked to theoretical and methodological traditions, including innovative and emergent methods, such as using social media and data visualization.
Key strategies are included to unravel the complexities of and controversies about causal analysis , generalizations , and triangulation .
Comprehensive references provide the scholarly foundations for qualitative theory and practice.

Sample Materials & Chapters

Table of Contents

Sage College Publishing

You can purchase this book and request an instructor sample on our US College site:

Qualitative Research & Evaluation Methods: Integrating Theory and Practice

Student resources.

This site is intended to enhance your use of Qualitative Research & Evaluation Methods, Fourth Edition , by Michael Quinn Patton. Please note that all the materials on this site are especially geared toward maximizing your understanding of the material.

Acknowledgments

We gratefully acknowledge Michael Quinn Patton for writing an excellent text and creating the materials on this site.

Qualitative Research & Evaluation Methods 4th Edition Integrating Theory and Practice

Cover image: Qualitative Research & Evaluation Methods 4th edition 9781412972123

Author(s) Michael Quinn Patton
Publisher SAGE Publications, Inc

Print ISBN 9781412972123, 1412972124

Etext isbn 9781483376059, 1483376052.

Edition 4th
Copyright 2015
Available from $ 65.00 USD SKU: 9781483376059R90

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Qualitative Research & Evaluation Methods: Integrating Theory and Practice 4th Edition is written by Michael Quinn Patton and published by SAGE Publications, Inc. The Digital and eTextbook ISBNs for Qualitative Research & Evaluation Methods are 9781483376059, 1483376052 and the print ISBNs are 9781412972123, 1412972124. Save up to 80% versus print by going digital with VitalSource. Additional ISBNs for this eTextbook include 9781483314815, 9781483301457.

Qualitative Research & Evaluation Methods Integrating Theory and Practice

Michael Quinn Patton - Utilization-Focused Evaluation, Saint Paul, MN

Format	Published Date	ISBN	Price
Hardcover	06/01/2015	9781412972123	£143.00
Electronic Version	29/10/2014	9781483301457	£94.00
Electronic Version	08/11/2014	9781483314815	£94.00
Electronic Version	07/02/2023	9781483376059	£94.00
Electronic Version	13/02/2023	9781483376059	£94.00

“The content itself, based in years of thinking, reading, doing, conversing, is a huge strength. Reading the chapters is like sitting at the feet of one of the masters.”

"Very thoughtful and thorough coverage of qualitative design and study."

I have used Patton for this course historically; I will continue to use him for this course. I have used previous editions as well.

Michael Quinn Patton

Michael Quinn Patton is author of more than a dozen books on evaluation including Qualitative Research & Evaluation Methods, 4th ed (2015), Blue Marble Evaluation (2020), Principles-Focused Evaluation (2018), Facilitating Evaluation (2018) and Developmental Evaluation (2011). Based in Minnesota, he was on the faculty of the University of Minnesota for 18 years and is a former president of the American Evaluation Association (AEA). Michael is a recipient of the Alva and Gunnar Myrdal Evaluation Practice Award, the Paul F. Lazarsfeld Evaluation Theory Award, and the Research on Evaluation Award, all from AEA He has also received the Lester F. Ward Distinguished Contribution to Applied and Clinical Sociology Award from the Association for Applied and Clinical Sociology. In 2021 he received the first Transformative Evaluator Award from EvalYouth. He is an active speaker, trainer, and workshop presenter who has conducted applied research and evaluation on a broad range of issues and has worked with organizations and programs at the international, national, state, provincial, and local levels. Michael has three children—a musician, an engineer, and an evaluator—and four grandchildren. When not evaluating, he enjoys exploring the woods and rivers of Minnesota, where he lives.

Find My Rep

Qualitative Research & Evaluation Methods Integrating Theory and Practice

Michael Quinn Patton - Utilization-Focused Evaluation, Saint Paul, MN
Description
Author(s) / Editor(s)

Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied research and evaluation, t his Fourth Edition illuminates all aspects of qualitative inquiry through new examples, stories, and cartoons; more than a hundred new summarizing and synthesizing exhibits; and a wide range of new highlight sections/sidebars that elaborate on important and emergent issues . For the first time, full case studies are included to illustrate extended research and evaluation examples. In addition, each chapter features an extended "rumination," written in a voice and style more emphatic and engaging than traditional textbook style, about a core issue of persistent debate and controversy.

Supplements

"Very thoughtful and thorough coverage of qualitative design and study."

“The content itself, based in years of thinking, reading, doing, conversing, is a huge strength. Reading the chapters is like sitting at the feet of one of the masters.”

I have used Patton for this course historically; I will continue to use him for this course. I have used previous editions as well.

Great book - not currently teaching a course in evaluation - will definitely consider this text when I do next teach such a course.

Adopted Creswell 3rd ed (Sage)

Good resource for students looking to develop their qualitative research skills.

Will use as a secondary text in the Qualitative Research Methods course I teach

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Sample materials & chapters.

Table of Contents

Michael Quinn Patton

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Qualitative Research & Evaluation Methods: Integrating Theory and Practice

Published 11 November 2014

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Navigating the qualitative manuscript writing process: some tips for authors and reviewers, professional self-understanding of teachers in different career stages: a phenomenological analysis, research on making interview questions among vietnamese students: difficulties, reflection and solutions – a perspective of learning by doing, qualitative methods in research, use of technology in social studies teaching: the journey of five teachers, the qualities, practices, and theories held by award-winning second language college teachers.

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Qualitative Research & Evaluation Methods 4th edition

Integrating theory and practice.

Michael Quinn Patton

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Full Title:	Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Edition:	4th edition
ISBN-13:	978-1483301457
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Publisher:	Sage Publications, Inc (10/29/2014)
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Part 1. Framing Qualitative Inquiry: Theory Informs Practice, Practice Informs Theory

Chapter 1. The Nature, Niche, and Value of Qualitative Inquiry

Module 1. How qualitative inquiry contributes to our understanding of the world

Module 2. What makes qualitative data qualitative

Module 3. Making methods decisions

Module 4. The fruit of qualitative methods: Chapter summary and conclusion

Chapter 2. Strategic Themes in Qualitative Inquiry

Module 5. Strategic design principles for qualitative inquiry

Module 6. Strategic principles guiding data collection and fieldwork

Module 7. Strategic principles for qualitative analysis and reporting findings

Module 8: Integrating the 12 strategic qualitative principles in practice

Chapter 3. Variety of Qualitative Inquiry Frameworks: Paradigmatic, Philosophical, and Theoretical Orientations

Module 9. Understanding the Paradigms Debate: Quants versus Quals

Module 10. Introduction to Qualitative Inquiry Frameworks

Module 11. Ethnography and Autoethnography

Module 12. Positivism, Postpositivism, Empiricism and Foundationalist Epistemologies

Module 13. Grounded Theory and Realism

Module 14 Phenomenology and Heuristic Inquiry

Module 15 Social Constructionism, Constructivism, Postmodernism, and Narrative Inquiry

Module 16. Ethnomethodology, Semiotics, and Symbolic Interaction, Hermeneutics and Ecological Psychology

Module 17 Systems Theory and Complexity Theory

Module 18. Pragmatism, Generic Qualitative Inquiry, and Utilization-Focused Evaluation

Module 19 Patterns and themes across inquiry frameworks: Chapter summary and conclusions

Chapter 4. Practical and Actionable Qualitative Applications

Module 20. Practical purposes, concrete questions, and actionable answers: Illuminating and enhancing quality

Module 21. Program evaluation applications: Focus on outcomes

Module 22 Specialized qualitative evaluation applications

Module 23 Evaluating program models and theories of change, and evaluation models especially aligned with qualitative methods

Module 24 Interactive and participatory qualitative applications

Module 25 Democratic evaluation, indigenous research and evaluation, capacity building, and cultural competence

Module 26 Special methodological applications

Module 27 A vision of the utility of qualitative methods: Chapter summary and conclusion

Part 2. Qualitative Designs and Data Collection

Chapter 5. Designing Qualitative Studies

Module 28 Design thinking: Questions derive from purpose, design answers questions

Module 29 Date Collection Decisions

Module 30 Purposeful sampling and case selection: Overview of strategies and options

Module 31 Single-significant-case sampling as a design strategy

Module 32 Comparison-focused sampling options

Module 33 Group characteristics sampling strategies and options

Module 34 Concept and theoretical sampling strategies and options

Module 35. Instrumental-use multiple-case sampling

Module 36 Sequential and emergence-driven sampling strategies and options

Module 37 Analytically focused sampling

Module 38 Mixed, stratified, and nested purposeful sampling strategies

Module 39 Information-rich cases

Module 40 Sample size for qualitative designs

Module 41 Mixed methods designs

Module 42 Qualitative design chapter summary and conclusion: Methods choices and decisions

Chapter 6. Fieldwork Strategies and Observation Methods

Module 43 The Power of direct observation

Module 44. Variations in observational methods

Module 45. Variations in duration of observations and site visits: From rapid reconnaissance to longitudinal studies over years

Module 46. Variations in observational focus and summary of dimensions along which fieldwork varies

Module 47. What to observe: Sensitizing concepts

Module 48. Integrating what to observe with how to observe

Module 49. Unobtrusive observations and indicators, and documents and archival fieldwork

Module 50. Observing oneself: Reflexivity and Creativity, and Review of Fieldwork Dimensions

Module 51. Doing Fieldwork: The Data Gathering Process

Module 52. Stages of fieldwork: Entry into the field

Module 53. Routinization of fieldwork: The dynamics of the second stage

Module 54. Bringing fieldwork to a close

Module 55. The observer and what is observed: Unity, separation, and reactivity

Module 56. Chapter summary and conclusion: Guidelines for fieldwork

Chapter 7. Qualitative Interviewing

Module 57 The Interview Society: Diversity of applications

Module 58 Distinguishing interview approaches and types of interviews

Module 59 Question options and skilled question formulation

Module 60 Rapport, neutrality, and the interview relationship

Module 61 Interviewing groups and cross-cultural interviewing

Module 62. Creative modes of qualitative inquiry

Module 63. Ethical issues and challenges in qualitative interviewing

Module 64. Personal reflections on interviewing, and chapter summary and conclusion

Part 3. Analysis, Interpretation, and Reporting

Chapter 8. Qualitative Analysis and Interpretation

Module 65. Setting the Context for Qualitative Analysis: Challenge, Purpose, and Focus

Module 66. Thick description and case studies: The bedrock of qualitative analysis

Module 67. Qualitative Analysis Approaches: Identifying Patterns and Themes

Module 68. The intellectual and operational work of analysis

Module 69. Logical and matrix analyses, and synthesizing qualitative studies

Module 70. Interpreting findings, determining substantive significance, phenomenological essence, and hermeneutic interpretation

Module 71. Causal explanation thorough qualitative analysis

Module 72. New analysis directions: Contribution analysis, participatory analysis, and qualitative counterfactuals

Module 73. Writing up and reporting findings, including using visuals

Module 74. Special analysis and reporting issues: Mixed methods, focused communications, and principles-focused report exemplar.

Module 75 Chapter summary and conclusion, plus case study exhibits

Chapter 9. Enhancing the Quality and Credibility of Qualitative Studies

Module 76. Analytical processes for enhancing credibility: systematically engaging and questioning the data

Module 77. Four triangulation processes for enhancing credibility

Module 78. Alternative and competing criteria for judging the quality of qualitative inquiries: Part 1, universal criteria, and traditional scientific research versus constructivist criteria

Module 79. Alternative and competing criteria, Part 2: artistic, participatory, critical change, systems, pragmatic, and mixed criteria

Module 80 Credibility of the inquirer

Module 81 Generalizations, Extrapolations, Transferability, Principles, and Lessons learned

Module 82 Enhancing the credibility and utility of qualitative inquiry by addressing philosophy of science issues

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Qualitative Research & Evaluation Methods Integrating Theory and Practice

Michael Quinn Patton - Utilization-Focused Evaluation, Saint Paul, MN
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Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied research and evaluation, t his Fourth Edition illuminates all aspects of qualitative inquiry through new examples, stories, and cartoons; more than a hundred new summarizing and synthesizing exhibits; and a wide range of new highlight sections/sidebars that elaborate on important and emergent issues . For the first time, full case studies are included to illustrate extended research and evaluation examples. In addition, each chapter features an extended "rumination," written in a voice and style more emphatic and engaging than traditional textbook style, about a core issue of persistent debate and controversy.

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"Very thoughtful and thorough coverage of qualitative design and study."

“The content itself, based in years of thinking, reading, doing, conversing, is a huge strength. Reading the chapters is like sitting at the feet of one of the masters.”

I have used Patton for this course historically; I will continue to use him for this course. I have used previous editions as well.

Great book - not currently teaching a course in evaluation - will definitely consider this text when I do next teach such a course.

Adopted Creswell 3rd ed (Sage)

Good resource for students looking to develop their qualitative research skills.

Will use as a secondary text in the Qualitative Research Methods course I teach

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Qualitative Research & Evaluation Methods: Integrating Theory and Practice Hardcover – 11 November 2014

ISBN-10 9781412972123
ISBN-13 978-1412972123
Edition 4th
Publisher SAGE Publications Inc
Publication date 11 November 2014
Language English
Dimensions 22.23 x 3.81 x 28.58 cm
Print length 832 pages
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Publisher ‏ : ‎ SAGE Publications Inc; 4th edition (11 November 2014)
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Hardcover ‏ : ‎ 832 pages
ISBN-10 ‏ : ‎ 9781412972123
ISBN-13 ‏ : ‎ 978-1412972123
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Strategies for knowledge mobilization by advanced practice nurses in three hospitals in Spain: a qualitative study

Concha Zaforteza-Lallemand 1 , 2 , 6 ,
Ian Blanco-Mavillard 1 , 3 , 6 ,
Sandra Pol-Castañeda 1 , 4 , 6 ,
Carlos Javier Villafáfila-Gomila 1 , 2 , 6 ,
Francisco Ferrer-Cruz 5 &
Miguel Ángel Rodríguez-Calero 6 , 7

BMC Nursing volume 23 , Article number: 440 ( 2024 ) Cite this article

Metrics details

Evidence-based practice, in conjunction with optimum care quality, improves patients’ clinical outcomes. However, its implementation in daily clinical practice continues to present difficulties. The aim of this study was to identify the strategies applied by Advanced Practice Nurses (APNs) to foster adherence to clinical practice guideline recommendations.

An exploratory qualitative study was conducted with six focus groups at three public hospitals belonging to the Balearic Islands Health Care Service (Spain). The study participants were 32 ward nurses and 5 advanced practice nurses working routinely with inpatients at these hospitals. The study was conducted from November 2020 to January 2021, using thematic analysis, based on the COREQ checklist.

Four major themes related to the facilitation process were identified either by RNs and APNs: the context of the project, APN contribution to nursing team management, healthcare provision on the ward, and the acquisition and application of knowledge.

Conclusions

The APNs adapted their actions to the characteristics and needs of the local context, employing strategies aimed at improving teamwork, healthcare, and knowledge management. Each of these contributions enhanced the sustainability of the changes made.

Peer Review reports

What is already known about this topic

According to implementation science, multimodal strategies are context-tailored and use multiple approaches for successful behavioral change among healthcare providers. However, when a program is designed and implemented, little is known about how it is displayed in real life: which are the strategies and skills unfolded by implementation leaders, or why do providers choose (or not) to make things happen? For instance, there is limited available evidence regarding the mechanisms that change an a priori staff mistrust of a program by engaging it.

What does this paper add

An intervention implementing APNs as facilitator agents of evidence-based practice (EBP) provides an improvement on patients’ health results. This paper underscores how the APNs tailored and managed to influence their peers’ adherence to EBP daily and face-to-face interaction. APNs’ multimodal strategies, skills and actions for practice change are well-described and acknowledged as valuable for changing behavior by peers and APNs themselves. In addition, the “making sense mechanism” triggered by a feedback strategy is identified as one of the leverages for trusting and valuing the intervention as positive for patients and the staff.

What are the implications

This qualitative study helps health managers and implementation scientists to identify suitable profiles for the role of clinical champions and early adopters aimed at influencing their peers’ practice. Moreover, it contributes to monitoring change processes and program implementation, as the making sense mechanism occurrence points to a relevant unfolding of the initiative.

Introduction

The implementation of evidence-based clinical practice (EBCP) [ 1 , 2 ] and clinical practice guidelines (CPGs) [ 3 ] can present challenges to healthcare professionals, healthcare organizations, and the patients themselves [ 1 ]. Difficulties may arise due to the variable quality and nature of clinical evidence [ 5 ] and because of individual and contextual factors [ 2 , 3 , 4 ].

Many studies have reported on successful multimodal interventions to implement new evidence-based recommendations, such as those aimed at reducing peripherally-inserted venous catheter failure [ 5 , 6 , 7 ] even avoiding iatrogenic consequences and costs [ 8 ], or reducing pressure ulcer rates [ 9 , 10 , 11 , 12 ]. However, EBCP implementation is a multifaceted and complex phenomenon in continual and dynamic interaction between evidence, context, users, and facilitation [ 13 , 14 ].

In addition, other studies have explored the role played by clinical champions [ 15 ] and Advanced Practice Nurses (APNs) as agents of change and enablers of evidence implementation [ 16 , 17 , 18 ]. Among other contributions, APNs provide problem-solving support and act as local agents of change [ 19 ], promoting awareness of and fidelity to best practices [ 14 , 20 ].

In 2016 the Balearic Islands Health Service (Spain) conducted an internal evaluation on nursing adherence to evidence-based practice (EBP) which highlighted that there was room for improvement on that issue (unpublished report). The research team was invited to develop a project for enhancing EBP among nurses. Then the mixed-methods project “Moving Evidence into Practice by Advanced Practice Nurses in Hospitalization Wards” was launched. It was aimed at evaluating the impact made by APNs on hospital wards and patient outcomes in comparison with wards from which they were absent [ 21 ]. Briefly, five APNs and five support nurses were assigned to five hospital wards and given the introduction of new work dynamics for improving clinical outcomes. In particular, the APNs designed actions to implement CPGs, adapted to the local context and its characteristics. Although no specific regulation on APN is available in Spain, Regional Public Health Systems have developed local regulation and recognized some APN roles. The APNs participating in this project received formal appointments by the Balearic Islands Health Services. Selection was based on postgraduate training. All the participating APNs received specific training for the project in 9 competency areas, further explained in a previous publication [ 21 , 22 ]. The CPGs adopted were “Care and maintenance of vascular access to reduce complications” [ 23 ] and “Prevention and treatment of pressure ulcers” [ 24 ], both in use in the Balearic Islands Health Service. Initial findings highlight that their presence improves adherence to CPGs and enhances patients’ clinical outcomes [ 22 ].

In this sense, Morena et al. [ 15 ], from a theoretical stand, highlight the need to empirically test how clinical implementation leaders (here APNs) impact provider behavior: what strategies do they deploy, and what mechanisms do they trigger to promote behavioral change? Our study findings could be of valuable assistance in further research efforts in this area [ 25 ], i.e. to foster the implementation and diffusion of evidence-based recommendations with the support of APNs. Therefore, as a part of the above-mentioned project, the objective of this part of the research was to identify the strategies applied by APNs to foster adherence to CPG recommendations.

Study design and setting

The study is an exploratory qualitative design, driven by a realist approach [ 26 ], in accordance with the i-PARIHS framework [ 14 ]. Under this theoretical lens, intended outcomes occur in a particular context in which certain mechanisms are triggered by how a program or policy is deployed.

The study was conducted in five wards in three Spanish State-funded acute care hospitals: Manacor Hospital, Inca County Hospital and Son Espases University Hospital that serve populations of 150,000, 134,000 and 330,000 inhabitants, respectively (see Table 1 ). The planned intervention has been briefly described above and published elsewhere [ 21 , 22 ].

Participant selection and recruitment

Hospital ward nurses working routinely with inpatients at intervention units in the three hospitals were considered for enrolment in the study. The research team approached key informants to identify suitable participants, who in turn recruited others through a ‘snowball’ technique. Inclusion criteria were at least 2 years of experience as RN, being working as RN at any of the intervention units when the focus groups were conducted and had been working at any of the intervention unit for at least 6 months during the intervention period. Priority was given to including participants from a variety of professional backgrounds and career pathways. Exclusion criteria were not having experience as RN, not being working at the intervention units for 6 months more and not willing to participate in the study. 32 ward nurses were enrolled in an intentional sample and distributed into five focus groups. The sixth focus group was formed by the 5 APN (one for each intervention unit) (Table 2 ). The characteristics of APNs are also described in Suppl file 1.

Participation was voluntary and without monetary compensation. Selection, recruitment and interviews ceased once data saturation had been achieved.

Data collection

All the focus groups were moderated by 2 members of the research team (CZ-L and IB-M), except the one conducted at Inca County Hospital, moderated by (SP-C and MAR-C). The other researchers (CV-G, FF-C, JdP-G) occasionally participated as observers, completing a team of 3 researchers per focus group. The interview guide used for the groups was piloted in May 2020. The scheduled duration of each focus group was about 45 min. The sessions were held between September 2020 and January 2021 at locations and times convenient for the participants. Field notes were taken during and after each session. All sessions were audio-recorded and transcribed-professional transcription service was hired, with answers anonymized before the analysis. The participants spoke either in Spanish and Catalan and the transcriptor respected the speaker’s original language.

Data analysis and rigor

A continuous and iterative thematic analysis was performed [ 27 ]. In the inductive phase, the transcripts were examined for units of meaning, concerning how facilitation by the APN took place in the hospital ward, and encoded. The resulting codes were then grouped into broader categories. Each focus group transcript was coded by two researchers (CZ-L and IB-M), working independently. During the deductive phase, the data were analyzed according to the elements proposed in the PARIHS theoretical framework and in the literature review.

Several triangulation strategies were employed, separately. The results were then compared and a triangulated coding tree was constructed and saturation agreed by three researchers (CZ-L, IB-M and SP-C) [ 28 ]. Two members of the research team (CZ-L and IB-M) discussed the data and the findings obtained. Another strategy applied to improve the experimental rigour was the development and recording of the researchers’ views on the methodological decisions taken during the study. An additional factor of importance is their dual status as clinicians and co-investigators [ 29 ]. Finally, the participants’ responses and the initial analysis were discussed by CF-Z and IB-M, who both have extensive experience in implementation science. Throughout this process, the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist was used.

Research team and reflexivity

The research team required detailed knowledge of the implementation process to properly interpret and contextualize the study data. Accordingly, four members of the research team (CZ-L, IB-M, MAR-C, SP-C), with previous experience in evidence implementation and social research, facilitated and conducted focus groups at the three participating hospitals. None had any previous relationship with any of the participants, which allowed them to establish a rapport and fostered an open and frank discussion. All of these researchers were healthcare professionals employed in the Balearic Islands Healthcare Service, except JdP-G, who teaches at the University of the Balearic Islands. The researchers are PhD, except CV-G, FF-C and SP-C who was a doctoral candidate at the moment of the study .CZ-L was the senior researcher in qualitative health research. IB-M and MAR-C were trained in qualitative research. CZ-L and SP-C are female; IB-M, MAR-C, CV-G, FF-C and JdP-G are male.

Four focus groups were conducted according to the mentioned methodology and guideline. All the invited participants were present in the focus groups, we did not register any withdrawal. In our analysis, four categories were identified: context (features of the context present at the beginning of the project), team management (how the APNs managed the team), healthcare management (how APNs managed the healthcare provision) and knowledge management. The coding tree, with these four categories, the codes and the verbatim transcripts, is shown in Supplementary Material 1 . Supplementary Material 3 explains the acronyms used to identify who the participant was in each verbatim.

The role of APNs is relatively unknown within the Spanish health system. For this reason, especially at the beginning of the project, when there were still no tangible results reflecting the impact of their work, the relevance of these nurses was questioned by colleagues and managers (mistrust of new roles). For this reason, the APNs in our study felt continually obliged to justify their role and, at the same time, to differentiate it from that of the ward supervisor.

Yes, you had to be constantly saying what your job was supposed to be. Because there are people [referring to other colleagues and managers] who thought this extra pay was nonsense, we could use this extra salary instead to have a back-up nurse and not for someone who’s there to, well, they didn’t know exactly what you were doing. (FG 5, APN 1)

In addition, the staff members in each of the hospital wards considered their workload to be very demanding and therefore viewed the new projects presented with some distrust regarding their usefulness and the demands imposed (mistrust of new projects).

As I said before, now what are they going to make us do? What are they [referring to managers] going to impose on us now? What control are they going to have over what we’re doing? And well, obviously it hasn’t been like that. (FG 3 HUSE 1O, Nurse 5)

Team management

The APNs employed three major facilitating strategies addressed to their colleagues, based on interpersonal relationships. Firstly, they sought to unite the team around a shared objective of excellence, via the implementation of EBCP (team cohesion).

I think my team feels more like a team. (FG 5, APN 3) [The APN mimics herself asking her colleagues], “ What do you think needs to be improved?” and,”How can we do it together to make it better?” And that’s how it was. (FG 5, APN 4)

Secondly, they sought to ensure a unity of discourse with the formal head of the ward unit, such that both would transmit the same message regarding healthcare excellence (consistency with institutional policy).

Consistency in the messages given. The message that you give is the same, I mean, the professional one, if one day you’re not there, she is [referring to the supervisor]; if you’re not there, she is, and in the ward it’s the same message. And it’s just as strong when she says it as when I say it (FG 5, APN 5).

Thirdly, mentoring was provided to newly recruited members of staff to ensure their rapid, effective integration into the work dynamics.

That happened to me, too, the same as with her [referring to a colleague who recounted a similar experience], I had never worked in the ward, I’d always been in the operating room… And when I arrived, I was useless, because everyone is, at first, why not, it’s normal, you don’t know anything and there’s so much medication and you have to give a certain medication for a certain… It’s all very… Everything is always the same in the operating room, right? It doesn’t change much and, well, here, I was lost and, well, especially as far as the computer was concerned because in the operating room, we don’t usually use it so much, we don’t have treatment plans or anything, it’s more technical […] And the truth is that a leader like her [referring to the APN of the ward], because it helped me a lot, really a lot. Well, and all my workmates, obviously (FG 2 HUSE 00, Nurse 3).

According to our analysis, concerning team management capabilities, the other ward staff members acknowledged that the APNs presented skills, knowledge and positive personal traits that facilitated change, generated confidence that this change was worthwhile and provided a valuable role model, encouraging them to follow this example. The healthcare professional traits cited were commitment, serenity, flexibility, patience, problem-solving capacity, discipline, and perseverance. Besides, the team members acknowledged that they had bought into the project due to APNs’ social skills and role-modelling traits.

Nurse 2: It’s reassuring when the work gets to be stressful, she comes and says, “Come on, first this, then that…”. Nurse 4: It’s a big relief (FG 3 HUSE 1O). Nurse 1: I don’t know, but I think the same job might have been done by someone else and I don’t think it would have been as successful. Because she [referring to the APN on her ward] is really tireless, she’s helped us a lot. Nurse 4: And she comes up behind you and says, “You haven’t seen this…”. Nurse 1: And she chases after you, and she tells you, “This isn’t right…”. Nurse 4: “I’d try to record it but if not, you do it, I don’t know what…” (FG 2 HUSE 0O).

Healthcare management

The APNs are instrumental in spurring the healthcare team to incorporate EBCP as a permanent aspect of daily practice. Among the actions applied to achieve this goal, the APN used to establish audits and evaluations of clinical results addressed to examine and analyze the evolution of health indicators. Based on these data, APNs implemented feedback rounds, informing the team about the impact on patient clinical status and the findings obtained in the audits. Finally, team meetings were organized, seeking consensus on the application of evidence, informing of news and developments and resolving any doubts/questions that may arise.

I think that after having done the audits and as concerns the patients with ulcers and their skin care and everything else, yes, there have been improvements. (FG 5, APN 5) When you take part in a feedback on the results they’ve achieved, that’s when they say, “Wow! Well, yes, we can really get somewhere.” (FG 5, APN 4). Yes, because every day we have a meeting at half past nine in the morning, and of course, she [referring to the APN of her ward] is there from Monday to Friday, and we have a meeting about all of the patients; yes, of course, she always contributes, so you don’t have to worry about yesterday’s problems and there’s no-one you know, you always have her, and she helps us. That means there is continuity. Because when you’re doing rotating shifts you never have continuity, and she, well, she helps us to have… (FG 4 HCIN HM1, Nurse 1).

In addition to these specific, instrumental actions, the APNs employed other, more diffuse strategies tailored to the culture of the wards, where nurses place great value on their proximity to patients and on maintaining good working relations. Taking these concerns into account, APNs used three strategies to facilitate the acceptance of practice change.

Firstly, they engaged, face-to-face, with the ward staff. Their permanent, physical presence on the ward, providing a fixed point of reference, meant that the other ward team members knew they could always rely on the APN for advice, support, knowledge, mediation, etc.

Nurse 6: I think she does get quite involved, because with her I can compare two situations on one ward with another situation on another [This nurse has worked in two wards with an APN]. Moderator: The thing is, she has different skills and characteristics. The other way was perhaps dealing with more bureaucratic issues and this way is more that the work… . Nurse 6: [overlapping] Right beside the patient. Nurse 3: Right, whatever, for us it’s very important that the work is done beside the patient, it’s very important. It is not the same as with an APN who’s dealing with bureaucratic issues, of course, and it isn’t the same. Nurse 6: Passing on data. Moderator: Presence… . Nurse 2: That’s right! Nurse 1: For us it’s… when we’re on the morning shift and we see her [referring to the APN on her ward] it’s as if we were seeing, Wow! My God! Nurse 4: Apart from the fact that it’s true, she’s always there […] And if she has to do it, for whatever reason, because she can see, because on top of everything, she can see it too, she’s ready to work with us. If she can see that we aren’t going to be able to do it, well, she will, she’s not afraid to muck in. The supervisors, though, they’re something else. (FG 3 HUSE 1O)

Secondly, the APNs were sensitive and adaptative to the requirements of the environment: on the one hand, their work is cognitive and conceptual; on the other, they also participated in the manual and physical tasks of patient care during periods of maximum activity, alleviating the workload on the team. This contribution is another positive aspect of their physical presence on the ward.

The third strategy is about empathetic, respectful communication: other team members appreciate the inclusive communication style adopted, in which the APN is open to dialogue and does not impose a pre-determined view. This attitude generates security and confidence and helps avoid mistrust when clinical audits are conducted.

You have to give it to her [referring to the APN], she’s done very well. Lots of tact. We never felt there was any type of imposition. She’s been really … when it came to, to focusing on how we should be doing it. She’s always been really friendly and we’ve never felt as if she was finding fault, which is what it might have seemed like at first with someone watching everything you do and what you don’t do. But it wasn’t like that. I mean, the APN did her job very well (FG 3 HUSE 1O, Nurse 5).

Knowledge management

The above-mentioned actions and strategies enabled APNs to act as effective intermediaries and distributors of knowledge. Face-to-face communication, mentoring and feedback were also influential in facilitating knowledge management.

In environments where actions to provide direct healthcare are predominant, it can be crucial to find the time to acquire new knowledge. In this respect, APNs facilitated access by organizing information and making it available to nurses through clinical sessions, the standardization of processes and the adaptation of evidence to local circumstances.

In addition, via feedback and team discussions, the APN triggered mechanisms to make sense of the indicators considered so that nurses associated the effort invested in changing their clinical practice with obtaining beneficial results for the patient and the organization. This assurance generated confidence in the value of the knowledge distributed by the APN and consolidated the sustainability of the changes effected.

Nurse 1: I’ve definitely seen an improvement. Because in my day to day work I know more, thanks to what [the APN] passed on to us [referring to feedback rounds and clinical data analysis]. Nurse 5: Me too. Nurse 1: Like updates on the latest treatment options… Even if you don’t try too hard [to stay up-to-date], you’ve got the latest knowledge, because there’s someone who does just that. Who does that job and makes sure you get what you need (FG6 HMAN 3 A). Nurse 6: Well, it’s made work in the ward more organized. Before, it was like everyone did things however they saw fit, right? Moderator: Let’s see, tell me about that. Nurse 1: In treatment plans, for surgical patients, now we have a structured plan that you just have to go there [referring to consulting the treatment plan]. I mean, they’ve made it a little easier for us. Exactly, and organizing the work, that’s it… . Moderator: Right. Nurse 6: She doesn’t mind spending time… she’s made us a kind of handbook, like a handbook, and we know when a patient comes in, what we have to do, if it is for an operation or if they need to be admitted, because being admitted to the ward… . Nurse 3: Yes, she’s set up a protocol, specific protocols. (FG2 HUSE O0)

Our study shows that the APNs, deploy context-aware strategies whereby the facilitation process ensures the viability of the intervention, improves team cohesion, and mobilizes the best knowledge available. The mixed-methods approach described [ 21 ] would be an appropriate way to describe and evaluate complex strategies for change. In line with Astbury and Leeuw [ 30 ], we find that the evaluation of programs and policies requires methodologies with both conceptual and empirical components. In our case, clinical data (the empirical component) obtained from the audits reveal improvements in health outcomes with respect to pressure ulcers, on the one hand, and complications associated with venous catheters, on the other [ 22 ].

Mentoring, through their leadership and influence, is the main strategic action performed by the APNs, provided both to newly recruited nurses and to long-standing members of the team [ 31 ]. This activity, and the acknowledgment of its value, constitutes the mechanism underpinning the ward team’s confidence in the project. In this respect, Jagosh et al. [ 32 ] referred to the theory of social influence, whereby respected members of a community, who are directly involved in a given project, can impel others to take part and to support it. In addition, Morena et al. [ 15 ] emphasize the relevance of mentorship skills as a means of changing subjective norms and provider attitudes that shape healthcare delivery.

In another crucial capacity, APNs progressively incorporate innovations in healthcare, whilst respecting the individual and organizational characteristics of the context. Moreover, they create physical and social opportunities to enhance the integration of new recommendations into the system [ 31 ], such that they are not perceived by the nurses as a threat, for example, in terms of increased workload or responsibilities. The APNs also ensure that the change is not perceived as a vertical imposition, but rather as an opportunity to improve quality in healthcare practice [ 32 ].

Furthermore, APNs manage the provision and acquisition of new knowledge, making sure that it is accessible, clear and comprehensible, ensuring it is applied correctly by all concerned. A fundamental aspect of the facilitation role played by APNs is their adaptation to local needs of the recommendations set out in the CPGs, in order to optimize the effort invested by nurses in acquiring and applying new knowledge. Simultaneously, through multiple rounds of feedback [ 33 ], ward members see how clinical outcomes are improved when EBCP is applied. In other words, a notable response or mechanism is activated in healthcare professionals, namely the attribution of value to the effort invested in changing clinical practices.

According to realist theory, this mechanism arises from the underlying (social) entities, processes and structures that operate in the environment in question, and which explain why and how a strategy brings about certain changes in behavior. In the case we discuss, this mechanism operates through the perceptions, reasoning and actions of the participants, determining how they make use of the resources at their disposal to make the changes happen and to sustain them over time [ 33 ]. By applying elements of a realist theory-driven analysis, we can identify the conceptual logic of the intervention. In this case, the strategy of supplying clinical data feedback to professionals who are engaged with the project triggers the mechanism that gives meaning to the indicators measured in the audits. This mechanism, moreover, enables professionals to escape the danger of taskification [ 34 ], but rather to understand the meaning of the effort they are making and to sustain the change over time.

In accordance with realist theory [ 26 ], the future of program evaluation must advance from implementation theory towards theory-driven evaluation or program theory [ 35 ]. In the first case, it is assumed that the implementation of a program is the cause of change: thus, an evaluation based on the implementation theory will indicate that “program A brought about result B”. In the second case, it is assumed that programs are successful only if people choose to make them work: an evaluation drawn from program theory will affirm, “In context 1, the application of program A triggered mechanisms B and C, following which outcome D occurred”. Working from program theory allows us to open up the black box of how programs work in different contexts, focusing on the responses made by participants.

Limitations

This study is subject to some limitations, which should be considered. Firstly, the results presented are strongly associated with the sociocultural, clinical, and organizational characteristics of the health and social systems prevailing in the Balearic Islands, and with the functions explicitly assigned and implicitly asserted by the nurses involved. In this study, moreover, focus groups were conducted with frontline nurses who participated in the areas addressed in the project; however, these nurses’ perceptions of the actions carried out at the organizational level may not accurately reflect current institutional policies, because the figure of the APN is not yet widely implemented in the Spanish healthcare system. On the other hand, a strong point of this study is that the consideration given to all the interventions made by the APNs provides a good basis for designing future interventions, better equipped to meet the needs of the diverse, changing contexts of the healthcare system. In addition, such a redesigned intervention would enhance the management of health teams, care provision and specialist knowledge.

In conclusion, APNs play a pivotal role in adapting initial projects to the particularities and needs of the local context, making use of appropriate strategies to improve the management of personnel, healthcare provision and specialist knowledge. Through the lens of a realist approach, our study elucidates the transformative power of knowledge management, via results feedback to the team, triggers the mechanism for attributing value to the effort invested in change. This realization enhances the team’s confidence in innovative proposals and contributes to the sustainability of changes in clinical practice.

Our findings highlight a paradigm shift in the healthcare system, driven by APNs’ strategic actions that integrate context-aware innovations and mentorship, improving both health outcomes and the work environment. Finally, to understand how and why such programs succeed, it is not sufficient to describe their results; it is essential to unpack the black box and identify the underlying mechanisms that make team members decide to make the program work. This consideration should be addressed in greater detail in future organizational evaluation and research.

Data availability

The data that support the findings of this study are available on request from the corresponding author, IB-M, upon reasonable request.

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Acknowledgements

We thank the Health Service of the Balearic Islands and the University of the Balearic Islands for their support. We also thank the nursing teams and advanced practice nurses who agreed to participate in the project for their time and dedication.

This work was supported by The College of Nursing of the Balearic Islands within the framework of Grants for Research Projects (Grant No. PI 2019/0217). This research received no specific grant from any funding agency in the commercial or not-for-profit sectors. IB-Salut is responsible for the replacement of the five nurses who performed the role of APN, supporting the project in these terms. None of the participating institutions influenced the results or the development of this research.

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Contributions

CZ-L, IB-M and MAR-C are the principal investigators of this part of the study. All authors contributed to the original idea and design of the study. CZ-L, SP-C, CJV-G, and FF-C are responsible for the conduct of the study. CZ-L prepared the first draft of the manuscript. CZ-L and IB-M provided qualitative expertise. MAR-C and SP-C contributed to data triangulation and analysis. All authors provided critical commentary on drafts and approved the final protocol manuscript. All authors have read and agree to the published version of the manuscript.

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Correspondence to Ian Blanco-Mavillard .

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The study was approved by the Research Ethics Committee of the Balearic Islands (No. IB3662/18PI) on 27 June 2018 (committee No. 06/18). All participants were informed about the purpose of the study and its implications. Written informed consent was obtained from all participants before the interview. All methods used in the study were carried out in accordance with relevant guidelines and regulations.

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Zaforteza-Lallemand, C., Blanco-Mavillard, I., Pol-Castañeda, S. et al. Strategies for knowledge mobilization by advanced practice nurses in three hospitals in Spain: a qualitative study. BMC Nurs 23 , 440 (2024). https://doi.org/10.1186/s12912-024-02095-5

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Evaluation of a knowledge-attitude-practice model based narrative life education program for community-dwelling older adults: a mixed-methods feasibility study

Xifeng Xie 1 na1 ,
Li Zhou 2 na1 ,
Xiaoling Zhang 1 ,
Huina Zou 1 ,
Yuanfeng Lu 1 &
Huimin Xiao 1 , 3

BMC Geriatrics volume 24 , Article number: 547 ( 2024 ) Cite this article

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The global aging population presents challenges that are particularly acute in China. Older Chinese adults’ attitudes towards death significantly impact their quality of life. Death education is crucial for promoting positive perspectives on life and death. Narrative education offers a promising approach to facilitating death education. Integrating the Knowledge-Attitude-Practice (KAP) model into death education will enhance the feasibility and acceptability of death education programs.

This mixed-methods feasibility study included a quasi-experimental trial and semi-structured interviews. Older adults in the intervention group ( N = 27) received a 6-week KAP-based narrative life education program in addition to standard community health education; participants in the control group ( N = 20) received only the normal community health education. In both groups, attitudes toward death and the meaning of life were assessed at baseline and immediately after the intervention. A post-intervention semi-structured interview and satisfaction survey were also conducted for the intervention group.

Forty out of 47 older adults completed the program for an 85.1% retention rate. All of the older adults in the experiment were very satisfied and satisfied with the life education program, and no adverse events were reported. Compared to the control group, participants in the intervention group had a significant decrease in the fear of death ( P = 0 .028), and substantial improvement in their value of life ( P = 0 .031), goal of life ( P = 0 .035), freedom of life ( P = 0 .003), and the total score for purpose in life ( P = 0 .017). The qualitative results yielded four themes: profound recognition of life and death, contradiction between thoughts and action, conflict between one’s acceptance and others’ avoidance, and evaluation of the life education program.

Conclusions

The KAP-based narrative life education program is feasible and acceptable for older Chinese community-dwelling adults. It is also potentially effective in improving attitudes toward death attitudes and the meaning of life in this cohort.

Trial registration

This study was retrospectively registered at China Clinical Trial Registry as ChiCTR2300069551 on 2023-03-20. URL of registration: https://www.chictr.org.cn/showproj.html?proj=183176 .

Peer Review reports

The elderly population is poised to significantly increase around the world. By 2050, adults over 65 are projected to account for 16% of the global population, with the proportion of individuals aged 60 and above in China likely reaching 35% [ 1 , 2 ]. Death is inevitable, but it is a sensitive topic, especially in China. Older adults are prone to being increasingly aware of death due to their decline in physical function, the threat of chronic disease, and an increased witnessing of their peers’ deaths [ 3 ].

Attitudes towards death are not only related to the physical and mental health of older adults, but also affect their preparation for death and quality of life beforehand [ 4 ]. Ignorance of death preparation increases fear and anxiety about death [ 5 ]. However, a deep-rooted traditional culture that, emphasizes life and neglects death has made death a taboo subject in China. It is not easy for most Chinese people to communicate about death-related issues [ 6 ]. Although older adults can accept death as a part of life, most of them still feel fear and avoid talking about death-related topics [ 7 ]. Compared to nursing home residents, community-dwelling older adults are more afraid of facing death and feel it is more difficult to deal with life-and death-related issues [ 8 ]. Thus, further exploration is needed regarding how to help Chinese older adults establish a reasonable understanding of and attitudes toward life and death.

The essence of life education for older adults is orientation regarding the subjects of life and death, with death education comprising the core content [ 9 ]. The program teaches individuals how to recognize and face death [ 10 ]. The goal is to facilitate acceptance of end of life, process of death, and experience of bereavement in terms of the individual’s knowledge, attitudes, and skills [ 11 , 12 ]. Previous studies have shown that death education promotes positive changes in death-related attitudes, enhances the sense of meaning in life, and improves the quality of life [ 13 , 14 , 15 ]. However, previous programs have mainly focused on the stages of life and meaning of death and failed to address cultural conflicts in the process of death education, which may result in participants’ psychological discomfort. Thus, developing death education programs have been proposed that operate from the perspective of life’s course in order to reduce negative emotions and the fear of death [ 16 ]. Given the sensitivity of the topic, the method of delivering such education must be carefully considered.

Narrative education is an approach to achieving educational and research purposes by narrating, explaining, and reconstructing the experiences of educators and participants [ 17 ]. When addressing a sensitive topic, narratives generate less resistance because of the storytelling model [ 18 ]. Narratives may also facilitate older adults establishing reasonable cognition, knowledge, and behaviors related to death through introspection regarding their experiences and creation of meaning in their lives [ 19 ]. Therefore, the method can be used in death education in older adults [ 20 , 21 ].

A theoretical model is critical for framing the program, guiding data collection, and interpreting findings [ 22 ]. Various death education models have been developed such as lecture teaching and experience-sharing models [ 16 , 23 ]. In fact, compared to non-narrative messages, messages in narrative education have a stronger persuasive impact on one’s attitudes, intentions, and behaviors, both immediately and over time [ 24 ]. Therefore, a model that comprehensively attaches information acceptance, attitude modification, and behavior transition should be employed. The theory of Knowledge-Attitude-Practice (KAP) was first proposed by Cust and Mayo to explain the progressive relationship of moving from knowledge acquisition to behavior modification in individuals [ 25 ]. With the goal of helping individuals establish positive attitudes and beliefs and shifting towards correct behavior based on the reception and mastery of relevant knowledge, the theory has been widely applied in predicting health-related behaviors and implementing practice-improvement programs [ 26 ]. However, few studies have integrated the KAP model into death education for older adults, though it has the potential to communicate essential information, achieve reasonable life and death cognition, facilitate the maintenance of a positive attitude, and encourage the development of death-coping strategies [ 27 ]. Therefore, this study aimed to develop a KAP-based narrative life education program and explore its feasibility and effects on attitudes toward death and sense of meaning of life in older community-dwelling adults.

Study design

This mixed-methods feasibility study involved a quasi-experimental trial and semi-structured interviews. The goal was to determine the feasibility, acceptability, and primary efficacy of a narrative death education program for community-dwelling older adults. This study was reported following the Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR-RHS) and was performed in accordance with the Declarations of Helsinki [ 28 ].

Setting and sample

From September to November 2022, older adults were recruited from a community located in Fuzhou City, China, from September to November 2022. It home to approximately 4,500 individuals aged 60 and above, constituting more than 19.90% of the total residential population. The inclusion criteria were: (a) aged 60 years and above and (b) able to understand and communicate in Chinese. The exclusion criteria were: (a) with cognitive impairment or (b) with severe visual, auditory, or mental disorders. A sample size between 24 and 50 participants is recommended for feasibility studies [ 29 ]. A total of 47 community-dwelling older adults were recruited for this study. Details of recruitment are in Additional file 1 .

Recruitment

Participants were recruited at the community health service center via two approaches. For on-site recruitment, a recruitment poster was posted at the center. Potential participants who were interested in the study could directly contact the research assistant (RA). The RA then introduced this study to them through a face-to-face interview. For tele-recruitment, the RA interviewed potential participants via telephone, based on a list of older adults provided by the center. Written informed consent was obtained from each participant. After baseline data collection, individuals were invited to voluntarily join either the intervention or control group according to their preferences. Given the sensitivity of the topic of death among Chinese older adults, we did not employ randomization.

Intervention program

Both groups received the usual health education provided by the community health center. The intervention group also received the KAP-based Narrative Life Education (KAPNLE) program.

Intervention group

The KAPNLE program was initially drafted after reviewing KAP theory and multimedia material on life education developed by the research team and engaging in internal brainstorming. Details of the program were revised according to two rounds of comments from a six-expert panel whose research areas involved geriatric nursing, life education, community nursing, psychology, and social work. We also conducted interviews with five community-dwelling older adults and further refined the program based on their feedback.

The final version was composed of four modules: Understanding Life and Death (Knowledge), Viewing Life and Death (Attitude), Preparing for Death (Practice), and Transcending Life and Death (Practice). These four modules covered a total of six sessions, including Life Course , Growing Old Peacefully , Passing Away in Pain , Saying “Goodbye” Well , Expressing “Love” , and Living a Wonderful Life . Each session was conducted according to a four-step narrative process by a researcher who served as the facilitator. Initially, the facilitator presented material on life and death issues and created a context within which participants could easily discuss topics of life and death. Participants were then invited to redescribe the topics in their own way and share their impressions. Next, they were guided to further reflect on their own experiences and discuss views on issues related to life and death. In the final step, activities on related themes were conducted in a relaxed environment to deepen participants’ knowledge and experience of life and death. The program was conducted once a week over six weeks and lasted 30 to 60 min per session. It was held offline in the visiting room of the community healthcare center and attended by groups of six or seven older adults. The details of the program are shown in Additional file 2 .

Control group

The control group met twice a month and only received the usual community health education, which includes topics related to chronic diseases, medication safety, and lifestyle management, their course did not involve life education.

Measurements

Basic information questionnaire.

Demographics and information regarding life and death issues were collected by a self-reported questionnaire designed by our research team (Additional file 3 ). The demographic information included age, gender, religion, education level, marital status, living status, and number of children. The issues related to life and death included life-threatening illness experiences, self-perceived physical health, most profound encounters with death, and communication about death topics.

Death Attitude Profile-Revised (DAP-R)

Death attitudes were assessed using the Chinese version of Death Attitude Profile Revised (DAP-R) [ 30 ]. It consists of 32 items and five dimensions: fear of death, death avoidance, neutral acceptance, approach acceptance, and escape acceptance. Each item is rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Death attitudes are judged by the scores for each dimension. The higher the score, the more inclined the respondent is to this dimension’s attitude. In Chinese older adults, the Cronbach’s α values for the five dimensions were 0.796, 0.670, 0.621, 0.842 and 0.771.

Purpose in Life Test (PIL)

Meaning of life was measured using the Chinese version of Purpose in Life Test (PIL) [ 31 ]. It contains 20 items across four dimensions: quality of life, value of life, goal of life, and freedom of life. Scores are assigned using a five-point Likert scale, with each dimension including positive and negative questions. Scores selected for negative questions are reversed. Higher total scores indicate a greater sense of meaning of life. The Chinese version of the PIL has been validated, with a Cronbach’s α of 0.878.

Satisfaction of the program questionnaire

Respondents’ satisfaction was assessed using a self-designed questionnaire with six items: education theme, education content, education form, education schedule, benefits and practicability, and overall satisfaction. Each item is rated from “strongly satisfied” to “strongly dissatisfied” (Additional file 4 ).

Semi-structured interview

To assess the feasibility of the program for Chinese older adults, we conducted semi-structured interviews with the intervention participants. The interview outline was developed by the research team and began with a primary open-ended question: “What are your perceptions of the KAPNLE?” This question allowed participants to freely express their feelings and feedback about the program. Probing questions were then asked to facilitate in-depth exploration. The interview guideline is shown in Additional file 5 .

Data collection

The quantitative data were collected by another trained RA, who was blind to the group assignments. All participants’ death attitudes and ideas regarding the meaning of life were assessed at baseline and immediately after the program. In addition, the experimental participants were invited to describe their satisfaction with the program.

Participants in the intervention group were interviewed about their perceptions and experiences immediately after the program. A one-on-one semi-structured interview of each was conducted by the RA in the visiting room of the community healthcare center. Each interview lasted about 30 to 45 min, and the content was recorded with the participants’ informed consent.

Data analysis

Quantitative data.

The quantitative data were analyzed using IBM SPSS 27.0. The data were normality tested before being analyzed. Mean and standard deviation, median (P 25 , P 75 ), number, and percentage were determined to describe the older adults’ characteristics. A Chi-square test, t-test, Fisher’s Exact Test, Wilcoxon rank sum test, and multiple regression were used in this study. The Wilcoxon rank sum test was employed to test differences in the attitudes toward death and meaning of life between the groups for data with abnormal distributions. Multiple regression analysis was used to adjust for baseline imbalances in attitudes toward death and meaning of life between the two groups. Line graphs were used to describe any changes.

Qualitative data

The interviews were transcribed verbatim by a researcher within 24 h of their being conducted. Qualitative content analysis was used to analyze the qualitative data [ 32 ]. The steps applied were as follows: (a) identify and segment meaningful sentences within each interview text to generate “meaning units”, (b) condense semantic units into “condensed meaning units”, (c) abstract condensed semantic units to generate “codes”, (d) compare codes for commonalities, categorize codes into “categories”, (e) discuss and consensus on categories and formulate “themes” (Table 1 ). The interview data were coded by two researchers working independently. To ensure the credibility of the results, we used peer debriefing, member checks and held regular meetings to discuss the data analysis process and inconsistent opinions.

Feasibility of the program

A total of 47 older adults were recruited, including 27 in the intervention group and 20 in the control group. Seven in the intervention group withdrew from the study. Therefore, a total of 40 individuals completed the follow-up measurement and were included in analysis (Additional file 3 ). The total retention rate was 85.1%. Sixteen participants in the intervention group finished four to six sessions of the program, while four participants missed three out of six sessions. Their reasons included physical illness, family members’ illness or death, schedule conflicts, and self-isolation due to COVID-19 infection. The completion rate was 80.0% (16/20). All 20 intervention participants were very satisfied or satisfied with the education program, including its modules, sessions, implementation theme, and overall participation experience. No adverse events were reported during the study.

Participant characteristics

The mean age of the participants was 73.33 (6.16) years, with ages ranging from 63 to 88 years. Most of them were women (62.5%), not religious (75.0%), married (75.0%), had a high school education or above (75.0%), had one child (62.5%), lived with their children or spouse (85.0%), perceived themselves as in general or poor physical health (65.0%),were moved by their parents’ death (72.5%), and never communicated about death (62.5%). A small percentage had suffered (22.5%) or had family member who suffered (15.0%) from a life-threatening disease. There were no significant differences in demographic characteristics between the two groups (Additional file 6 ).

Preliminary efficacy of the program

Death attitudes.

Compared to the control group, a significant decrease was observed in fear of death in the intervention group ( P = 0.028), no significant differences were detected in the other dimensions or total score of the DAP-R ( P > 0.05). However, upward trends were observed in the DAP-R’s natural acceptance and approach acceptance. For the dimensions of death avoidance and escape acceptance, slight changes could also be found. After the intervention, there was no significant difference in total score of the DAP-R between the two groups, but the score for the control group fluctuated greatly during the follow-up.

Meaning of life

Compared to the baseline measurement, there were greater increases in value of life, goal of life, freedom of life, and total score of the PIL for the intervention group ( P < 0.05), and a slight upward trend was observed for freedom of life. However, no significant difference in the PIL’s quality of life was found between the two groups ( P = 0.141). As shown in the line chart, differences were observed in the trends in the total scores for the PIL between the two groups, after the intervention, the scores for the intervention group increased markedly compared to the control group after the intervention (Additional file 7 and Additional file 8 ).

Perceptions of the program

According to the post-intervention interview, four themes and ten sub-themes were identified: (a) profound recognition of life, (b) contradiction between thoughts and action, (c) conflict between self-acceptance and others’ avoidance, and (d) evaluation of the life education program.

Profound recognition of life

This theme relates to older adults’ cognition of life and death, and contains three sub-themes:

Vague concept of life and death at the early stage

Some respondents stated that they had a vague understanding of life and death at the beginning of the program and had difficulties in describing or explaining them. They also expressed that they paid no attention to life and death-related issues in their daily lives over in years past.

“When you asked me about life and death, I really didn’t know how to answer. I never thought about it before. Life means I’m still alive; and death means I am away from the world. Is it right?” (Participant 2) .

Gradually clarifying life and death issues

After the first two sessions of the program. participants expressed that they had a figurative understanding of life and death. They realized the logical relationship between the two, and further accepted their unique lives.

“I didn’t know what life was like before, but now I do. My life is like a sunflower gone to seed. If I pass away like a flower withers, I still have something left in this world.” (Participant 1) .

“I feel my that life is a line with ups and downs, starting from zero, maybe ending at 100. Each number represents a stage of my life, and contains many important things.” (Participant 10) .

Discussing life and death with an open mind at the final stage

At the end of the program, participants expressed that they could easily discuss topics related to life and death and felt comfortable in the process. They also said that the program reduced their negative feelings about death and encouraged them to pursue meaning in their lives.

“Now I have a new perspective on life, and the fears about death seem to have vanished. Dying at the age of 20 or 100 are both lifetimes and being dead or alive cannot be decided by oneself. So, I will cherish my life when I am alive and enjoy life every day.” (Participant 11) .

“I realized that talking about death is not as difficult as I imagined. It actually could be very easy, just like this program.” (Participant 6) .

Contradictions between thoughts and actions

This theme is related to inconsistencies between positive thoughts about life and death and passive behaviors regarding death preparation, it includes the following two sub-themes:

Hold positive thoughts on to embrace life and deaths

Some participants expressed that they held rational and open attitudes about life and death after the program. They realized the inevitability of death, and calmly accept it as a normal phenomenon.

“I think that everyone will die in the end, and nobody can avoid death. I must go on my last journey well. As long as I have done all things, I can go without any regret.” (Participant 12) .

“I never thought about it (death) until I participate in this program. It reminded me that I would pass away one day. Then, I started to think about death issues in advance. If I had not participated in it, I wouldn’t have come to this step.” (Participant 5) .

Hesitating to make life and death plan

Some of the older adults emphasized living in the present, and were unwilling to make death preparation in advance.

“I am not thinking about what I should do about death at present. I just want live in the moment, do what I need to do at present, and stay happy.” (Participant 7) .

“I will think about these things, such as the cemetery or family arrangements, when I am more than 70 or 80 years old. But now, I live in the present and enjoy life.” (Participant 8) .

Conflict between one’s acceptance and others’ avoidance

This theme is related to the acceptability of life education, two sub-themes comprise this category.

Self-acceptance and openly discussion about life and death

Some participants noted that the program changed their attitudes about life and death. They not only felt comfortable talking about death-related topics, but also recommended the program to others.

“I think this program should be recommended to more older adults, especially to those who are sensitive and concerned about death. It can teach them how to deal with life and death, and overcome fear of death.” (Participant 10) .

Others’ opposition to life education due to stereotypes

Some participants mentioned that their family members or friends opposed their participation in the life education program due to the sensitivity of death-related topics.

“Most older adults around me resist talking about death. They tried to persuade me not to participate in life education because death is a taboo.” (Participant 4) .

“My family didn’t want me to attend such activity, for it will bring bad fortune. Therefore, I attended this class without telling my family.” (Participant 13) .

Evaluation of the life education program

This theme is related to the participants’ perspectives on the program and includes two sub-themes:

Affirmation of the program

Some of the older adults reflected that conversations about life and death were sensitive but acceptable. They further expressed that they could benefit from life education.

“It is not easy to talk about death-related topics, but I think life education is very important. Because it can help older adults do enough preparation and pass away without any regrets. I support this program.” (Participant 3) .

Some participants believed that the program was feasible because narrative life education enabled them to pick up death topic more easily. Moreover, the program was conducted in groups, which established a supportive environment.

“The most impressive thing about this program is telling stories. I have received various stories from others. Then, I felt pleased to share my thoughts and discuss with others about these stories.” (Participant 15) .

“It was easier for me to talk about life and death in groups. When someone started to talk about that, then we thought we could talk about that as well. You know, such an environment is important.” (Participant 17) .

Comments and suggestions

Some of the respondents mentioned that the group-based education might ignore individuals’ specific needs and suggested combining group education with individual counseling in the future.

“There was often someone absent in the group. Therefore, I think the program could add some individual education content, which would help the absentee to catch up with the progress.” (Participant 10) .

Regarding the resistance of their family or close friends to this program, some of the older adults hoped that the program could expand to include outside participants, such as by allowing them to invite people around them to participate.

“In fact, I still hope to get support and understanding from my family or friends, so maybe you can try to invite them to participate in this life education together.” (Participant 4) .

To the best of our knowledge, this is the first study to develop and evaluate the feasibility and preliminary effects of the KAPNLE. Our quantitative findings demonstrate that the program is effective at promoting a positive transition in death attitude and improving the meaning of life for community-dwelling older adults. The qualitative results indicate that the program is both acceptable and feasible. It also supports the potential of using the KAPNLE to change people’s attitudes toward life and death.

Our study indicates an acceptable feasibility among older adults. Seven participants withdrew from the study (a dropout rate of 14.8%), which was higher than a previous study [ 33 ]. One possible reason for the dropout rate may be that the sensitivity of the topic may have negatively affected these Chinese older adults’ willingness to participate [ 34 ]. Additionally, the study was conducted during the period of the COVID-19 pandemic, when older adults were more concerned about their physical health and less likely to engage in social activities [ 35 ]. There were no reported adverse events during the study for the intervention group, and all participants were either very satisfied or satisfied with the KAPNLE, indicating that the program is acceptable and safe. The KAP theory focuses on shared goals, transparency, accountability, and respect, and these factors are essential for effective collaboration in patient engagement [ 36 ]. Based on group-formatted discussions, the contents of the KAPNLE programs matched knowledge to attitudes, and then to action, in sequence rather than in a fragmented fashion. Participants’ feeling of freedom was encouraged at every step to promote their acceptance of death education. The older adults participating in our study stated that narration helped them address topics of life and death more easily and discuss related issues with less emotional resistance. In fact, the narrative approach emphasized finding psychosocial strengths and highlighting their own personal meaning of life [ 37 ]. Compared to didactic messages, those in narrative form tend to be more acceptable due to their natural format and the emotional engagement, and positive thoughts they inspire [ 38 ]. The narrative method can provide rich insights into the meanings associated with phenomena due to its deep subjectivity and inherent explanations of information [ 39 ]. Based on the multimedia cases we provided, the KAPNLE program adopted a four-step group-based narrative process that created a relaxed and supportive environment by focusing on storytelling, thus promoting acceptance of issues related to life and death [ 40 ]. This approach is useful in helping older adults understand and reconsider events in their lives, encouraging them to share information and transform their attitudes about death in an acceptable way [ 41 ].

Our quantitative results demonstrate that it is feasible to use the KAPNLE to promote a positive transition in attitudes toward death, especially in terms of reducing the fear of death, and these results are consistent with previous studies [ 33 , 42 ]. The post-program qualitative interviews indicated similar findings. The program provided relevant information about the process of life, hospice care, living wills, and death preparations. Correlating with KAP theory, the provision of comprehensive information about death can promote a more positive attitude, which can then help bridge the knowledge-intention gap in discussions about and preparations for death [ 43 ]. Moreover, participants also disclosed that the program had a promising effect on their understanding of the meaning of life and improved their acceptance of death. The KAPNLE guided these older adults to realize the inevitability of death through free discussion in a non-didactic group format and relaxing circumstance. Once their cognition of death was modified, they may experience greater openness to the possibilities available to them throughout the rest of their lives [ 44 ]. In line with previous studies, our results suggest that the KAPNLE improves the sense of meaning of life in older adults [ 45 , 46 ]. Participants were guided to be more aware of their achievements and self-value by reviewing their lives, and resist the consciousness of death by perceiving and maintaining a positive sense of self-meaning [ 47 ]. In line with concepts of KAP theory, modification of the cognition of and attitudes about death plays a crucial role in clarifying the meaning of life, finding purpose in life, and identifying suitable coping strategies [ 48 ].

Although the program encouraged participants to set goals and make plans for the rest of their lives, no direct changes in participants’ behavior were observed. The behaviors related to death preparation among older adults are often affected by family circumstances and subjective norms, and it is challenging to establish advanced death preparation due to the Chinese culture [ 49 , 50 ]. In addition, health status is associated with death preparation in older adults. Most participants in our study were not facing life-threatening illnesses, which may have reduced their initiative to engage with this program [ 51 ].

This study has some limitations, because of the cultural influences and stereotypes of death education from older adults’ family members, the dropout rate was relatively high. Moreover, although most participants had accepted the life process and found the meaning of life, they remained negative about making pre-death plans. This indicates that some of them may not have been operationally prepared for death and thus could not achieve the behavioral transition envisioned by the KAP model. Some participants also suggested that their family members or acquaintances should be involved in this program. In fact, due to the sensitivity of discussing about death within the traditional views of Chinese older adults, we allowed participants to choose group assignment by themselves to prevent ethical conflicts. This probably introduced selection bias for participants who chose to receive the intervention may have already been more open-minded about discussing death. In addition, this study did not employ a randomized controlled trial because our purpose was to explore the feasibility and acceptability of the program. Further research with rigorous design is needed to enhance participants’ adherence to narrative death education and to optimize intervention strategies.

This study constructed a KAP-based narrative life education program for community-dwelling older adults. We found that the life education program is acceptable and feasible among this cohort and could potentially improve attitudes toward death and the meaning of life. Future research with a rigorous design is necessary to test the effectiveness of narrative death education in older adults.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy and ethical restrictions.

Abbreviations

Knowledge-Attitude-Practice

KAP-based Narrative Life Education

Research assistant

Death Attitude Profile-Revised

Purpose in Life Test

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Acknowledgements

The authors gratefully thank all participants for their support and cooperation.

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Xifeng Xie and Li Zhou contributed equally to this work.

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School of Nursing, Fujian Medical University, Fuzhou City, Fujian Province, China

Xifeng Xie, Xiaoling Zhang, Huina Zou, Yuanfeng Lu & Huimin Xiao

Nanjie Community Health Service Center, Fuzhou City, Fujian Province, China

Research Center for Nursing Humanity, Fujian Medical University, Fuzhou City, Fujian Province, China

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X.X.: Methodology, Investigation, Data Curation, Data Analysis, Visualization, Writing - Original Draft; L.Z.: Methodology, Investigation, Data Curation, Data Analysis; X.Z.: Data Curation, Data Analysis; H.Z.: Data Curation, Data Analysis; Y.L.: Writing-Review & Editing, Revision; H.X.: Conceptualization, Methodology, Resources, Supervision, Writing-Review & Editing. All authors reviewed the manuscript.

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Xie, X., Zhou, L., Zhang, X. et al. Evaluation of a knowledge-attitude-practice model based narrative life education program for community-dwelling older adults: a mixed-methods feasibility study. BMC Geriatr 24 , 547 (2024). https://doi.org/10.1186/s12877-024-05153-4

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DOI : https://doi.org/10.1186/s12877-024-05153-4

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Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied research and evaluation, this Fourth Edition of ...
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Michael Quinn Patton is author of more than a dozen books on evaluation including Qualitative Research & Evaluation Methods, 4th ed (2015), Blue Marble Evaluation (2020), Principles-Focused Evaluation (2018), Facilitating Evaluation (2018) and Developmental Evaluation (2011). Based in Minnesota, he was on the faculty of the University of ...
Qualitative research & evaluation methods: integrating theory and practice
The fourth edition of Michael Quinn Patton's Qualitative Research & Evaluation Methods Integrating Theory and Practice, published by Sage Publications, analyses and provides clear guidance and advice for using a range of different qualitative methods for evaluation. Contents Part 1. Framing Qualitative Inquiry: Theory Informs Practice, Practice Informs Theory
Qualitative Research & Evaluation Methods
Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied ...
Qualitative Research & Evaluation Methods
About the author (2002) Michael Quinn Patton is author of more than a dozen books on evaluation including Qualitative Research & Evaluation Methods, 4th ed (2015), Blue Marble Evaluation (2020), Principles-Focused Evaluation (2018), Facilitating Evaluation (2018) and Developmental Evaluation (2011). Based in Minnesota, he was on the faculty of ...
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Buy Qualitative Research & Evaluation Methods: Integrating Theory and Practice Fourth by Patton, Michael Quinn (ISBN: 9781412972123) from Amazon's Book Store. Everyday low prices and free delivery on eligible orders.
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Now offering more balance between applied research and evaluation, this Fourth Edition of Qualitative Research & Evaluation Methods illuminates all aspects of qualitative inquiry through new examples, stories, and cartoons; more than a hundred new summarizing and synthesizing exhibits; and a wide range of new highlight sections/sidebars that ...
Qualitative Research & Evaluation Methods
Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied research and evaluation, this Fourth Edition ...
Qualitative Research & Evaluation Methods
Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied ...
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied ...
Qualitative Research & Evaluation Methods 4th Edition
Qualitative Research & Evaluation Methods: Integrating Theory and Practice 4th Edition is written by Michael Quinn Patton and published by SAGE Publications, Inc. The Digital and eTextbook ISBNs for Qualitative Research & Evaluation Methods are 9781483376059, 1483376052 and the print ISBNs are 9781412972123, 1412972124. Save up to 80% versus print by going digital with VitalSource.
Qualitative Research & Evaluation Methods
Qualitative Research & Evaluation Methods Integrating Theory and Practice. Part 1. Framing Qualitative Inquiry: Theory Informs Practice, Practice Informs Theory. Chapter 1. The Nature, Niche, and Value of Qualitative Inquiry. Module 1. How qualitative inquiry contributes to our understanding of the world. Module 2.
Qualitative Research and Evaluation Methods : Integrating Theory and
Find 9781412972123 Qualitative Research and Evaluation Methods : Integrating Theory and Practice 4th Edition by Michael Quinn Patton at over 30 bookstores. Buy, rent or sell.
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Qualitative Research & Evaluation Methods: Integrating Theory and Practice. Expertly curated help for Qualitative Research & Evaluation Methods: Integrating Theory and Practice. Get access to 5+ million textbook and homework solutions, access to subject matter experts, math solver, and premium writing tools with bartleby+. Get your 1 st month ...
Qualitative research & evaluation methods : integrating theory and practice
Qualitative research & evaluation methods : integrating theory and practice. Author: Michael Quinn Patton (Author) Summary: Patton has created the most comprehensive, systematic, and up-to-date review of qualitative methods available. The Third Edition has retained and expanded upon the exhibits, which highlight and summarize major issues ...
Qualitative Research & Evaluation Methods
Integrating Theory and Practice. Fourth Edition. Michael Quinn Patton - Utilization-Focused Evaluation, Saint Paul, MN; ... Michael Quinn Patton is author of more than a dozen books on evaluation including Qualitative Research & Evaluation Methods, 4th ed (2015), Blue Marble Evaluation (2020), Principles-Focused Evaluation (2018), Facilitating ...
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
C. Roberts Koshila Kumar G. Finn. Sociology. BMC medical education. 2020. TLDR. Advice is themed around long-established criteria for the quality of qualitative research developed by Lincoln and Guba, in the form of several practical steps pertinent to the process of writing up qualitative research. Expand. 10.
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Michael Quinn Patton is author of more than a dozen books on evaluation including Qualitative Research & Evaluation Methods, 4th ed (2015), Blue Marble Evaluation (2020), Principles-Focused Evaluation (2018), Facilitating Evaluation (2018) and Developmental Evaluation (2011). Based in Minnesota, he was on the faculty of the University of Minnesota for 18 years and is a former president of the ...
Qualitative Research & Evaluation Methods Integrating Theory and
Integrating Theory and Practice. EISBN: 1483301451. EISBN-13: 9781483301457. Authors: Michael Quinn Patton. Out of Stock. ... Rent 📙Qualitative Research & Evaluation Methods 4th edition (978-1483301457) today, or search our site for other 📚textbooks by Michael Quinn Patton.
Qualitative Research & Evaluation Methods
Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied ...
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today.
Whose Um Voice is it Anyway? Leveraging "Thick Transcription" to
Integrating transcript alignment into their practice, qualitative researchers can reaffirm the naturalistic tenet of "investigator as instrument," generate "thick transcription," and ultimately carry forward an ethos of participant inclusion throughout data analysis and presentation activities.
Qualitative Research & Evaluation Methods
Drawing on more than 40 years of experience conducting applied social science research and program evaluation, author Michael Quinn Patton has crafted the most comprehensive and systematic book on qualitative research and evaluation methods, inquiry frameworks, and analysis options available today. Now offering more balance between applied research and evaluation, this Fourth Edition ...
Qualitative Research Journal
Qualitative Research Journal. Articles & Issues. Menu. Articles & Issues. Latest issue; All issues; ... reflections on methods, practices and ethics in researching with children using zoom video interviews ... select article Culturally responsive and communicative teaching for multicultural integration: qualitative analysis from public ...
Strategies for knowledge mobilization by advanced practice nurses in
Background Evidence-based practice, in conjunction with optimum care quality, improves patients' clinical outcomes. However, its implementation in daily clinical practice continues to present difficulties. The aim of this study was to identify the strategies applied by Advanced Practice Nurses (APNs) to foster adherence to clinical practice guideline recommendations. Methods An exploratory ...
Evaluation of a knowledge-attitude-practice model based narrative life
Background The global aging population presents challenges that are particularly acute in China. Older Chinese adults' attitudes towards death significantly impact their quality of life. Death education is crucial for promoting positive perspectives on life and death. Narrative education offers a promising approach to facilitating death education. Integrating the Knowledge-Attitude-Practice ...
Qualitative Research & Evaluation Methods: Integrating Theory and Practice
Michael Quinn Patton is author of more than a dozen books on evaluation including Qualitative Research&Evaluation Methods, 4th ed (2015), Blue Marble Evaluation (2020), Principles-Focused Evaluation (2018), Facilitating Evaluation (2018) and Developmental Evaluation (2011). Based in Minnesota, he was on the faculty of the University of Minnesota for 18 years and is a former president of the ...

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Strategies for knowledge mobilization by advanced practice nurses in three hospitals in Spain: a qualitative study

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