advantages of qualitative research in nursing

Introduction to qualitative nursing research

This type of research can reveal important information that quantitative research can’t.

• Qualitative research is valuable because it approaches a phenomenon, such as a clinical problem, about which little is known by trying to understand its many facets.
• Most qualitative research is emergent, holistic, detailed, and uses many strategies to collect data.
• Qualitative research generates evidence and helps nurses determine patient preferences.

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

All nurses are expected to understand and apply evidence to their professional practice. Some of the evidence should be in the form of research, which fills gaps in knowledge, developing and expanding on current understanding. Both quantitative and qualitative research methods inform nursing practice, but quantitative research tends to be more emphasized. In addition, many nurses don’t feel comfortable conducting or evaluating qualitative research. But once you understand qualitative research, you can more easily apply it to your nursing practice.

What is qualitative research?

Defining qualitative research can be challenging. In fact, some authors suggest that providing a simple definition is contrary to the method’s philosophy. Qualitative research approaches a phenomenon, such as a clinical problem, from a place of unknowing and attempts to understand its many facets. This makes qualitative research particularly useful when little is known about a phenomenon because the research helps identify key concepts and constructs. Qualitative research sets the foundation for future quantitative or qualitative research. Qualitative research also can stand alone without quantitative research.

Although qualitative research is diverse, certain characteristics—holism, subjectivity, intersubjectivity, and situated contexts—guide its methodology. This type of research stresses the importance of studying each individual as a holistic system (holism) influenced by surroundings (situated contexts); each person develops his or her own subjective world (subjectivity) that’s influenced by interactions with others (intersubjectivity) and surroundings (situated contexts). Think of it this way: Each person experiences and interprets the world differently based on many factors, including his or her history and interactions. The truth is a composite of realities.

Qualitative research designs

Because qualitative research explores diverse topics and examines phenomena where little is known, designs and methodologies vary. Despite this variation, most qualitative research designs are emergent and holistic. In addition, they require merging data collection strategies and an intensely involved researcher. (See Research design characteristics .)

Although qualitative research designs are emergent, advanced planning and careful consideration should include identifying a phenomenon of interest, selecting a research design, indicating broad data collection strategies and opportunities to enhance study quality, and considering and/or setting aside (bracketing) personal biases, views, and assumptions.

Many qualitative research designs are used in nursing. Most originated in other disciplines, while some claim no link to a particular disciplinary tradition. Designs that aren’t linked to a discipline, such as descriptive designs, may borrow techniques from other methodologies; some authors don’t consider them to be rigorous (high-quality and trustworthy). (See Common qualitative research designs .)

Sampling approaches

Sampling approaches depend on the qualitative research design selected. However, in general, qualitative samples are small, nonrandom, emergently selected, and intensely studied. Qualitative research sampling is concerned with accurately representing and discovering meaning in experience, rather than generalizability. For this reason, researchers tend to look for participants or informants who are considered “information rich” because they maximize understanding by representing varying demographics and/or ranges of experiences. As a study progresses, researchers look for participants who confirm, challenge, modify, or enrich understanding of the phenomenon of interest. Many authors argue that the concepts and constructs discovered in qualitative research transcend a particular study, however, and find applicability to others. For example, consider a qualitative study about the lived experience of minority nursing faculty and the incivility they endure. The concepts learned in this study may transcend nursing or minority faculty members and also apply to other populations, such as foreign-born students, nurses, or faculty.

Qualitative nursing research can take many forms. The design you choose will depend on the question you’re trying to answer.

A sample size is estimated before a qualitative study begins, but the final sample size depends on the study scope, data quality, sensitivity of the research topic or phenomenon of interest, and researchers’ skills. For example, a study with a narrow scope, skilled researchers, and a nonsensitive topic likely will require a smaller sample. Data saturation frequently is a key consideration in final sample size. When no new insights or information are obtained, data saturation is attained and sampling stops, although researchers may analyze one or two more cases to be certain. (See Sampling types .)

Some controversy exists around the concept of saturation in qualitative nursing research. Thorne argues that saturation is a concept appropriate for grounded theory studies and not other study types. She suggests that “information power” is perhaps more appropriate terminology for qualitative nursing research sampling and sample size.

Data collection and analysis

Researchers are guided by their study design when choosing data collection and analysis methods. Common types of data collection include interviews (unstructured, semistructured, focus groups); observations of people, environments, or contexts; documents; records; artifacts; photographs; or journals. When collecting data, researchers must be mindful of gaining participant trust while also guarding against too much emotional involvement, ensuring comprehensive data collection and analysis, conducting appropriate data management, and engaging in reflexivity.

Data usually are recorded in detailed notes, memos, and audio or visual recordings, which frequently are transcribed verbatim and analyzed manually or using software programs, such as ATLAS.ti, HyperRESEARCH, MAXQDA, or NVivo. Analyzing qualitative data is complex work. Researchers act as reductionists, distilling enormous amounts of data into concise yet rich and valuable knowledge. They code or identify themes, translating abstract ideas into meaningful information. The good news is that qualitative research typically is easy to understand because it’s reported in stories told in everyday language.

Evaluating a qualitative study

Evaluating qualitative research studies can be challenging. Many terms—rigor, validity, integrity, and trustworthiness—can describe study quality, but in the end you want to know whether the study’s findings accurately and comprehensively represent the phenomenon of interest. Many researchers identify a quality framework when discussing quality-enhancement strategies. Example frameworks include:

• Trustworthiness criteria framework, which enhances credibility, dependability, confirmability, transferability, and authenticity
• Validity in qualitative research framework, which enhances credibility, authenticity, criticality, integrity, explicitness, vividness, creativity, thoroughness, congruence, and sensitivity.

With all frameworks, many strategies can be used to help meet identified criteria and enhance quality. (See Research quality enhancement ). And considering the study as a whole is important to evaluating its quality and rigor. For example, when looking for evidence of rigor, look for a clear and concise report title that describes the research topic and design and an abstract that summarizes key points (background, purpose, methods, results, conclusions).

Application to nursing practice

Qualitative research not only generates evidence but also can help nurses determine patient preferences. Without qualitative research, we can’t truly understand others, including their interpretations, meanings, needs, and wants. Qualitative research isn’t generalizable in the traditional sense, but it helps nurses open their minds to others’ experiences. For example, nurses can protect patient autonomy by understanding them and not reducing them to universal protocols or plans. As Munhall states, “Each person we encounter help[s] us discover what is best for [him or her]. The other person, not us, is truly the expert knower of [him- or herself].” Qualitative nursing research helps us understand the complexity and many facets of a problem and gives us insights as we encourage others’ voices and searches for meaning.

When paired with clinical judgment and other evidence, qualitative research helps us implement evidence-based practice successfully. For example, a phenomenological inquiry into the lived experience of disaster workers might help expose strengths and weaknesses of individuals, populations, and systems, providing areas of focused intervention. Or a phenomenological study of the lived experience of critical-care patients might expose factors (such dark rooms or no visible clocks) that contribute to delirium.

Successful implementation

Qualitative nursing research guides understanding in practice and sets the foundation for future quantitative and qualitative research. Knowing how to conduct and evaluate qualitative research can help nurses implement evidence-based practice successfully.

When evaluating a qualitative study, you should consider it as a whole. The following questions to consider when examining study quality and evidence of rigor are adapted from the Standards for Reporting Qualitative Research.

Jennifer Chicca is a PhD candidate at the Indiana University of Pennsylvania in Indiana, Pennsylvania, and a part-time faculty member at the University of North Carolina Wilmington.

Amankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3):121-7.

Cuthbert CA, Moules N. The application of qualitative research findings to oncology nursing practice. Oncol Nurs Forum . 2014;41(6):683-5.

Guba E, Lincoln Y. Competing paradigms in qualitative research . In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research. Thousand Oaks, CA: SAGE Publications, Inc.;1994: 105-17.

Lincoln YS, Guba EG. Naturalistic Inquiry . Thousand Oaks, CA: SAGE Publications, Inc.; 1985.

Munhall PL. Nursing Research: A Qualitative Perspective . 5th ed. Sudbury, MA: Jones & Bartlett Learning; 2012.

Nicholls D. Qualitative research. Part 1: Philosophies. Int J Ther Rehabil . 2017;24(1):26-33.

Nicholls D. Qualitative research. Part 2: Methodology. Int J Ther Rehabil . 2017;24(2):71-7.

Nicholls D. Qualitative research. Part 3: Methods. Int J Ther Rehabil . 2017;24(3):114-21.

O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med . 2014;89(9):1245-51.

Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice . 10th ed. Philadelphia, PA: Wolters Kluwer; 2017.

Thorne S. Saturation in qualitative nursing studies: Untangling the misleading message around saturation in qualitative nursing studies. Nurse Auth Ed. 2020;30(1):5. naepub.com/reporting-research/2020-30-1-5

Whittemore R, Chase SK, Mandle CL. Validity in qualitative research. Qual Health Res . 2001;11(4):522-37.

Williams B. Understanding qualitative research. Am Nurse Today . 2015;10(7):40-2.

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Differences between Qualitative & Quantitative Research

" Quantitative research ," also called " empirical research ," refers to any research based on something that can be accurately and precisely measured.  For example, it is possible to discover exactly how many times per second a hummingbird's wings beat and measure the corresponding effects on its physiology (heart rate, temperature, etc.).

" Qualitative research " refers to any research based on something that is impossible to accurately and precisely measure.  For example, although you certainly can conduct a survey on job satisfaction and afterwards say that such-and-such percent of your respondents were very satisfied with their jobs, it is not possible to come up with an accurate, standard numerical scale to measure the level of job satisfaction precisely.

It is so easy to confuse the words "quantitative" and "qualitative," it's best to use "empirical" and "qualitative" instead.

Hint: An excellent clue that a scholarly journal article contains empirical research is the presence of some sort of statistical analysis

See "Examples of Qualitative and Quantitative" page under "Nursing Research" for more information.

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• You are here: Public health

Qualitative research and its role in nursing knowledge

16 May, 2006 By NT Contributor

According to Rowe (2000), accountability and the quest for professional status has contributed to the acknowledgement that nursing needs to be knowledge centred. 

VOL: 102, ISSUE: 20, PAGE NO: 32

Angela Hall MSc, PGCE, BSc, RGN, DN, RNT, is tutor, public health and primary care and care of the older person, Swansea University

Exploring sources of knowledge and their contribution should be a question the profession addresses (Hall, 2005). Nurses use a diverse range of knowledge, including that from research, to make their clinical decisions and to plan care with patients.

The development of qualitative research in nursing is a result of the influence of various traditions. Compared with quantitative, the qualitative approach is relatively new and various techniques and strategies are therefore emerging.

Eraut (1994) identified that research of all types should aim to systematically investigate and contribute to the body of knowledge that helps to shape and guide the profession. Therefore, nurses should use the ‘best’ research evidence available.

Despite the qualitative method being traditionally a less widely valued source of research evidence, there are a number of factors that add to the significance of the contribution qualitative research makes to nursing knowledge. Like all research, qualitative research needs to be assessed on its merits if practitioners are to be able to assess its worth.

The literature suggests that the contribution of qualitative research is growing and it is advancing nursing knowledge, particularly in relation to certain aspects of that knowledge. This implies it is important that nurses in practice understand it and can judge its worth and relate it to their care of patients.

It is logical that knowledge claims that originate from qualitative research should be open to critique and formal evaluation. This implies that there is a need for qualitative research to be open to searching, audit and criticism. This is the means to assess its contribution to advancing nursing knowledge in terms of testing, extending or challenging what is already known or believed.

Certainly, as Corner (1990) identified some time ago, the whole issue of the value of various research approaches and their roles to nursing knowledge advancement has been a source of debate in the literature. The recognition of the importance of qualitative nursing research has recently increased. More is known about the use of related research methods in nursing and a number of authors have contributed significantly (Holloway, 2005; Green and Thorogood, 2004; Mason, 2002; Brewer, 2000; Cresswell, 1998; Silverman, 1998; Koch, 1995; Bryman, 1992; Morse, 1991; Atkinson, 1990).

Definitions

It is difficult to be definitive because both ‘qualitative research’ and ‘nursing knowledge’ are relatively new, evolving and complex aspects of the nursing profession. They are both dynamic, multidimensional and context-bound terms.

Qualitative research

According to Denzin and Lincoln (2000), qualitative research is a distinct field of enquiry in its own right. The literature indicates that qualitative research methodology refers to the ideas and principles that researchers use to base their procedures and strategies (methods) on (Holloway, 2005; Green and Thorogood, 2004; Flick et al, 2004; Mason, 2002).

Qualitative research ‘is a form of social enquiry that focuses on the way people interpret and make sense of their experiences and the world in which they live’ (Atkinson, 1990, p7).

The main debate has traditionally been the value of the contribution of quantitative versus qualitative research in terms of knowledge development for nursing (Smith and Heshusius, 1986; Goodwin and Goodwin, 1984), although Webb (1989) claims the differences between the approaches are overstated.

The evidence indicates that ‘qualitative research’ is generally more interpretive and it is increasingly used to study ‘concepts’ and ‘phenomena’. It is different from quantitative research because it occurs in the natural context without an attempt to change or control the research. The aim is to understand complex relationships rather than demonstrate ‘cause and effect’. The diversity of responses is valuable.

Maggs-Rapport (2000) identified that qualitative research is often humanistic and descriptive in nature. It has many dimensions, where researchers need a self-conscious approach. As a result, the contribution of qualitative research not only reinforces knowledge but also uncovers new information that is perhaps less likely with other approaches.

Nursing knowledge

‘Nursing knowledge’ is also multidimensional. It is about viewing patients as unique human beings and considering their social dynamics in a clinical setting or any setting where care is provided (Hall, 2005).

It is also knowledge nurses have that influences the process of professional caring and outcome. Parse (1996) highlights an important distinction between ‘general knowledge per se that can be used by nurses’ and ‘nursing knowledge’. This is what makes the key difference between lay carers or HCAs and nurses. This ‘nursing knowledge’ is recognised as the ‘body of knowledge’ that marks nursing as a profession and which can be communicated to other nurses.

Qualitative nursing knowledge is dynamic and is always provisional because new data can refute it. Despite these and other complications in trying to define knowledge that belongs to the profession, numerous authors have tried to classify what nurses know. These authors come from a range of perspectives (Chinn and Kramer 1999; Marriner-Tomey, 1994; Benner and Wrubel, 1989; Parse, 1987; Benner, 1984; Watson, 1979; Carper, 1978).

Some authors refer to ‘domains’. These links with the various ‘domains’ or ‘classifications’ of nursing knowledge are influential because any valid theory developed will guide the discipline of nursing. There appears to be an affinity between knowledge needed to care for patients and the relatively holistic approach of qualitative research knowledge.

Most aspects of care generally draw on knowledge from a range of sources. Nursing is much more than just application of knowledge. It is an interactive ‘art’. Maggs-Rapport (2000) claims nursing is a complex concept, perhaps ‘unknowable’ in its entirety.

Qualitative knowledge

Qualitative knowledge is dependent on information on the social context with a core item being the understanding of human experiences. It is especially useful when little is known about the topic and in nursing this is true with many aspects of care.

The contribution is often in terms of generation of concepts and new theoretical ideas. Conversely, the underlying philosophy and methods leave the approach vulnerable to criticism that it is potentially unsystematic, subjective, lacks objectivity and generalisibility and that it is a ‘soft’ approach compared with approaches that contribute to so-called ‘empirical’ and ‘scientific’ knowledge.

Parahoo (1997) and Morse and Field (2002) claim the evidence is not viewed as being as powerful as that generated by quantitative work. Many of the strengths of qualitative research are viewed as weaknesses by those who subscribe to different methodologies.

It ensures a unique perspective and is often a relatively deep insight into human beings. It generates knowledge that is needed to care for patients as it is usually person centred, holistic, interactive and inductive. It is based on ‘emic’ perspectives - views of people, their perceptions and meanings - and is useful for exploring knowledge questions related to feelings, behaviour, experiences and meanings (Parahoo, 1997).

Roots of knowledge

Qualitative research in nursing in a similar way to nursing practice has, in a relatively short period of time, descended from numerous other disciplines of often diverse traditions. It has its roots in history, anthropology, philosophy and sociology. It tends to be research carried out in the field or natural settings where data is analysed in non-statistical ways. 

Usually analysis is thematic and constantly comparative in nature. The outcome is usually written text or ‘stories’. Researchers’ reports from the field are often based on some form of observation, for example, ‘field work’, ‘case studies’ or ‘stories from the field’ (Darlington and Scott, 2002; Burgess,1984). Within qualitative research the various methods have their individual perspective in terms of nursing knowledge. Morse and Field (2002) advise the most appropriate method to answer the question should be selected.

Qualitative research is traditionally divided into ethnography (social issues - individuals studied in context), phenomenology (focuses upon individuals’ perceptions) and grounded theory (develops theory).

There are also many new and flexible forms of enquiry such as conversational analysis and discourse analysis. Each method has developed from a different background. There is also a tendency for certain forms of social enquiry that are especially relevant to nursing to use qualitative methods such as ‘feminist approaches’ and ‘action research’.

Nursing is a profession that borrows much of its knowledge from other often diverse disciplines such as medicine and psychology. It seems appropriate that the research strategy should encompass elements from other disciplines. The strategy should be dependent to some extent on which aspect of the profession is being researched. Of course there are difficulties in applying any method when researching nursing, which is a complicated practice profession and where many participants are particularly vulnerable.

Developing knowledge

In relation to the development of qualitative research in the UK, it is important to remember the wider nursing context. Nurses have traditionally been taught the quantitative approaches, partly because the nursing profession initially tried to align and compete with medicine and science (Sim and Wright, 2000).

As the nursing profession began attempting to produce its own knowledge base, it started to identify the differences with medical knowledge. During these decades nurse education changed dramatically with an increasing awareness of accountability. Slowly these factors began to give more credence to qualitative methods and the knowledge generated from these approaches.

Many experienced nurses have only relatively recently been introduced to qualitative approaches. It is important to realise that knowledge created by quantitative research also has its place in enhancing patient care. For example, clinical trials provide the valuable data on oncology treatments and interventions. Approaches and methods should be used pragmatically depending on the question and then the knowledge can be evaluated based on methodological clarity and transparency (Cutcliffe and McKenna, 1999). Nurses also need to pragmatically judge research then apply it if it enhances their practice.

In terms of practice knowledge created by qualitative research, it helps ensure patients are viewed as individual patients rather than medical conditions. In healthcare research this is an important perspective when trying to make effective policy and practice decisions (Bowling and Ebrahim, 2005). It is clear that qualitative research continues to evolve and increase its contribution but it is based on a number of relevant assumptions that add an important perspective to its suitability for many nursing questions.

The underpinning ideas and principles increase the value of knowledge created for nursing by qualitative research. This is because it acknowledges the multidimensional nature of knowledge and that perceptions vary for each individual, which implies that many different meanings are possible (Burns and Grove, 2002).

Some see qualitative research as weak and claim quantitative research methodologies are needed to ‘validate’ the knowledge provided by qualitative studies - claiming this adds to robustness. Their view is that this validation is the only way for findings to ever become part of professional knowledge.

Qualitative research can be complementary to a more statistically-orientated approach. It can illuminate issues and contribute to theory development or new ‘Gestalts’ (Ihde, 1977). Certainly, from my own experience of practice in oncology qualitative research, it does contribute significantly in terms of helping to explain large quantitative studies in detail to provide completeness. They are useful methods that can perhaps look at issues in more depth from the patient perspective.

It is a general interpretive and inductive approach that can develop knowledge, in particular about human health and the illness experience within an integral approach. The subjects of qualitative approaches provide descriptions of how they see phenomena. The researcher immersed in the data tries to understand this within the background of the possible discourses within the knowledge domain. The relationship between subject and context is a key focus to the knowledge developed. The emphasis is on the social character of knowledge as opposed to viewing knowledge as a mirror of ‘reality’ that can be quantified.

It can be useful for helping to develop knowledge in relation to communication and about roles and relationships. Some authors suggest it can empower the researcher because of its distinct characteristics (Flick et al, 2004).

Hierarchical order

Quantitative research has traditionally been referred to as the ‘gold standard’. However, Foss and Ellefsen (2002) do not recognise this hierarchical order and do not place different values on research methodologies. This links directly with knowledge since types of knowledge that result from different research sources are actually offering different contributions to knowledge. Rather than a value based on theoretical underpinning or hierarchical philosophical values, the worth should be assessed on the quality of the research - if it is applied and used by practitioners. A major strength is that as a strategy that can provide an important insight into the whole process of knowledge production (Barbour, 1999). The ‘benefits’ of qualitative studies in terms of patient care are being acknowledged.

This type of research may lead to the development of ‘nursing specific’ research methods in the future. This is somewhat ironic as the profession is increasingly multidisciplinary and collaboration is being encouraged, yet at the same time the profession is seeking its own professional status and identity. Now more than ever, the knowledge needed to care for patients is borrowed from other professions and research needs to be collaborative. It is important to add that qualitative research contributes to the knowledge of other professions.

In terms of contribution, rigour is usually assessed with regard to ‘trustworthiness’ and ‘transferability’ rather than ‘validity’ and ‘reliability’, which are means to assess quantitative research. A key issue is that in order to assess its contribution, qualitative research should be assessed in relation to its own terms, rather than ‘generalisability’, which is one of the elements used to assess quantitative research. Qualitative studies need to demonstrate their rigour in terms of a systematic study design and analysis. For example, by means of an audit trial (Holloway, 2005).

While it can be seen that underlying ideas and principles significantly influence the contribution, the second major issue identified from the literature is ‘applicability’. This is because the importance of the suitability of the research in terms of using it as evidence to inform practice is vital in relation to assessing its worth.

Applicability

Varying approaches examine different issues and concerns. But the contribution of qualitative research to that knowledge is particularly useful to patient care as it is enlightening for nurses. It can answer relevant questions and has applicability for practice.

Qualitative research is especially relevant to practice knowledge. This is perhaps an oversimplification. Its interpretation and application of this knowledge in practice is not without difficulties, as sometimes ideas conflict and competing views are often produced. The context-bound nature of the research means care is needed when considering the implications for patients generally because their unique context or situation will inevitably be different from those who have been researched.

There are other problems with the knowledge produced, as qualitative research may generate knowledge that is abstract in nature. As it is often conducted in a natural setting, the researcher is involved in and may be part of the data collection process and has to be open to the subject’s perceptions rather than attach her or his own meanings.

Data needs to create general conclusions but this also leaves the knowledge from qualitative research open to criticism as being just ‘a story’. Conversely, from experience on a practical level, nurses can see the relevance of data and there are usually some implications that will help improve practice. For example, the direct quotes of participants are presented and many practitioners find this easier to interpret rather than statistics.

Qualitative knowledge generated will never be totally precise as human beings do not always act in a logical or predictable manner. Experience means people’s views and perceptions vary over time. In addition, as new knowledge constantly develops this will cause nurses to question what was thought previously. The qualitative research process is relevant to these issues as it is a methodology that is developmental and dynamic and often there is no rigid protocol. Sometimes what is found during the process guides the research.

Nursing is interpretive. Nurses have an interest in the day-to-day experiences of patients and much qualitative research makes nurses think about and question their practice. These are important factors in advancing knowledge. Patients have a variety of perspectives on an issue that do not always fit into often numerical quantitative-type approaches.

Qualitative research is better equipped to provide information on the meaning of illness for patients and how it has affected patients’ lives. It is also frequently richer in terms of the knowledge regarding social and personal experience. 

Nurses in practice cannot be effective if they do not understand the patient’s viewpoint. They need to be able to consider the whole range of circumstances that affect the individual. Therefore, nurses can see the relevance of this research and the interest in this type of research is growing partly as a result. From experience of practice ‘action research’ is becoming popular among practitioners, many see it as emancipatory and it can include topical issues for those in practice.

There is an affinity between the knowledge needed to care for patients and qualitative research that tries to encompass the complexity of practice when establishing nursing knowledge. Despite it being a relatively new approach, nurses need to evaluate the contribution of qualitative research to advancing nursing knowledge.

Nursing is unique in terms of the knowledge used and it appears many things are better served by the qualitative rather than traditional methods. Traditional so-called scientific methods of investigation generally have their foundations in different philosophies and methods and some argue these do not always fit the dynamic and complicated world of the human sciences.

It is evident that some aspects of knowledge of care have been significantly advanced by qualitative research, especially suited to beliefs about health and illness, attitudes and behaviours.

It is also relevant that qualitative research is especially suited to when little is known about a subject. As nursing is a constantly changing profession, there are certainly many aspects that affect care about which relatively little is known. From experience of practice, nurses often see the relevance of the research.

Nurses are beginning to research in their own clinical settings especially ‘action research’ although this is not without difficulties. Qualitative research cannot be replicated but it can be audited and its worth assessed. There needs to be excellence in the design process and reporting.

As with any knowledge from any source, the knowledge is always provisional and subject to revision as new data may refute it and this is the case regardless of methodology. It makes more general conclusions using reflection and evaluation by employing a critical, rigorous stance.

Research findings must be communicated and applied if they can be considered ‘nursing knowledge’. Despite being a newer strategy and although it has its critics, it appears the contribution to nursing knowledge is significant for a number of reasons. It advances nursing knowledge considerably and, importantly, it is valuable, as good qualitative research can be used to enhance patient care.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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• Systematic Review
• Open access
• Published: 30 May 2024

Patient experiences: a qualitative systematic review of chemotherapy adherence

• Amineh Rashidi 1 ,
• Susma Thapa 1 ,
• Wasana Sandamali Kahawaththa Palliya Guruge 1 &
• Shubhpreet Kaur 1  

BMC Cancer volume  24 , Article number:  658 ( 2024 ) Cite this article

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Metrics details

Adherence to chemotherapy treatment is recognized as a crucial health concern, especially in managing cancer patients. Chemotherapy presents challenges for patients, as it can lead to potential side effects that may adversely affect their mobility and overall function. Patients may sometimes neglect to communicate these side effects to health professionals, which can impact treatment management and leave their unresolved needs unaddressed. However, there is limited understanding of how patients’ experiences contribute to improving adherence to chemotherapy treatment and the provision of appropriate support. Therefore, gaining insights into patients’ experiences is crucial for enhancing the accompaniment and support provided during chemotherapy.

This review synthesizes qualitative literature on chemotherapy adherence within the context of patients’ experiences. Data were collected from Medline, Web of Science, CINAHL, PsychINFO, Embase, Scopus, and the Cochrane Library, systematically searched from 2006 to 2023. Keywords and MeSH terms were utilized to identify relevant research published in English. Thirteen articles were included in this review. Five key themes were synthesized from the findings, including positive outlook, receiving support, side effects, concerns about efficacy, and unmet information needs. The review underscores the importance for healthcare providers, particularly nurses, to focus on providing comprehensive information about chemotherapy treatment to patients. Adopting recommended strategies may assist patients in clinical practice settings in enhancing adherence to chemotherapy treatment and improving health outcomes for individuals living with cancer.

Peer Review reports

Introduction

Cancer can affect anyone and is recognized as a chronic disease characterized by abnormal cell multiplication in the body [ 1 ]. While cancer is prevalent worldwide, approximately 70% of cancer-related deaths occur in low- to middle-income nations [ 1 ]. Disparities in cancer outcomes are primarily attributed to variations in the accessibility of comprehensive diagnosis and treatment among countries [ 1 , 2 ]. Cancer treatment comes in various forms; however, chemotherapy is the most widely used approach [ 3 ]. Patients undergoing chemotherapy experience both disease-related and treatment-related adverse effects, significantly impacting their quality of life [ 4 ]. Despite these challenges, many cancer patients adhere to treatment in the hope of survival [ 5 ]. However, some studies have shown that concerns about treatment efficacy may hinder treatment adherence [ 6 ]. Adherence is defined as “the extent to which a person’s behaviour aligns with the recommendations of healthcare providers“ [ 7 ]. Additionally, treatment adherence is influenced by the information provided by healthcare professionals following a cancer diagnosis [ 8 ]. Patient experiences suggest that the decision to adhere to treatment is often influenced by personal factors, with family support playing a crucial role [ 8 ]. Furthermore, providing adequate information about chemotherapy, including its benefits and consequences, can help individuals living with cancer gain a better understanding of the advantages associated with adhering to chemotherapy treatment [ 9 ].

Recognizing the importance of adhering to chemotherapy treatment and understanding the impact of individual experiences of chemotherapy adherence would aid in identifying determinants of adherence and non-adherence that are modifiable through effective interventions [ 10 ]. Recently, systematic reviews have focused on experiences and adherence in breast cancer [ 11 ], self-management of chemotherapy in cancer patients [ 12 ], and the influence of medication side effects on adherence [ 13 ]. However, these reviews were narrow in scope, and to date, no review has integrated the findings of qualitative studies designed to explore both positive and negative experiences regarding chemotherapy treatment adherence. This review aims to synthesize the qualitative literature on chemotherapy adherence within the context of patients’ experiences.

This review was conducted in accordance with the Joanna Briggs Institute [ 14 ] guidelines for systemic review involving meta-aggregation. This review was registered in PROSPERO (CRD42021270459).

Search methods

The searches for peer reviewed publications in English from January 2006-September 2023 were conducted by using keywords, medical subject headings (MeSH) terms and Boolean operators ‘AND’ and ‘OR’, which are presented in the table in Appendix 1 . The searches were performed in a systematic manner in core databases such including Embase, Medline, PsycINFO, CINAHL, Web of Science, Cochrane Library, Scopus and the Joanna Briggs Institute (JBI). The search strategy was developed from keywords and medical subject headings (MeSH) terms. Librarian’s support and advice were sought in forming of the search strategies.

Study selection and inclusion criteria

The systematic search was conducted on each database and all articles were exported to Endnote and duplicates records were removed. Then, title and abstract of the full text was screened by two independent reviewers against the inclusion criteria. For this review, populations were patients aged 18 and over with cancer, the phenomenon of interest was experiences on chemotherapy adherence and context was considered as hospitals, communities, rehabilitation centres, outpatient clinics, and residential aged care. All peer-reviewed qualitative study design were also considered for inclusion. Studies included in this review were classified as primary research, published in English since 2006, some intervention implemented to improve adherence to treatment. This review excluded any studies that related to with cancer and mental health condition, animal studies and grey literature.

Quality appraisal and data extraction

The JBI Qualitative Assessment and Review Instrument for qualitative studies was used to assess the methodological quality of the included studies, which was conducted by the primary and second reviewers independently. There was no disagreement between the reviews. The qualitative data on objectives, study population, context, study methods, and the phenomena of interest and findings form the included studies were extracted.

Data synthesis

The meta-aggregation approach was used to combine the results with similar meaning. The primary and secondary reviewers created categories based on the meanings and concept. These categories were supported by direct quotations from participants. The findings were assess based on three levels of evidence, including unequivocal, credible, and unsupported [ 15 , 16 ]. Findings with no quotation were not considered for synthesis in this review. The categories and findings were also discussed by the third and fourth reviewers until a consensus was reached. The review was approved by the Edith Cowan University Human Research Ethics Committee (2021–02896).

Study inclusion

A total of 4145 records were identified through a systematic search. Duplicates ( n  = 647) were excluded. Two independent reviewers conducted screening process. The remaining articles ( n  = 3498) were examined for title and abstract screening. Then, the full text screening conducted, yielded 13 articles to be included in the final synthesis see Appendix 2 .

Methodological quality of included studies

All included qualitative studies scored between 7 and 9, which is displayed in Appendix 3 . The congruity between the research methodology and the research question or objectives, followed by applying appropriate data collection and data analysis were observed in all included studies. Only one study [ 17 ] indicated the researcher’s statement regarding cultural or theoretical perspectives. Three studies [ 18 , 19 , 20 ] identified the influence of the researcher on the research and vice-versa.

Characteristics of included studies

Most of studies conducted semi-structured and in-depth interviews, one study used narrative stories [ 19 ], one study used focus group discussion [ 21 ], and one study combined focus group and interview [ 22 ] to collect data. All studies conducted outpatient’s clinic, community, or hospital settings [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. The study characteristics presented in Appendix 4 .

Review findings

Eighteen findings were extracted and synthesised into five categories: positive outlook, support, side effects, concern about efficacy and unmet information needs.

Positive outlook

Five studies discussed the link between positivity and hope and chemotherapy adherence [ 19 , 20 , 23 , 27 , 28 ]. Five studies commented that feeling positive and avoid the negativity and worry could encourage people to adhere in their mindset chemotherapy: “ I think the main thing for me was just keeping a positive attitude and not worrying, not letting myself worry about it ” [ 20 ]. Participants also considered the positive thoughts as a coping mechanism, that would help them to adhere and complete chemotherapy: “ I’m just real positive on how everything is going. I’m confident in the chemo, and I’m hoping to get out of her soon ” [ 23 ]. Viewing chemotherapy as part of their treatment regimen and having awareness of negative consequences of non-adherence to chemotherapy encouraged them to adhere chemotherapy: “ If I do not take medicine, I do not think I will be able to live ” [ 28 ]. Adhering chemotherapy was described as a survivor tool which helped people to control cancer-related symptoms: “ it is what is going to restore me. If it wasn’t this treatment, maybe I wasn’t here talking to you. So, I have to focus in what he is going to give me, life !” [ 27 ]. Similarly, people accepted the medical facts and prevent their life from worsening; “ without the treatment, it goes the wrong way. It is hard, but I have accepted it from the beginning, yes. This is how it is. I cannot do anything about it. Just have to accept it ” [ 19 ].

Finding from six studies contributed to this category [ 20 , 21 , 23 , 24 , 25 , 29 ]. Providing support from families and friends most important to the people. Receiving support from family members enhanced a sense responsibility towards their families, as they believed to survive for their family even if suffered: “ yes, I just thought that if something comes back again and I say no, then I have to look my family and friends in the eye and say I could have prevented it, perhaps. Now, if something comes back again, I can say I did everything I could. Cancer is bad enough without someone saying: It’s your own fault!!” [ 29 ]. Also, emotional support from family was described as important in helping and meeting their needs, and through facilitation helped people to adhere chemotherapy: “ people who genuinely mean the support that they’re giving […] just the pure joy on my daughter’s face for helping me. she was there day and night for me if I needed it, and that I think is the main thing not to have someone begrudgingly looking after you ” [ 20 ]. Another study discussed the role family, friends and social media as the best source of support during their treatment to adhere and continue “ I have tons of friends on Facebook, believe it or not, and it’s amazing how many people are supportive in that way, you know, just sending get-well wishes. I can’t imagine going through this like 10 years ago whenever stuff like that wasn’t around ” [ 23 ]. Receiving support from social workers was particularly helpful during chemotherapy in encouraging adherence to the chemotherapy: “ the social worker told me that love is courage. That was a huge encouragement, and I began to encourage myself ” [ 25 ].

Side effects

Findings from five studies informed this category [ 17 , 21 , 22 , 25 , 26 ]. Physical side effects were described by some as the most unpleasure experience: “ the side effects were very uncomfortable. I felt pain, fatigue, nausea, and dizziness that limited my daily activities. Sometimes, I was thinking about not keeping to my chemotherapy schedule due to those side effect ” [ 17 ]. The impact of side effects affected peoples’ ability to maintain their independence and self-care: “ I couldn’t walk because I didn’t have the energy, but I wouldn’t have dared to go out because the diarrhoea was so bad. Sometimes I couldn’t even get to the toilet; that’s very embarrassing because you feel like you’re a baby ” [ 26 ]. Some perceived that this resulted in being unable to perform independently: “ I was incredibly weak and then you still have to do things and you can’t manage it ” [ 22 ]. These side effect also decreased their quality of life “ I felt nauseated whenever I smelled food. I simply had no appetite when food was placed in front of me. I lost my sense of taste. Food had no taste anymore ” [ 25 ]. Although, the side effects impacted on patients´ leisure and free-time activities, they continued to undertake treatment: “ I had to give up doing the things I liked the most, such as going for walks or going to the beach. Routines, daily life in general were affected ” [ 21 ].

Concern about efficacy

Findings form four studies informed this category [ 17 , 18 , 24 , 28 ]. Although being concerned about the efficacy of the chemotherapy and whether or not chemotherapy treatment would be successful, one participant who undertook treatment described: “the efficacy is not so great. It is said to expect about 10% improvement, but I assume that it declines over time ” [ 28 ]. People were worried that such treatment could not cure their cancer and that their body suffered more due to the disease: “ I was really worried about my treatment effectiveness, and I will die shortly ” [ 17 ]. There were doubts expressed about remaining the cancer in the body after chemotherapy: “ there’s always sort of hidden worries in there that whilst they’re not actually taking the tumour away, then you’re wondering whether it’s getting bigger or what’s happening to it, whether it’s spreading or whatever, you know ” [ 24 ]. Uncertainty around the outcome of such treatment, or whether recovering from cancer or not was described as: “it makes you feel confused. You don’t know whether you are going to get better or else whether the illness is going to drag along further” [ 18 ].

Unmet information needs

Five studies contributed to this category [ 17 , 21 , 22 , 23 , 26 ]. The need for adequate information to assimilate information and provide more clarity when discussing complex information were described. Providing information from clinicians was described as minimal: “they explain everything to you and show you the statistics, then you’re supposed to take it all on-board. You could probably go a little bit slower with the different kinds of chemo and grappling with these statistics” [ 26 ]. People also used the internet search to gain information about their cancer or treatments, “I’ve done it (consult google), but I stopped right away because there’s so much information and you don’t know whether it’s true or not ” [ 21 ]. The need to receive from their clinicians to obtain clearer information was described as” I look a lot of stuff up online because it is not explained to me by the team here at the hospital ” [ 23 ]. Feeling overwhelmed with the volume of information could inhibit people to gain a better understanding of chemotherapy treatment and its relevant information: “ you don’t absorb everything that’s being said and an awful lot of information is given to you ” [ 22 ]. People stated that the need to know more information about their cancer, as they were never dared to ask from their clinicians: “ I am a low educated person and come from a rural area; I just follow the doctor’s advice for my health, and I do not dare to ask anything” [ 17 ].

The purpose of this review was to explore patient’s experiences about the chemotherapy adherence. After finalizing the searches, thirteen papers were included in this review that met the inclusion criteria.

The findings of the present review suggest that social support is a crucial element in people’s positive experiences of adhering to chemotherapy. Such support can lead to positive outcomes by providing consistent and timely assistance from family members or healthcare professionals, who play vital roles in maintaining chemotherapy adherence [ 30 ]. Consistent with our study, previous research has highlighted the significant role of family members in offering emotional and physical support, which helps individuals cope better with chemotherapy treatment [ 31 , 32 ]. However, while receiving support from family members reinforces individuals’ sense of responsibility in managing their treatment and their family, it also instils a desire to survive cancer and undergo chemotherapy. One study found that assuming self-responsibility empowers patients undergoing chemotherapy, as they feel a sense of control over their therapy and are less dependent on family members or healthcare professionals [ 33 ]. A qualitative systematic review reported that support from family members enables patients to become more proactive and effective in adhering to their treatment plan [ 34 ]. This review highlights the importance of maintaining a positive outlook and rational beliefs as essential components of chemotherapy adherence. Positive thinking helps individuals recognize their role in chemotherapy treatment and cope more effectively with their illness by accepting it as part of their treatment regimen and viewing it as a tool for survival. This finding is supported by previous studies indicating that positivity and positive affirmations play critical roles in helping individuals adapt to their reality and construct attitudes conducive to chemotherapy adherence [ 35 , 36 ]. Similarly, maintaining a positive mindset can foster more favourable thoughts regarding chemotherapy adherence, ultimately enhancing adherence and overall well-being [ 37 ].

This review identified side effects as a significant negative aspect of the chemotherapy experience, with individuals expressing concerns about how these side effects affected their ability to perform personal self-care tasks and maintain independent living in their daily lives. Previous studies have shown that participants with a history of chemotherapy drug side effects were less likely to adhere to their treatment regimen due to worsening symptoms, which increased the burden of medication side effects [ 38 , 39 ]. For instance, cancer patients who experienced minimal side effects from chemotherapy were at least 3.5 times more likely to adhere to their treatment plan compared to those who experienced side effects [ 40 ]. Despite experiencing side effects, patients were generally willing to accept and adhere to their treatment program, although one study in this review indicated that side effects made some patients unable to maintain treatment adherence. Side effects also decreased quality of life and imposed restrictions on lifestyle, as seen in another study where adverse effects limited individuals in fulfilling daily commitments and returning to normal levels of functioning [ 41 ]. Additionally, unmet needs regarding information on patients’ needs and expectations were common. Healthcare professionals were considered the most important source of information, followed by consultation with the internet. Providing information from healthcare professionals, particularly nurses, can support patients effectively and reinforce treatment adherence [ 42 , 43 ]. Chemotherapy patients often preferred to base their decisions on the recommendations of their care providers and required adequate information retention. Related studies have highlighted that unmet needs among cancer patients are known factors associated with chemotherapy adherence, emphasizing the importance of providing precise information and delivering it by healthcare professionals to improve adherence [ 44 , 45 ]. Doubts about the efficacy of chemotherapy treatment, as the disease may remain latent, were considered negative experiences. Despite these doubts, patients continued their treatment, echoing findings from a study where doubts regarding efficacy were identified as a main concern for chemotherapy adherence. Further research is needed to understand how doubts about treatment efficacy can still encourage patients to adhere to chemotherapy treatment.

Strengths and limitation

The strength of this review lies in its comprehensive search strategy across databases to select appropriate articles. Additionally, the use of JBI guidelines provided a comprehensive and rigorous methodological approach in conducting this review. However, the exclusion of non-English studies, quantitative studies, and studies involving adolescents and children may limit the generalizability of the findings. Furthermore, this review focuses solely on chemotherapy treatment and does not encompass other types of cancer treatment.

Conclusion and practical implications

Based on the discussion of the findings, it is evident that maintaining a positive mentality and receiving social support can enhance chemotherapy adherence. Conversely, experiencing treatment side effects, concerns about efficacy, and unmet information needs may lead to lower adherence. These findings present an opportunity for healthcare professionals, particularly nurses, to develop standardized approaches aimed at facilitating chemotherapy treatment adherence, with a focus on providing comprehensive information. By assessing patients’ needs, healthcare professionals can tailor approaches to promote chemotherapy adherence and improve the survival rates of people living with cancer. Raising awareness and providing education about cancer and chemotherapy treatment can enhance patients’ understanding of the disease and its treatment options. Utilizing videos and reading materials in outpatient clinics and pharmacy settings can broaden the reach of educational efforts. Policy makers and healthcare providers can collaborate to develop sustainable patient education models to optimize patient outcomes in the context of cancer care. A deeper understanding of individual processes related to chemotherapy adherence is necessary to plan the implementation of interventions effectively. Further research examining the experiences of both adherent and non-adherent patients is essential to gain a comprehensive understanding of this topic.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. on our submission system as well.

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First author (AR) and second author (ST) conceived the review and the second author oversight for all stages of the review provided by the second author. All authors (AR), (ST), (WG) and (SK) undertook the literature search. Data extraction, screening the included papers and quality appraisal were undertaken by all authors (AR), (ST), (WG) and (SK). First and second authors (AR) and (ST) analysed the data and wrote the first draft of the manuscript and revised the manuscript and all authors (AR), (ST), (WG) and (SK) approved the final version of the manuscript.

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Correspondence to Amineh Rashidi .

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The review was approved by the Edith Cowan University Human Research Ethics Committee (2021–02896). A proposal for the systematic review was assessed by the Edith Cowan University Human Research Ethics Committee and deemed not appropriate for full ethical review. However, a Data Management Plan (2021-02896-RASHIDI) was approved and monitored as part of this procedure. Raw data was extracted from the published manuscripts and authors could not identify individual participants during or after this process.

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Rashidi, A., Thapa, S., Kahawaththa Palliya Guruge, W. et al. Patient experiences: a qualitative systematic review of chemotherapy adherence. BMC Cancer 24 , 658 (2024). https://doi.org/10.1186/s12885-024-12353-z

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The factors of job crafting in emergency nurses: regression models versus qualitative comparative analysis

• Yu Wang 2 ,
• Qiaofang Yang 2 ,
• Luwen Wang 3 ,
• Qingwei Zhang 2 &
• Yingli Li 1  

BMC Nursing volume  23 , Article number:  369 ( 2024 ) Cite this article

Metrics details

Job crafting is defined as a series of proactive behaviors exhibited by employees in order to balance work resources and needs, which has a significant positive impact on the nurses. It is necessary to find the core factors that influence the job crafting, as emergency nurses deal with the most complex tasks, so as to improve their job satisfaction.

To investigate the core factors of job crafting among emergency nurses.

A cross-sectional design was used in the study. A total of 255 nurses were recruited from two hospitals in Zhengzhou and Shenzhen, China in December 2021. 255 nurses completed an online questionnaire. Hierarchical regression models and fsQCA models were used to explore the factors influencing job crafting among emergency nurses and helped us to identify core factors.

The hierarchical regression model and the fsQCA model found that the occupational benefit, psychological empowerment, and research experience were the core factors affecting their job crafting. Job involvement was not significant in the regression model, but the QCA model indicated that it needs to be combined with other factors to impact on job crafting. The QCA model uncovered seven key conditional configurations that led to high and low job crafting among emergency nurses, explaining 80.0% of the results for high job crafting and 82.6% of the results for the low job crafting, respectively.

Conclusions

The results of this study provide valuable insights into the job crafting experienced by emergency nurses. Junior emergency nurses should be granted a high level of psychological empowerment without assigning them overly complex tasks, such as research tasks, as these challenges can stop their job crafting. Intermediate and senior emergency nurses, on the other hand, can be assigned research tasks coupled with high psychological empowerment to enhance their job crafting.

Peer Review reports

Introduction

As diseases become more complex and technology evolves rapidly, nursing work is changing, which has posed new tasks and demands for the nurses these days. It was noted that employees should work stepwise in the traditional human resource management system. However, in recent years, researchers have encouraged employees to change their jobs in line with the reality of their work. ‘Job crafting’ is an employee-focused approach to job redesigning [ 1 ].Job crafting is defined as a series of proactive behaviors exhibited by employees in order to balance work resources and needs, with the aim of aligning their work with their own preferences, motivations, and passions [ 2 ].YEPES-BALDÓ surveyed 530 Spanish nurses and found that the job crafting score was 3.17 ± 0.66 [ 3 ]. BAGHDADI conducted a survey among 594 nurses in Saudi Arabia, reporting the job crafting score was 3.54 ± 0.50 [ 4 ]. In summary, it is observed that there are variations in the level of job crafting among nurses, which is generally at a moderate level.

Wrzesniewski first proposed job crafting, suggesting that employees could engage in job crafting in three dimensions: cognitive, task, and relational [ 1 ]. Job demand-resource was further integrated by Tims and Bakker, and it suggested that all working conditions can be classified as job demands or resources [ 5 , 6 ], which includes four dimensions: reducing hindering job demands, increasing challenging job demands, increasing structural job resources and increasing social job resources. Promoting-focused job crafting has been shown to be positively related to job involvement and satisfaction, and negatively related to burnout, depression, and illness [ 7 , 8 ]. Furthermore, studies conducted in the field of career development have shown that promotion-focused job crafting is positively related to career competency and career promotion [ 9 ]. Emergency nurses encounter more complex clinical environments and problems than other departments. The emergency department serves as the first line of defense in hospitals to save patients’ lives. However, it is also the department where adverse events such as nurse-patient disputes and complaints are most likely to occur. According to reports, emergency nurses experience higher occupational stress than other departments, which can lead to dissatisfaction with nursing work among nurses, and even turnout [ 10 ]. This, in turn, will result in a shortage of emergency nurses, further increasing the occupational stress on those remaining in the emergency department. Furthermore, nurses face additional research tasks and pressures in addition to solving clinical problems in China. So, we defined emergency nurse’s hindering and challenging demands as a research experience, professional position, number of night shifts, etc.

Autonomy is an important work feature, as it can be associated with a better capacity to handle stress [ 6 ]. Structural and psychological empowerment are two categories of authority that can give nurses some autonomy at work. Psychological empowerment as an extension of structural empowerment, focuses on the internal feelings of an individual toward organizational empowerment. Spritzer defined psychological empowerment as a sense of control over one’s work environment, which includes the dimensions of impact, meaning, competence, and self-determination [ 11 ]. Increased psychological empowerment of nurse has been shown to lead to job satisfaction and more positive organizational behavior [ 12 ]. The sense of control over their work behaviors can be increased if nurses have a stronger psychological empowerment. They feel more confident acquiring the required knowledge and skills to do their job, and also have a greater perception of their impact on organizational management, decision-making, and performance [ 13 ]. This helps nurses take the initiative toward rebuilding the organizational relationships and actively redesigning work content to address the challenges on the job [ 14 ]. Therefore, we defined the work resources as the level of psychological empowerment given to nurses by their organizations.

Occupational benefits are internal, personal motivators that nurses blend with their good work experiences and cognitive assessments [ 15 ]. It can also result in greater job satisfaction, the promotion of creative behavior, and a reduction in burnout and turnover intentions [ 16 ]. Occupational benefits reflect how satisfied employees are with the organization’s management, which has a significant impact on whether or not they want to stay. According to the JD-R theory, nurses’ job crafting has resulted in favorable occupational benefits for them. Emergency nurses are often faced with critically ill patients, and their nursing work demands a high level of expertise. Correspondingly, the rehabilitation of patients can bring them a sense of accomplishment and self-worth, providing a strong sense of occupational benefits [ 17 ]. In order to continually obtain this feeling, emergency nurses may engage in job crafting to reshape their work.Their practice reflects how they view the rewards and advantages of their profession, which supports their involvement in their work.

Job involvement, as a type of work commitment, is the psychological recognition of an individual’s work. It is more linked with the satisfaction of internal needs.From the perspective of an organization, Pfeffe stated that job involvement is crucial for motivating employees [ 18 ]. However, there is a disagreement at the moment on whether or not job involvement affects individual performance [ 19 ]. On the other hand, some studies have shown that job involvement is the only variable associated with the nurses’ intention to continue working in their current position, not withstanding their work environment [ 20 ]. When demands exceed resources, employees feel immense pressure, leading to negative emotions and affecting job involvement [ 21 ]. Thus, this suggests that work involvement may arise from job crafting. From this, we hypothesized that emergency nurses with high levels of job involvement may pay more attention to the details of work, which in turn identifies work processes or tasks that need to be improved and triggers job crafting. Therefore, it is worth to be further analyzed whether job involvement would have an impact on job crafting.

Due to the growing complexity of the nurses’ work, one antecedent variable cannot fully explain the causes of the findings. Regression model could only examine the net effect of one of the independent variables on outcomes rather than exploring complex causal relationships between the antecedent variables [ 22 ]. The configuration theory is based on the idea of sets, as it allows the analysis of configuration effects generated by multiple conditional variables of the organization’s management [ 23 ]. This study used both regression modeling and fsQCA modeling. fsQCA adds depth by showing complex paths to job crafting, where variables can combine differently to explain outcomes. Even non-significant regression variables can impact job crafting in fsQCA. Combining both methods gives a comprehensive view of why emergency nurses reshape their work, revealing intrinsic motivations. Therefore, the aim of our study is to explore the core factors influencing job crafting in emergency nurses through a hierarchical regression model and fuzzy set qualitative comparative analysis.

A convenience sampling method was applied in the study, an online questionnaire was sent to the emergency nurses through a mobile program in the cities of Shenzhen and Zhengzhou, China, in March 2023. The inclusion criteria were: working in the emergency department; working for more than 1 year; voluntary participation, and informed consent. The exclusion criteria were: trainee nurses, vacation nurses. Based on sample size estimation principles, this study calculated the required sample size to be 5–10 times the number of independent variables. We calculated a required sample of 110–220, given 22 independent variables. Considering a 20% invalid questionnaire rate, we distributed 280 questionnaires.

Instruments

General information questionnaire.

The general information questionnaire was designed by the researcher and includes gender, age, monthly income, etc.

Perceived occupational benefits Questionnaire[ 24 ]

The questionnaire contains 5 dimensions and 29 items. The questionnaire had a 5-point Likert scale, with 1 indicating “strongly disagree” and 5 indicating “strongly agree”. No reverse scoring items were available for the scale. The scores represented the nurses’ perception of professional benefits along with a Cronbach’s alpha of 0.96 in the study.

Job crafting Scale[ 2 ]

With 21 items, the scale is scored on a 5-point Likert scale. Here, higher scores indicate better job crafting. The scale comprises four dimensions: increasing structural work resources, increasing social work resources, increasing challenging work demands, and decreasing hindering work demands. The Cronbach’s alpha coefficient is 0.93 in the study.

Psychological empowerment Scale[ 25 ]

This scale includes 4 dimensions: work meaning, autonomy, self-efficacy, and work influence. Each dimension has 3 items under it, totaling 12 items. The 5-point Likert scale is used, where a higher total score indicates a higher degree of PE. The Cronbach’s alpha coefficient of this scale was tested to be 0.94.

Job involvement Scale[ 26 ]

The scale consists of 10 items on a 5-point Likert scale, with items 2 and 7 being reverse-scored. The level of score indicates the extent of job involvement. The Cronbach’s alpha coefficient of the scale in the study was tested to be 0.82.

Date collection

Researchers contacted nursing management personnel from various hospitals to obtain their consent and support. Nurses were informed about the research objectives, significance, and principles of anonymity and then shared the questionnaire links to those who agreed to participate. The survey was set up through a survey platform, and to ensure quality, all questions were mandatory. Each nurse gets the link via WeChat and is limited to one response. After the survey concluded, a total of 280 questionnaires were collected. Among them, those questionnaires with identical responses for all items and completion times less than 3 min were excluded. Ultimately, 255 questionnaires were valid, resulting in an effective response rate of 91.07%.

SPSS 24.0 software was used to analyze the data; it was described using frequencies, percentages, or means ± standard deviations, depending on the data type. Comparisons between groups were analyzed using independent samples t-test or one-way ANOVA with a test level of α = 0.05. The paper looks at the amount of variance explained by demographic factors on Job crafting(R 2 ) in the one-way analysis of the first level of the hierarchical regression model. In the second level of the hierarchical regression model, other factors that may affect job crafting are integrated to observe the amount of variance explained variance (ΔR 2 ).

Qualitative comparative analysis (QCA ) is a new method for analysing complex causal relationships in histological problems based on Boolean algebra and set theory.QCA is a new method that combines quantitative and qualitative analysis, providing strong support for studying the configuration problem. Based on variable type, QCA is divided into csQCA, mvQCA, and fsQCA. fsQCA has been selected in this paper to analyze the configuration effects of job crafting factors among emergency nurses. QCA requires the calibration of the original data into the set. Calibration is the process of assigning sets to cases. Sociodemographic variables that were meaningful for univariate analysis were included in the analysis of the fsQCA model. In this case (Research experience: 0 = None; 1 = have), (Professional Position: 0 = Advanced; 0.5 = Intermediate; 1 = Junior). The fuzzy set requires setting three critical values according to the theoretical or conceptual settings: fully affiliated, crossover, and fully unaffiliated, and with the affiliation of the transformed set between 0 and 1. For the continuous variables, the 0.05th, 0.5th and 0.95th percentile of the data were taken and substituted into the Calibrate function (x, fully in, crossover, fully out).It was analyzed whether the antecedent variable was necessary for job crafting in emergency nurses before the sufficient analysis. If the antecedent variable was greater than 0.9 [ 27 ], it was considered necessary. A truth table for sufficient analysis was constructed using fsQCA 3.0, with consistency set to 0.8 and frequency set to 1. If variables appear in both parsimonious and intermediate solutions, they are called core conditions. If they only appear in intermediate solutions, they are called edge conditions [ 28 ].

Descriptive and univariate analysis

A total of 255 nurses were included, of which 228 (89.4%) were female and up to 209 (82.0%) had no research experience. The results demonstrated that research experience and job position were considered influential variables for job crafting among emergency nurses. Also, the differences were all statistically significant ( p  < 0.05), as seen in Table  1 .

Hierarchical regression models

A variance variation of 0.047 was obtained after entering the sociodemographic factors into the regression model, with significance in the one-way analysis. In the paper, it was shown that nurses with no research experience had a lower job crafting than nurses with research experience( P <0.05) In the second step, three psychological variables were added, and it was found that a variance variation of 0.283 was obtained. The significant variables were research experience (β=-0.135, p  < 0.05), perceived occupational benefits (β = 0.177, p  < 0.05), and psychological empowerment (β = 0.317, p  < 0.001), as can be seen in Table  2 .

Necessary analysis

The consistency score was considered necessary for evaluating whether the antecedent variable was available as the outcome variable. The consistency score is similar to the significance of the coefficient in a regression model. It represents the extent to which the outcome has to rely on the antecedent variable. In this study, no variable existed as a necessary condition since none of the antecedent variables reached 0.9. Refer to Table  3 for details.

Sufficient analysis

Six conditional configurations that generated high job crafting and six conditional configurations that generated low job crafting were analyzed together. The twelve configurations were sufficient conditions to constitute high and low job crafting for the emergency nurses. The overall solution coverage of high and low job crafting was 0.800 and 0.826, as seen in Table  4 . This shows that the twelve configurations explain 80% of the results for high job crafting and 82.6% for low. The paper remove unique coverage of less than 0.1 for the configuration because it was hard to cover 10% of the samples. Three configurations of high job crafting and four configurations of low job crafting for emergency nurses are obtained.The raw coverage of H1 was 0.106 in the high job crafting configuration, which meant that this configuration could explain 10.6% of the sample.Among the low job crafting configurations, it was found that L2 had the highest raw coverage. The configurations are elaborated as follows: ① H1: high psychological empowerment + high job involvement + junior professional position + no research experience. ② H2: high psychological empowerment + high job involvement + have research experience. ③ H3:high job involvement + high perceived occupational benefits + senior professional position + no research experience. ④ L1: low perceived occupational benefits + senior professional position + no research experience. ⑤ L2: low psychological empowerment + senior professional position + no research experience. ⑥ L3: high job involvement + senior professional position + low perceived occupational benefits. ⑦ L4: low job involvement + senior professional position + research experience.The most relevant pathway or combination to explain low job crafting was L2 (raw coverage = 0.038; consistency = 0.879), which explained 64.3% of the cases. The most relevant pathway or combination to explain high job crafting was H1 (raw coverage = 0.106; consistency = 0.798), which explained 60.1% of the cases.Refer to Table 4 for details.

Discussions

This study explored the effects of sociodemographic variables, psychological empowerment, occupational benefits, and job involvement, on job crafting among the emergency nurses. The majority of existing studies have concentrated on linear regression models. This neglects the complement of other methods, like the fsQCA model [ 29 ]. The study overlooked the synergy between factors if the researcher focuses only on regression models. In helping the researcher to construct intervention plans, the fsQCA models with different pathways formed by the synergy between factors are particularly important [ 30 ]. Regression models indicated that research experience, psychological empowerment and occupational benefits were associated with job crafting, which is consistent with existing research [ 31 ]. Based on the results of the fsQCA analysis, no necessary conditions for job crafting were found. In terms of the sufficiency analysis, it was found that H1 has the highest coverage, explaining 10.6% of cases after comparing the raw coverage of the three configurations that stimulate high job crafting among emergency nurses. This suggested that the majority of emergency nurses who exhibit high job crafting are influenced by the conditions present in H1, and psychological empowerment is the core condition. For the four paths of the low job crafting, L2 has the highest raw coverage. This indicated that nurses with junior professional position and no research experience who lack sufficient psychological empowerment are unlikely to engage in job crafting. Once again, psychological empowerment emerges as a core condition in this path, reinforcing the results obtained through regression analysis.

We can discuss the professional position and research experience from “increasing the challenging work demands” and “lessening hindering work demands”, based on the job crafting theory [ 6 ]. Since junior emergency nurses were newly exposed to clinical nursing work along with the special characteristics of emergency nursing, they faced higher work stress when addressing clinical problems that were primarily acute and serious. The problems mentioned above can also serve as a cause of stress that constantly reduces self-efficacy in the emergency care process. Additionally, the junior emergency nurses lack knowledge and experience in nursing research when they were students, and the research ability of nurses working in clinical settings is low in China [ 32 ]. Most nurses are under pressure to perform the job guided by the goal of job position improvement [ 33 ], and the inner drive to explore and solve research problems was insufficient [ 34 ]. If the nurses were assigned to research work by the organization, the work demands would inevitably exceed their abilities, leading to work hindrances. Junior nurses experience less pressure about job position improvement, and they may be fearful of research work. This may create defensive job crafting by lessening hindering work demands. Although this helps them to accomplish their clinical goals, it may reduce their work motivation and job involvement. The second dimension of job crafting is about increasing the challenging work demands. It has been revealed that a lack of challenging work may lead to absences and job dissatisfaction. Research tasks, as a challenge, may lead to the creation of job crafting for advanced practice nurses. By expanding task boundaries and increasing challenging work demands, the nurses have contributed to the organization. It was shown that challenge demands were associated with goal achievement and work motivation [ 6 ]. The H2, with research experience as a core condition, confirmed that the high job crafting was associated with the individuals’ promotion of “challenge demands”.

The high level of psychological empowerment in nurses was a core condition that influenced the level of job crafting on both core configurations (H1&L2). From regression models, it was also seen that psychological empowerment was a core element affecting job crafting (β = 0.317, p  < 0.001). This means that the job crafting gradually increased with the psychological empowerment. The self-determination theory suggests that autonomous motivational orientation, as opposed to control motivational orientation, would be more beneficial in addressing the basic psychological needs. A high level of psychological empowerment as a variable of autonomous motivational orientation could enhance individual job performance and job ability [ 35 ]. The resource conservation theory states that employees can experience higher psychological security as they sense higher levels of psychological empowerment through a cycle of resource loss and gain spirals. These positive job resources assist them in conserving and building more resources to cope with the prospect of poor career outcomes and job demands [ 36 ], which precisely confirm the findings of this paper.

In the emergency departments, nurses face a large number of job challenges on a daily basis. The ability of nurses to cope better with these challenges is closely related to perceived occupational benefits. Emergency nurses who perceive high levels of empowerment were better able to respond to the work challenges [ 37 ]. With increased resources for employees to do their jobs, a positive impact was bound to be seen on their psychological empowerment [ 14 ]. By acquiring and conserving resources, nurses are most likely to achieve the most appropriate match between people and job demands. Nurses who are motivated and empowered can develop more job crafting [ 38 ]. If this goal is achieved, it would increase nurses’ satisfaction and thus would promote job crafting resulting in a virtuous circle. To summarize, the results of both the QCA and the regression model demonstrated that the psychological empowerment was a core condition that influenced job crafting among the emergency nurses. From H1, H2 and L2, it can also be proved that high psychological empowerment was the core condition for a high job crafting, regardless of whether or not they had done clinical research work.

The identification with one’s job based on its potential to meet one’s needs and expectations is called job involvement. The job involvement has been mentioned in the literature as a reason why nurses feel so committed to their jobs [ 39 ]. Nurses with a high level of job involvement deliberately consider their work an important part of their lives. Whether or not they can feel good about themselves is closely related to their personal work. Thus, a healthy management structure should consider job involvement as an important predictor of organizational productivity. This attitude of nurses toward their jobs should be promoted [ 20 ]. However, the regression model shows that job involvement does not influence job crafting. Meanwhile, the H1-H3 all indicated that job involvement was an impact on job crafting, and two of these paths indicated that job involvement was a core condition for a high job crafting. Job involvement is influenced by the worker’s identification with the job they are doing. This is, in turn, derived from whether the job can meet the needs of the worker or not. This means that once a nurse has job involvement, a balance between job resources and demands can be reached and the nurse’s job crafting would be suspended. The QCA model revealed that job involvement may need to have an impact on job crafting in conjunction with the other factors. Several studies have also shown that job involvement is correlated with psychological empowerment [ 40 ]. The impact of nurses’ job involvement on their job crafting needs to be further explored.

The occupational benefits of nurses is a cognitive assessment of their feelings about the content of their work, which comes from their internal traits and the external work environment [ 41 ]. Job crafting is a positive behavior for individuals to balance job demands and resources. It can help individuals use available job resources to cope with the stress of job demands and achieve higher levels of job performance [ 42 ]. It enables the nurses to perceive occupational benefits. The H3 demonstrated that both the occupational benefits and the job involvement must be maintained at high levels for junior emergency nurses to lead to a high job crafting. The existence of a low occupational benefits and job involvement will inevitably lead to low job crafting, as seen from L3 and L4. When junior emergency nurses perceive occupational benefits, it may lead to more job autonomy which results in increased psychological recognition of their work [ 43 ]. High levels of job involvement allow nurses to be fully immersed in their work, improving efficiency and quality. With increased efficiency and quality, nurses can obtain more job performance and achievement, in turn bringing them stronger occupational benefits.

Limitations

Although the study obtained some results that could be effective in improving the job crafting for the emergency nurses, the limitations of the study are as follows. First, this cross-sectional survey was conducted with emergency nurses in China, which may limit the extension of these results to other regions. And convenient sampling techniques and the non-calculated sample size of the study limits the generalizability. Secondly, the cross-sectional study does not allow for the detection of possible changes in the levels of job crafting in each participant over time. Lastly, the data were collected from participants using self-report measures, and thus may not reflect their true feelings.

Implications for the profession

The findings of the paper provided two important insights for motivating job crafting in emergency nurses. Firstly, we recognized challenge demands have a significant contribution to job crafting. As such, nursing managers in emergency departments should assign nurses challenging tasks, such as participating in nursing research. These challenges not only stimulate nurses’ potential but also foster their personal growth. However, it’s crucial to align these challenging work demands with commensurate rewards, such as promotion in position, bonus allocation, etc. Meanwhile, it is necessary to give adequate psychological empowerment and cultivate a proper understanding of challenge demands such as research tasks to inspire job crafting in the nurses. This approach will encourage nurses to more actively engage in job crafting, continually improving their work efficiency. Secondly, emergency nursing managers should should carry out a layered method and focus on the main job demands of the nurses at different levels. Junior nurses experience more difficulty in facing the challenges brought by clinical work, which may not deal with the busy and ever-changing work of the emergency department. Thus, special attention should be paid to their psychological endurance and work stress to prevent job burnout and turnover when assigning research or other challenging tasks to them. For senior nurses, management should provide more psychological empowerment, making them feel trusted and respected by the organization. An organization that meets the staff needs and promotes staff development on priority allows nurses to perceive occupational benefits, enhances their sense of emotional belonging, and lastly, boosts the job crafting with a rise in job involvement [ 44 ]. Nurses will be more proactive in participating in work planning and implementation, actively adjusting and optimizing work processes to better meet the various challenges in the emergency department.

The study explored various influencing factors on the job crafting of emergency nurses through hierarchical regression and fsQCA models. Both the models have demonstrated that research experience, psychological empowerment, and occupational benefits were predictors of job crafting, along with high levels of psychological empowerment being the core condition on the higher paths (H1 & S2). Based on research findings, junior emergency nurses should be granted a high level of psychological empowerment without assigning them overly complex tasks, such as research tasks, as these challenges can stop their job crafting. Intermediate and senior emergency nurses, on the other hand, can be assigned research tasks coupled with high psychological empowerment to enhance their job crafting.

Data availability

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

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This work was supported by grants from Henan Provincial Medical Science and Technology Research Project(LHGJ20200109);and Jiaxing University Research Fund (CD70522005).

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Department of Nursing, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China

Yu Wang, Qiaofang Yang & Qingwei Zhang

Heart Failure Ward, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China

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Contributions

Yu Wang : Preparation, creation and/or presentation of the published work, specifically writing the initial draft (including substantive translation). Development or design of methodology; creation of models. Qiaofang Yang : Provision of study materials, participants, instrumentation, computing resources, or other analysis tools. Luwen Wang : Visualization, Investigation. Qingwei Zhang: Application of statistical, mathematical, computational, or other formal techniques to analyze or synthesize study data, and acquisition of the financial support for the project leading to this publication. Yingli Li : Writing- Reviewing and Editing, and Funding acquisition.

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Wang, Y., Yang, Q., Wang, L. et al. The factors of job crafting in emergency nurses: regression models versus qualitative comparative analysis. BMC Nurs 23 , 369 (2024). https://doi.org/10.1186/s12912-024-02035-3

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The strengths and weaknesses of quantitative and qualitative research: what method for nursing?

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• PMID: 7822608
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The overall purpose of research for any profession is to discover the truth of the discipline. This paper examines the controversy over the methods by which truth is obtained, by examining the differences and similarities between quantitative and qualitative research. The historically negative bias against qualitative research is discussed, as well as the strengths and weaknesses of both approaches, with issues highlighted by reference to nursing research. Consideration is given to issues of sampling; the relationship between the researcher and subject; methodologies and collated data; validity; reliability, and ethical dilemmas. The author identifies that neither approach is superior to the other; qualitative research appears invaluable for the exploration of subjective experiences of patients and nurses, and quantitative methods facilitate the discovery of quantifiable information. Combining the strengths of both approaches in triangulation, if time and money permit, is also proposed as a valuable means of discovering the truth about nursing. It is argued that if nursing scholars limit themselves to one method of enquiry, restrictions will be placed on the development of nursing knowledge.

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Mixed Methods in Nursing Research : An Overview and Practical Examples

Ardith z. doorenbos.

School of Nursing, University of Washington, USA, Box 357266, Seattle, WA 98177

Mixed methods research methodologies are increasingly applied in nursing research to strengthen the depth and breadth of understanding of nursing phenomena. This article describes the background and benefits of using mixed methods research methodologies, and provides two examples of nursing research that used mixed methods. Mixed methods research produces several benefits. The examples provided demonstrate specific benefits in the creation of a culturally congruent picture of chronic pain management for American Indians, and the determination of a way to assess cost for providing chronic pain care.

Introduction

Mixed methods is one of the three major research paradigms: quantitative research, qualitative research, and mixed methods research. Mixed methods research combines elements of qualitative and quantitative research approaches for the broad purpose of increasing the breadth and depth of understanding. The definition of mixed methods, from the first issue of the Journal of Mixed Methods Research, is “research in which the investigator collects and analyzes data, integrates the findings, and draws inferences using both qualitative and quantitative approaches or methods in a single study or program of inquiry” ( Tashakkori & Creswell, 2007 , p.4).

Mixed methods research began among anthropologists and sociologists in the early 1960s. In the late 1970s, the term “triangulation” began to enter methodology conversations. Triangulation was identified as a combination of methodologies in the study of the same phenomenon to decrease the bias inherent in using one particular method ( Morse, 1991 ). Two types of sequencing for mixed methods design have been proposed: simultaneous and sequential. Type of sequencing is one of the key decisions in mixed methods study design. Simultaneous sequencing is postulated to be simultaneous use of qualitative and quantitative methods, where there is limited interaction between the two sources of data during data collection, but the data obtained is used in the data interpretation stage to support each method's findings and to reach a final understanding. Sequential sequencing is postulated to be the use of one method before the other, as when the results of one method are necessary for planning the next method.

Since the 1960s, the use of mixed methods has continued to grow in popularity ( O'Cathain, 2009 ). Currently, although there are numerous designs to consider for mixed methods research, the four major types of mixed methods designs are triangulation design, embedded design, explanatory design, and exploratory design ( Creswell & Plano Clark, 2007 ). The most common and well-known approach to mixed methods research continues to be triangulation design.

There are many benefits to using mixed methods. Quantitative data can support qualitative research components by identifying representative patients or outlying cases, while qualitative data can shed light on quantitative components by helping with development of the conceptual model or instrument. During data collection, quantitative data can provide baseline information to help researchers select patients to interview, while qualitative data can help researchers understand the barriers and facilitators to patient recruitment and retention. During data analysis, qualitative data can assist with interpreting, clarifying, describing, and validating quantitative results.

Four broad types of research situations have been reported as benefiting particularly from mixed methods research. The first situation is when concepts are new and not well understood. Thus, there is a need for qualitative exploration before quantitative methods can be used. The second situation is when findings from one approach can be better understood with a second source of data. The third situation is when neither a qualitative nor a quantitative approach, by itself, is adequate to understanding the concept being studied. Lastly, the fourth situation is when the quantitative results are difficult to interpret, and qualitative data can assist with understanding the results ( Creswell & Plano Clark, 2007 ).

The purpose of this article is to illustrate mixed methods methodology by using examples of research into the chronic pain management experience among American Indians. These examples demonstrate the methodology used to provide (a) a detailed multilevel understanding of the chronic pain care experience for American Indians using triangulation design (multilevel model), and (b) a comparison of cost for two different chronic pain care delivery models, also using triangulation design (data transformation model).

An Example : Understanding the Pain Management Experience Among American Indians

Chronic pain poses unique challenges to the American health care system, including ever-escalating costs, unintentional poisonings and deaths from overdoses of painkillers, and incalculable suffering for patients as well as their families. Approximately 100 million adults in the United States are affected by chronic pain, with treatment costs and losses in productivity totaling $635 billion annually ( Institute of Medicine, 2011 ). Symptoms of pain are the leading reason patients visit health care providers ( Hing, Cherry, & Woodwell, 2006 ).

At the level of the community-based primary care provider, especially in tribal areas of the United States, there is often not enough capacity to manage complex chronic pain cases, and this is often due to lack of access to specialty pain care ( Momper, Delva, Tauiliili, Mueller-Williams, & Goral, 2013 ). The American Indian population in particular is underserved by health care and the most vulnerable to the impact of chronic pain, with high rates of drug poisoning due to opioid analgesics ( Warner, Chen, Makuc, Anderson, & Minino, 2011 ). There are 2.9 million people who report exclusive and an additional 1.6 million who report partial American Indian ancestry in the United States. They are a diverse group, residing in 35 states and organized into 564 federally recognized tribes ( U.S. Census Bureau, 2010 ). However, there is a scarcity of published literature exploring the experience, epidemiology, and management of pain among American Indians ( Haozous, Knobf, & Brant, 2010 ; Haozous & Knobf, 2013 ; Jimenez, Garroutte, Kundu, Morales, & Buchwald, 2011 ).

Using Mixed Methods to Overcome Barriers to Research

Barriers to effective research into chronic pain management among American Indians include the relatively small number of American Indian patients in any circumscribed area or tribe, the limitations of individual databases, and widespread racial misclassification. A mixed methods research approach is needed to understand the complex experience, epidemiology, and management of chronic pain among American Indians and to address the strengths and weaknesses of quantitative methodologies (large sample size, trends, generalizable) with those of qualitative methodologies (small sample size, details, in-depth).

This first example is from an ongoing study that uses triangulation design to provide a better understanding of the phenomenon of chronic pain management among American Indians. The study uses a multilevel model in which quantitative data collected at the national and state levels will be analyzed in parallel with the collection and analysis of the qualitative data at the patient level (see Figure 1 ). This allows the weakness of one approach to be offset by the strengths of the other. The results of the separate level analyses will be compared, contrasted, and blended leading to an overall interpretation of results.

Role of quantitative data

Previous examination of U.S. national databases has reported a higher prevalence of lower back pain in American Indians than in the general population (35% compared to 26% ; Deyo, Mirza, & Martin, 2002 ). Thus, at level 1, quantitative administrative data sets representing health care received by American Indians, both across the United States and in broad regions, will be used to evaluate macro-level trends in utilization of health care and in basic outcomes, such as opioid-related deaths.

At level 2, more detailed quantitative Washington state tribal clinic data will be used to identify American Indian populations, evaluate breakdowns in the delivery of care, and identify processes that lead to unsuccessful outcomes. For example, in a study conducted with community health practitioners in Alaska, participants reported low levels of knowledge and comfort around discussing cancer pain ( Cueva, Lanier, Dignan, Kuhnley, & Jenkins, 2005 ).

Role of qualitative data

At level 3, qualitative research through focus groups and key informant interviews will provide even more refined information about perceptions of recommended and received care. These interviews will provide insight into selected immediate and proximal factors. These factors include patients' choice and use of services; attitudes, motivations, and perceptions that influence their decisions; interpersonal factors, such as social support; and perceived discrimination. This qualitative data will shed light on potential barriers to care that are not easily recognized in administrative or clinical records, and thereby will provide greater detail about patient views of chronic pain care.

Role of (qualitative) indigenous methodologies

Since the focus of this study is on the chronic pain experience among American Indian patients, it is important that the qualitative work in level 3 be guided by indigenous methodologies, in both data collection and analysis. The phrase “indigenous methodologies” refers to an evolving framework for creating research that places the epistemologies of indigenous participants and communities at the center of the work, while building an equitable and respectful setting for bidirectional learning ( Evans, Hole, Berg, Hutchinson, & Sookraj, 2009 ; Louis, 2007 .; Smith, 2004 ). Although the tenets of indigenous methodologies vary according to the source, there is agreement among sources that research with indigenous populations should be wellness-oriented, holistic, community-oriented, and focused on indigenous knowledge, and should incorporate bidirectional learning ( Louis, 2007 ; Smith, 2004 ).

The ongoing project aligns with these guidelines by building knowledge about the chronic pain experience from the perspective of American Indian patients. The data is being interpreted with the goal of designing a usable and relevant model that will resonate at the American Indian community level. The researchers have conducted focus groups with the needs and priorities of the participants placed at the forefront, to best achieve the goals of learning and building knowledge that reflects the participants' experiences. Specifically, the focus groups were scheduled within three tribes, ensuring high familiarity and social support among group members. These focus groups met either at a tribal community center or in a nearby tribally owned casino in the evening. Each focus group started with a dinner, followed by discussion.

The focus group facilitator was well-known to the community, and although not American Indian, had been an active participant in community events and had provided expert knowledge and consultation to the tribes. Additionally, each focus group was co-facilitated by a tribal elder. The high familiarity among the participants and the research team was an important component of the bidirectional learning: it helped reduce much of the mistrust that has historically prevented medical researchers from obtaining high-quality data in similarly vulnerable populations ( Guadagnolo, Cina, & Helbig, 2009 ).

Benefits of Triangulation Design: Multilevel Model

In summary, only a mixed methods study that included quantitative and qualitative methods could provide the data required for a comprehensive multilevel assessment of the chronic pain experience among American Indians. Although this study is ongoing, the plan is for a nationwide analysis of variations in chronic pain outcomes among American Indians to examine the structure of service delivery and organization. Analysis of the state tribal clinic data will address intermediate factors and will examine community-level variation in pain management and local access to pain specialists. Preliminary analysis of the focus group data has already demonstrated that there is insufficient pain management among American Indians, due in part to lack of knowledge about pain management among providers and lack of access to pain specialists.

An Example; Comparing the Costs of Two Models for Providing Chronic Pain Care to American Indians

Telehealth is one innovative approach to providing access to high-quality interdisciplinary pain care for American Indians. A telehealth model with a unique approach based on provider-to-provider videoconference consultations allows community-based providers to present complex chronic pain cases to a panel of pain specialists through a videoconferencing infrastructure that also incorporates longitudinal outcomes tracking to monitor patient progress. Telehealth is an innovative model of health care delivery, and its use among American Indians has been expanding over the past several years ( Doorenbos et al., 2010 ; Doorenbos et al., 2011a ; 2011b ). Although the use of telehealth for providing chronic pain consultation is still in early stages, the long-term effectiveness of this approach and its impact on increasing capacity for pain management among community providers is being investigated ( Haozous et al., 2012 ; Tauben, Towle, Gordon, Theodore, & Doorenbos, 2013 ). The mixed methods approach for this transaction cost analysis used a unique triangulation design with a data transformation model to build a body of evidence for telehealth pain management.

With ever increasing mandates to reduce the cost and increase the quality of pain management, health care institutions are faced with the challenge of demonstrating that new technologies provide value while maintaining or even improving the quality of care ( Harries & Yellowlees, 2013 ). Transaction cost analysis can provide this evidence by using mixed methods research methodologies to provide comparative evaluation of the costs and consequences of using alternative technologies and the accompanying organizational arrangements for delivering care ( Williamson, 2000 ).

The theory of transaction cost developed from the observation that our structures for governing transactions—the ways in which we organize, manage, support, and carry out exchange — have economic consequences ( Williamson, 1991 ). Though prices matter, this theory recognizes that prices can and do deviate from the cost of production and do not include the cost of transacting ( Coase, 1960 ). Setting aside neoclassical economic conceptions of price, output, demand, and supply, the transaction becomes the unit of analysis ( Williamson, 1985 ).

In transactions, there are typically two parties engaging in the exchange of goods or services, and both exert effort to carry out the transaction, incurring costs in the hope or with the expectation of realizing benefits. Some ways of structuring or supporting a given transaction, such as consultation or treatment for a patient from a health care provider, may be more efficient than others. The analysis examines the actual costs incurred and the related consequences experienced by the parties over time, with the hypothesis that efficiency results from the discriminating alignment of transactions with alternative, more efficient structures of governance ( Williamson, 2002 ).

Specialty health care services participating in the study described here included the University of Washington (UW) Center for Pain Relief and the UW TelePain program. The UW Center for Pain Relief is an outpatient multispecialty consultation and treatment clinic that uses the assembled expertise and skills of physicians and other medical team providers to assist in diagnosis and care for chronic pain, for example for people with painful disorders that have persisted beyond expected duration, or for people who have persistent uncontrolled pain despite appropriate treatment for the underlying medical condition. The clinic also offers pain consultation and treatment for a variety of new-onset or acute problems that may benefit from selective anesthetic procedures, such as nerve blocks or spinal nerve root compression.

The UW TelePain program serves tribal providers in the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region. These tribal providers include primary care physicians, physician assistants, and nurse practitioners. The tribal providers have access to weekly videoconferences both with other community providers and with university-based pain and symptom management experts. During videoconferences, providers manage cases, engage in evidence-based practice activities, and receive peer support. Throughout the process, these community providers are responsible for direct patient care, and they act on recommendations of the consulting pain specialists.

The two care delivery models discussed above — traditional in-clinic consultation at the Center for Pain Relief and telehealth case consultation through TelePain — provided this mixed methods study using triangulation design and a data transformation model with two comparative arrangements for delivering the same transaction: delivery of pain care to patients (see Figure 2 ).

Qualitative and Quantitative Data Collection Procedures

Participant observation and structured interviews were used to identify and describe two comparable completed transactions for patients with chronic pain. Members of the clinical care teams selected one transaction from each service for which the care could be said to represent the routines and norms of their health care organization. The chosen transactions were carried out with patients of the same gender, similar age, and similar health characteristics. For the study, clinical care teams from each service provided two qualitative on-site interviews documenting clinical work flow and processes (i.e., the steps in the transaction). For the in-clinic transaction, members of the clinical care team interviewed included a nurse care coordinator, pain specialist, medical assistant, patient outcomes assessment coordinator, nurse triage manager, patient support services supervisor, and financial authorization specialist. For the Tele-Pain transaction, team members interviewed included the TelePain nurse care coordinator, two pain specialists, an information technology specialist, and the clinic provider.

The following details the process of the mixed methods analysis. First, individual steps, or discrete tasks, within each transaction (in-clinic versus TelePain) were identified using qualitative interviews and itemized in detail. Details from the qualitative data included a description of each task, the person (s) engaged, the duration of engagement of each person in minutes, the information accrued to the patient's medical record, the technologies employed, and the locations where tasks were conducted and information was transmitted or stored.

The quantitative data collected included date and time, and therefore duration in business days, that accumulated with each step in the transaction. Finally, the costs of each step collected from the qualitative data were identified and transformed into quantitatively estimated data for each transaction. Analysis focused on the primary costs in health care: the value of people's time. These values were limited to labor costs for the in-clinic and telehealth personnel; proxies for the value of time were used with estimates of time for the patient. Costs were estimated as a function of time spent per task and per patient, and the actual wage, including benefits, of personnel engaged in the transaction.

Qualitative and Quantitative Data Analysis

Personal identifiable information was redacted from each patient's medical record, and the records were reviewed for comparability as well as for norms and routines of care for the in-clinic and telehealth organizations. The characteristics of the two patients were similar. Both were first-time patients to their respective organizations, and were referred by their primary care providers for specialized care. The reasons for seeking care and report of conditions potentially related to chronic pain were similar. Both transactions resulted in a consultation recommending referral for additional specialized care or treatment.

Two work flows, one in-clinic and one telehealth, were developed by documenting actual tasks undertaken during the transactions. In follow-up interviews, these work flows were presented to participants for review and comment. These interviews resulted in a complete itemized list of dates, personnel, and time spent per person on discrete steps or tasks. Tables and graphs expressing the steps, with cost accrual over time and in sum, were developed and compared for each transaction, to each other, and with respect to participants' rationales for the tasks in each transaction.

The equation expressing the cost per transaction is as follows, where the total cost of the transaction ( C T ) is the sum of the costs of each discrete task ( k i ) in the transaction, measured per participant ( x, y, z …) on the task, as the product of time ( t ) and wage rate ( w ), or in the case of the patient ( x, y, z …), a proxy for the value of time ( w ) and estimated time ( t ).

In total, 46 discrete steps were taken for the typical in-clinic transaction at the UW Center for Pain Relief (one patient case, reviewed by two pain specialists) versus 27 steps for the typical TelePain transaction (three patient cases, reviewed by six pain specialists). The greater number and types of administrative steps taken to schedule, execute, and follow up the in-clinic consultation resulted in greater duration of time between receipt of initial referral request and completion of the initial consultation with the pain specialists. A total of 153 business days (213 calendar days) elapsed between referral and the completion of the entire in-clinic transaction, versus 4 business days (4 calendar, days) for the TelePain transaction. Importantly, for the transaction at the UW Center for Pain Relief, 72 business days transpired before consultation concluded with a referral for the patient's record; the same conclusion was reached in 4 days in the TelePain transaction. These methods used to determine transaction costs provide an excellent example of mixed methods research, where both qualitative and quantitative data and analysis are needed to provide the transaction cost results.

Mixed methods are increasingly being used in nursing research. We have detailed two studies in which mixed methods research with triangulation design brought a richness to the examination of the phenomenon that a single methodology would not In the two examples described, a major advantage of the triangulation design is its efficiency, because both types of data are collected simultaneously. Each type of data can be collected and analyzed separately and independently, using the techniques traditionally associated with each data type. Both simultaneous and sequential data collection lend themselves to team research, in which the team includes researchers with both quantitative and qualitative expertise.

Challenges include the effort and expertise required due to the simultaneous data collection, and the fact that equal weight is usually given to each data type. Thus this research requires a team, or extensive training in both quantitative and qualitative methodologies, and careful adherence to the methodological rigor required for both methodologies. Nursing researchers may face the possibility of inconsistency in research findings arising from the objectivity of quantitative methods and the subjectivity of qualitative methods. In these cases, additional data collection may be required.

The first example, regarding the pain management experience among American Indians, used triangulation design in a multilevel model format. The multilevel model was useful in designing this study as different methods were needed at different levels to fully understand the complex health care system. In this example, quantitative data is being collected and analyzed at the national and state levels, and qualitative data is being collected at the patient level. Both qualitative and quantitative data are being collected simultaneously. The findings from each level will then be blended into one overall interpretation.

The second example, a transaction cost analysis, also used triangulation design, but the model used was that of data transformation. As in the multilevel model used in the first example, the data transformation model involved the separate but concurrent collection of qualitative and quantitative data. A novel step in this model involves transforming the qualitative data into quantitative data, and then comparing and interrelating the data sets. This required the development of procedures for transforming the qualitative data, related to, time spent on a step and salary of the provider, into quantitative cost data.

The two studies presented as examples demonstrate mixed methods research resulting in the creation of (a) a rich description of the American Indian chronic pain experience, and (b) a way to assess cost for providing chronic pain care via tribal clinics. In both examples, the quantitative data and their subsequent analysis provide a general understanding of the research problem. The qualitative data and their analysis refine and explain the results by exploring participants' views in more depth. Research using a single methodology would not have been able to achieve the same results.

Acknowledgments

Research reported in this paper was supported by the National Institute of Nursing Research of the National Institutes of Health under award number #R01NR012450 and the National Cancer Institute of the National Institutes of Health under award number #R42 CA141875. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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• Janice Jones 1 ,
• Joanna Smith 2
• 1 Institute of Vocational Learning, School of Health and Social Care, London South Bank University , London , UK
• 2 Children’s Nursing, School of Healthcare, University of Leeds , Leeds , UK
• Correspondence to Dr Janice Jones, Institute of Vocational Learning, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; jonesj33{at}lsbu.ac.uk

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Introduction

Collectively qualitative research is a group of methodologies, with each approach offering a different lens though which to explore, understand, interpret or explain phenomena in real word contexts and settings. This article will provide an overview of one of the many qualitative approaches, ethnography , and its relevance to healthcare. We will use an exemplar based on a study that used participant-as-observer observation and follow-up interviews to explore how occupational therapists embed spirituality into everyday practice, and offer insights into the future directions of ethnography in response to increased globalisation and technological advances.

What is ethnography?

What research methods do ethnographic researchers adopt.

Ethnographic methods are diverse and a range of approaches can be adopted; they are based on observation, often complemented with interviews, and detailed analysis often at a micro level. Although the methods used are not exclusive to ethnography, it is the depth of fieldwork and the continuous process of engaging with participants and their natural environments that is central and adds strength to the findings of ethnographic studies. 6 Participant observation requires immersion in the setting under investigation, and observing the language, behaviours and values of the participants. 7 Consequently, paramount to undertaking an ethnographic study is the role of the researcher in data collection.

Engaging with participants in the real world poses several challenges; first the researcher must decide whether to adopt an overt or covert approach to data collection and observation. In an overt approach the participants know they are being observed, whereas in a covert approach the participants are unaware they are being observed. The rationale for undertaking covert data collection in healthcare contexts needs careful consideration because of ethical implications, and the tensions with the principles of good research governance such as the right to choice whether to participate, information provision and gaining consent. 8 Second, the researcher must consider ‘their position’ either as an ‘insider’ (emic) or ‘outsider’ (etic). 5 Broadly, an emic approach is aligned with immersing into the culture, observing and recording participants’ way of life and activity, in contrast to the etic approach that observes and describes communities and cultures ( table 1 ). Both methods produce rich, in-depth data aiming to make sense of the context or phenomena under investigation, and require the researcher to be reflexive when undertaking fieldwork, accounting for their own assumptions and presuppositions to strengthen the findings. 5

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Approaches to participant observation 7

Ethnographic approaches to data collection produce voluminous unstructured data from a range of sources, for example fieldwork notes, diary entries, memos and, where appropriate, interview transcripts. The volume of data can be challenging to analyse and we would recommend a structured approach such as the framework approach. 9 The framework approach is rigorous, logical and transparent, and is particularly suitable to manage large amounts of textual information, while remaining close to the original data. 10 Framework approach supports the process of crystallisation, where the multiple facets of an ethnographic study are iteratively analysed, and constantly reviewed to identify patterns and associations across the data. 9 While the final stage in the framework approach aims to present the data in a way that is meaningful to the reader by grouping findings into categories and themes, the role of the researcher is to offer explanations about ‘how and why’ events, actions and interactions occur. 9 10

Table 2 outlines the methods adopted, rationale for decisions made and challenges of undertaking an ethnographical study that explored how occupational therapists incorporate spiritual care into their everyday practice. 11 Data were collected through participant-as-observer, recognising JJ’s role as an occupational therapist and knowledge of the study setting, with semistructured interviews used to explore with participants their decisions and thoughts by reflection on the observational data collected. Several key findings emerged; first spirituality is more meaningfully described than defined for occupational therapy practice. Second, central to occupational therapy practice is supporting patients during times of vulnerability; addressing the spiritual constructs of practice is essential to holistic person-centred care. Finally, organisational and contextual factors influenced how the occupational therapists framed their practice, and adopted strategies to retain their commitment to holistic, person-centred practice. 11

Methods, rationale for decision and challenges undertaking ethnographical research

How flexible is ethnography to social changes, globalisation and technological advances?

Rapidly advancing technology and increased globalisation require healthcare organisations to adapt and change; similarly approaches to undertaking qualitative research must evolve. 12 The increased use of web-based platforms as a means of sharing information, offering support networks and monitoring patients is creating opportunities for health researchers to study the naturally occurring and vast amount of data generated online. The rapid advancement of online communities has resulted in the emergence of online research methodologies such as netnography. 13 Netnography is rooted in ethnographical methods that aim to explore the social interactions of online communities, and can be adapted across the spectrum of online activities. 14

The emergence of team-based ethnography, as a departure from the traditional lone researcher working ‘ in the field’ , is in part in response to the globalisation of societies, economies and ororganisations. 15 Multisite or global ethnography is a new way of conceptualising ethnography that offers opportunities to study the interconnectedness of modern society, 15 and could be appropriate to study healthcare systems globally.

In summary, it is not surprising that qualitative research has been widely adopted as a means of understanding healthcare from the patient experience, and exploring service provision, care delivery and organisational cultures. The value of focused ethnographic studies in healthcare is essential to develop an in-depth understanding of healthcare cultures and explore complex phenomenon in real world contexts.

• Ritchie J ,
• Streubert HJ ,
• Carpenter DR
• Hammersley M ,
• Edgecombe N
• McNaughton Nichols C ,
• Angrosino M
• Hammersley M
• Costello L ,
• McDermott M ,
• Kozinets RV
• Jarzabkowski P ,
• Bednarek R ,
• Cabantous L
• Monahan T ,

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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