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Chapter 5: Qualitative descriptive research

Darshini Ayton

Learning outcomes

Upon completion of this chapter, you should be able to:

• Identify the key terms and concepts used in qualitative descriptive research.
• Discuss the advantages and disadvantages of qualitative descriptive research.

What is a qualitative descriptive study?

The key concept of the qualitative descriptive study is description.

Qualitative descriptive studies (also known as ‘exploratory studies’ and ‘qualitative description approaches’) are relatively new in the qualitative research landscape. They emerged predominantly in the field of nursing and midwifery over the past two decades. 1 The design of qualitative descriptive studies evolved as a means to define aspects of qualitative research that did not resemble qualitative research designs to date, despite including elements of those other study designs. 2

Qualitative descriptive studies  describe  phenomena rather than explain them. Phenomenological studies, ethnographic studies and those using grounded theory seek to explain a phenomenon. Qualitative descriptive studies aim to provide a comprehensive summary of events. The approach to this study design is journalistic, with the aim being to answer the questions who, what, where and how. 3

A qualitative descriptive study is an important and appropriate design for research questions that are focused on gaining insights about a poorly understood research area, rather than on a specific phenomenon. Since qualitative descriptive study design seeks to describe rather than explain, explanatory frameworks and theories are not required to explain or ‘ground’ a study and its results. 4 The researcher may decide that a framework or theory adds value to their interpretations, and in that case, it is perfectly acceptable to use them. However, the hallmark of genuine curiosity (naturalistic enquiry) is that the researcher does not know in advance what they will be observing or describing. 4 Because a phenomenon is being described, the qualitative descriptive analysis is more categorical and less conceptual than other methods. Qualitative content analysis is usually the main approach to data analysis in qualitative descriptive studies. 4 This has led to criticism of descriptive research being less sophisticated because less interpretation is required than with other qualitative study designs in which interpretation and explanation are key characteristics (e.g. phenomenology, grounded theory, case studies).

Diverse approaches to data collection can be utilised in qualitative description studies. However, most qualitative descriptive studies use semi-structured interviews (see Chapter 13) because they provide a reliable way to collect data. 3 The technique applied to data analysis is generally categorical and less conceptual when compared to other qualitative research designs (see Section 4). 2,3 Hence, this study design is well suited to research by practitioners, student researchers and policymakers. Its straightforward approach enables these studies to be conducted in shorter timeframes than other study designs. 3 Descriptive studies are common as the qualitative component in mixed-methods research ( see Chapter 11 ) and evaluations ( see Chapter 12 ), 1 because qualitative descriptive studies can provide information to help develop and refine questionnaires or interventions.

For example, in our research to develop a patient-reported outcome measure for people who had undergone a percutaneous coronary intervention (PCI), which is a common cardiac procedure to treat heart disease, we started by conducting a qualitative descriptive study. 5 This project was a large, mixed-methods study funded by a private health insurer. The entire research process needed to be straightforward and achievable within a year, as we had engaged an undergraduate student to undertake the research tasks. The aim of the qualitative component of the mixed-methods study was to identify and explore patients’ perceptions following PCI. We used inductive approaches to collect and analyse the data. The study was guided by the following domains for the development of patient-reported outcomes, according to US Food and Drug Administration (FDA) guidelines, which included:

• Feeling: How the patient feels physically and psychologically after medical intervention
• Function: The patient’s mobility and ability to maintain their regular routine
• Evaluation: The patient’s overall perception of the success or failure of their procedure and their perception of what contributed to it. 5(p458)

We conducted focus groups and interviews, and asked participants three questions related to the FDA outcome domains:

• From your perspective, what would be considered a successful outcome of the procedure?

Probing questions: Did the procedure meet your expectations? How do you define whether the procedure was successful?

• How did you feel after the procedure?

Probing question: How did you feel one week after and how does that compare with how you feel now?

• After your procedure, tell me about your ability to do your daily activities?

Prompt for activities including gardening, housework, personal care, work-related and family-related tasks.

Probing questions: Did you attend cardiac rehabilitation? Can you tell us about your experience of cardiac rehabilitation? What impact has medication had on your recovery?

• What, if any, lifestyle changes have you made since your procedure? 5(p459)

Data collection was conducted with 32 participants. The themes were mapped to the FDA patient-reported outcome domains, with the results confirming previous research and also highlighting new areas for exploration in the development of a new patient-reported outcome measure. For example, participants reported a lack of confidence following PCI and the importance of patient and doctor communication. Women, in particular, reported that they wanted doctors to recognise how their experiences of cardiac symptoms were different to those of men.

The study described phenomena and resulted in the development of a patient-reported outcome measure that was tested and refined using a discrete-choice experiment survey, 6 a pilot of the measure in the Victorian Cardiac Outcomes Registry and a Rasch analysis to validate the measurement’s properties. 7

Advantages and disadvantages of qualitative descriptive studies

A qualitative descriptive study is an effective design for research by practitioners, policymakers and students, due to their relatively short timeframes and low costs. The researchers can remain close to the data and the events described, and this can enable the process of analysis to be relatively simple. Qualitative descriptive studies are also useful in mixed-methods research studies. Some of the advantages of qualitative descriptive studies have led to criticism of the design approach, due to a lack of engagement with theory and the lack of interpretation and explanation of the data. 2

Table 5.1. Examples of qualitative descriptive studies

Qualitative descriptive studies are gaining popularity in health and social care due to their utility, from a resource and time perspective, for research by practitioners, policymakers and researchers. Descriptive studies can be conducted as stand-alone studies or as part of larger, mixed-methods studies.

• Bradshaw C, Atkinson S, Doody O. Employing a qualitative description approach in health care research. Glob Qual Nurs Res. 2017;4. doi:10.1177/2333393617742282
• Lambert VA, Lambert CE. Qualitative descriptive research: an acceptable design. Pac Rim Int J Nurs Res Thail. 2012;16(4):255-256. Accessed June 6, 2023. https://he02.tci-thaijo.org/index.php/PRIJNR/article/download/5805/5064
• Doyle L et al. An overview of the qualitative descriptive design within nursing research. J Res Nurs. 2020;25(5):443-455. doi:10.1177/174498711988023
• Kim H, Sefcik JS, Bradway C. Characteristics of qualitative descriptive studies: a systematic review. Res Nurs Health. 2017;40(1):23-42. doi:10.1002/nur.21768
• Ayton DR et al. Exploring patient-reported outcomes following percutaneous coronary intervention: a qualitative study. Health Expect. 2018;21(2):457-465. doi:10.1111/hex.1263
• Barker AL et al. Symptoms and feelings valued by patients after a percutaneous coronary intervention: a discrete-choice experiment to inform development of a new patient-reported outcome. BMJ Open. 2018;8:e023141. doi:10.1136/bmjopen-2018-023141
• Soh SE et al. What matters most to patients following percutaneous coronary interventions? a new patient-reported outcome measure developed using Rasch analysis. PLoS One. 2019;14(9):e0222185. doi:10.1371/journal.pone.0222185
• Hiller RM et al. Coping and support-seeking in out-of-home care: a qualitative study of the views of young people in care in England. BMJ Open. 2021;11:e038461. doi:10.1136/bmjopen-2020-038461
• Backman C, Cho-Young D. Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home – a qualitative descriptive study. Patient Prefer Adherence. 2019;13:617-626. doi:10.2147/PPA.S201054

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• Developing the Quantitative Research Design
• Qualitative Descriptive Design

Overview of Descriptive Design

Sources of data.

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A descriptive design is a flexible, exploratory approach to qualitative research. Descriptive design is referred to in the literature by other labels including generic, general, basic, traditional, interpretive, and pragmatic. Descriptive design as an acceptable research design for dissertation and other robust scholarly research has received varying degrees of acceptance within the academic community. However, descriptive design has been gaining momentum since the early 2000’s as a suitable design for studies that do not fall into the more mainstream genres of qualitative research (ie. Case study, phenomenology, ethnography, narrative inquiry and grounded theory). In contrast to other qualitative designs, descriptive design is not aligned to specific methods (for example, bracketing in phenomenology, bounded systems in case study, or constant comparative analysis in grounded theory). Rather, descriptive design “borrows” methods appropriate to the proposed study from other designs. 

Arguments supporting the flexible nature of descriptive designs describe it as being preferable to forcing a research approach into a design that is not quite appropriate for the nature of the intended study. However, descriptive design has also been criticized for this mixing of methods as well as for the limited literature describing it. The descriptive design can be the foundation for a rigorous study within the ADE program. Because of the flexibility of the methods used, a descriptive design provides the researcher with the opportunity to choose methods best suited to a practice-based research purpose.   

• Example Descriptive Design in an Applied Doctorate

Sources of Data in Descriptive Design

Because of the exploratory nature of descriptive design, the triangulation of multiple sources of data are often used for additional insight into the phenomenon. Sources of data that can be used in descriptive studies are similar to those that may be used in other qualitative designs and include interviews, focus groups, documents, artifacts, and observations.

The following video provides additional considerations for triangulation in qualitative designs including descriptive design: Triangulation: Pairing Thematic and Content Analysis

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An overview of the qualitative descriptive design within nursing research

Affiliations.

• 1 Associate Professor in Mental Health Nursing, School of Nursing and Midwifery, Trinity College Dublin, Ireland.
• 2 Associate Professor in General Nursing, School of Nursing and Midwifery, Trinity College Dublin, Ireland.
• 3 Assistant Professor in Mental Health Nursing, School of Nursing and Midwifery, Trinity College Dublin, Ireland.
• 4 Chair of Nursing and Chronic Illness, School of Nursing and Midwifery, Trinity College Dublin, Ireland.
• 5 Assistant Professor in General Nursing, School of Nursing and Midwifery, Trinity College Dublin, Ireland.
• PMID: 34394658
• PMCID: PMC7932381
• DOI: 10.1177/1744987119880234

Background: Qualitative descriptive designs are common in nursing and healthcare research due to their inherent simplicity, flexibility and utility in diverse healthcare contexts. However, the application of descriptive research is sometimes critiqued in terms of scientific rigor. Inconsistency in decision making within the research process coupled with a lack of transparency has created issues of credibility for this type of approach. It can be difficult to clearly differentiate what constitutes a descriptive research design from the range of other methodologies at the disposal of qualitative researchers.

Aims: This paper provides an overview of qualitative descriptive research, orientates to the underlying philosophical perspectives and key characteristics that define this approach and identifies the implications for healthcare practice and policy.

Methods and results: Using real-world examples from healthcare research, the paper provides insight to the practical application of descriptive research at all stages of the design process and identifies the critical elements that should be explicit when applying this approach.

Conclusions: By adding to the existing knowledge base, this paper enhances the information available to researchers who wish to use the qualitative descriptive approach, influencing the standard of how this approach is employed in healthcare research.

Keywords: descriptive research; methodology; nursing research; qualitative research; research methods.

© The Author(s) 2019.

• Open access
• Published: 27 May 2024

Nurses, non-nurse healthcare providers, and clients’ perspectives, encounters, and choices of nursing gender in Tanzania: a qualitative descriptive study

• Racheal Mukoya Masibo 1 ,
• Stephen M. Kibusi 1 &
• Golden M. Masika 1  

BMC Nursing volume  23 , Article number:  353 ( 2024 ) Cite this article

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A growing share of male nurses in the nursing profession in Tanzania has changed the trend of diversity of nursing gender. This might have created a divergent perspective within the communities. Therefore, the current study aimed to explore the perspective, encounters, and choices of nursing gender among licensed nurses, non-nurse healthcare providers, and clients in Tanzania.

The study employed a qualitative descriptive design. The data were collected between August 2022 to January 2023 by the principal investigator and one research assistant. Twelve Focus Group Discussions (FGDs) were carried out in four different hospitals in Dar es Salaam comprised of total participants ( n  = 59). The participants were nurses, clients, and non-nurse healthcare providers. The data was collected through an interview guide developed by the principal investigator and validated by nurse experts. The data was analyzed using qualitative content analysis to generate themes and subthemes.

Eight themes and twenty-seven subthemes emerged from the study. The following are themes; ① Variations of male and female nurses in communication ② Differences of male and female nurses in carrying out leadership roles ③ Divergent clinical qualities and outcomes across nursing gender ④ Positive value of male nurses in clinical facilities from colleagues and patients ⑤ Different cooperation of male and female nurses at the clinical settings ⑥ Mixed perspective towards clinical competencies across nursing gender ⑦ Perspective towards gender diversity in nursing ⑧ Preferences of nurse’s gender, reasons, and opinion towards gender preferences.

Male nurses and female nurses differ in how they communicate, execute leadership roles, and clinical qualities. However, their variations don’t mean one gender is underrated than the other, but every gender has unique communication styles, leadership styles, and clinical qualities that both lead to effective outcomes. Diversity in nursing gender is very important and should be strategized. Since preferences of nursing gender seems to enhance somebody’s freedom and creates an environment where a person can discuss sensitive issues, nursing bodies and healthcare stakeholders might initiate a discussion about approaches to promote the implementation of nursing preference and perform the feasibility studies.

Peer Review reports

Introduction

Nursing is one of the most gendered professions globally, dominated by females and with little representation of males [ 1 ]. The data by the World Health Organization from 104 countries conform to the statement that men are underrepresented in nursing as follows; Africa (65%=Female nurses and 35%=Male nurses) [ 2 ], America (86%=Female nurses and 14%=Male nurses), Eastern Mediterranean (79%=Female nurses and 21%=Male nurses), Europe (84%=Female nurses and 16%=Male nurses), South-East Asia (79%=Female nurses and 21%=Male nurses) and Western Pacific (81%=Female nurses and 19%=Male nurses) [ 3 ]. Generally, male nurses make up 11% of the nursing workforce worldwide, while female nurses comprise 89% of the nursing workforce [ 4 ]. Following the disparity in nursing gender, the recent campaigns to encourage and attract more men to nursing are promising evidenced high the influx of men choosing nursing as a career [ 5 ]. The influx has slightly increased the trend of nursing gender, considering the number of employed male nurses in the United States has increased from 11.1% in 2019 to 13.3% in 2021, while the enrollment of male nurses in the program Doctor of Nursing Practice (DNP) has increased from 13.4% in 2018 to 14.8% in 2022 [ 2 ].

It is hypothetically assumed that having gender diversity in nursing is associated with the acceleration of professional development, a force for public policy change, and improving patient care by providing an opportunity to choose the gender of their preference [ 6 ]. Consistently gender theories put forth that gender diversity is good, for instance, Symbolic Interaction Theory in Gender sees gender diversity as a factor that allows us to form a relationship in daily life [ 7 ], while another theory by Bonnie, proposed that looking at masculinity and femininity assets of mutually created characteristics shape the lives [ 8 ]. Even though the benefits of gender diversity are reported hypothetically, there is a limited reported actual benefit in clinical settings. The study ought to explore the contribution of gender trends in the clinical areas.

The background of nursing shows that the profession’s image has always been determined by the public perspectives, whereby these perspectives have the power to affect the users of health services, the nurses’ performance, health policy, and even the choice to become a nurse [ 9 ]. Therefore, the changing trend of gender diversity of nurses triggers public perspective about the impact of diversity in nursing care, collaboration aspects, image of the profession, retention of male nurses, and preferences of nursing gender by patients [ 10 ]. Even though some studies have been previously conducted to discover the public perspective on nursing gender [ 11 , 12 ], there are still conflicting results as some reported positive perspectives and other negative perspectives and most of the studies targeted nursing students and patients while abandoned licensed nurses and non-healthcare providers. The current study involved licensed nurses, non-healthcare providers, and clients. Nursing gender disparity evolved since the origin of the nursing profession when women were considered fitting to care for clients because of their experiences in traditional caring roles like raising children, feeding and caring for members of the household, and organizing and maintaining the home, unlike men who were viewed to be in a position of engaging in productive roles [ 13 ]. The gender disparity was further exacerbated by Florence Nightingale in the 19th century, where she envisioned nursing as the most suitable profession for women because it was an extension of mothering [ 14 ]. In this aspect of gender disparity, every woman was thought to qualify as a nurse and men were refused to be registered as nurses [ 15 , 16 , 17 ].

However, with the 1970 campaign for gender balance, more men were recruited into nursing by downsizing the ‘feminine’ attributes in nursing and refocusing on the governance and scientific aspects [ 15 ]. Since 1970 to date the number of male nurses has tripled [ 18 ]. Studies have suggested the presence of competitive salaries, professional stability, shortage of nurses, leadership opportunities, ageing population, ageing workforce, burnout, vibrant job employment competition, and career development opportunities to be the reasons men are joining the nursing profession [ 19 , 20 ]. Even though there is adequate documentation about changing gender trends in nursing, previous studies have not captured the impact of the changing gender trends on nursing professional practice.

In Tanzania, in 2013, the disparity of nursing gender has been high, with female nurses (86%) and male nurses (14%) [ 21 ]. In 2015, the proportion of gender distribution of nurses changed with female nurses (70%) and male nurses (30%) [ 22 ]. The raised gender diversity is perpetuated by the unemployment rate, job stability, career flexibility, growth of the nursing field, rising income, changing of nursing entry qualifications, and presence of a variety of specialities in nursing [ 23 , 24 ]. Even though no published statistics on the changing trend of gender in nursing, the grey literature from the registry of Tanzania Nursing and midwifery council indicates a notable increase in male nurses at the bachelor’s level from 2015 to 2022 as follows; 2015 (540 = Female nurse and 167 = Male nurses), 2016 (565 = Female nurses and 205 = Male nurses), 2017 (501 = Female nurses and 221 = Male nurses), 2018 (508 = Female nurses and 242 = Male nurses), 2019 (410 = Female nurses and 272 = Male nurses), 2020 (362 = Female nurses and 310 = Male nurses), 2021 (311 = Female nurses and 337 = Male nurses), and 2022 (345 = Female nurses and 352 = Male nurses). This conforms to unpublished statistics and reports by Tanzania Nursing and Midwifery Council (TNMC), Tanzania Commission for Universities (TCU), and current qualitative findings of 15 experienced Tanzania nurses, which uncovered the changing gender trends in the enrollment of male student nurses pursuing nursing careers.

Since the public perspective toward nursing has been an issue in Tanzania throughout the transition stages of nursing development [ 25 , 26 , 27 , 28 ], the public perspective towards changing trends of nursing gender cannot be avoided.

The evolving gender trends in the nursing workforce call for an urgent investigation of perspectives towards the changing trend and its impact on the nursing professional practice. Moreover, the limited studies on the perspective of nursing gender increase the need to conduct this study. Therefore, the current study aimed to explore the perspectives, encounters, and choices of nursing gender among licensed nurses, non-nurse healthcare providers, and clients in Tanzania. The study objectives are; (1) to explore nurses, non-nurse healthcare providers, and clients’ perspectives towards nursing gender in Tanzania, (2) to explore the opinions of nurses, non-nurse healthcare providers, and clients towards nursing gender and (3) to describe the nursing gender preference among nurses, non-nurse healthcare providers, and clients.

Study designs

It is a qualitative descriptive design that explores the perspectives, euncounter and choices of nursing gender among nurses, non-nurse healthcare providers, and clients in Tanzania. The design was appropriate as it can generate data about ‘who, what, and where of events and is deemed important because it provides straightforward descriptions of experiences and perspectives [ 29 ].

Study setting and population

The study was conducted in Tanzania specifically in Dar es Salaam, because of the increased gender diversity workforce in different healthcare facilities in the urban of Dar es Salaam. There is evidence in Tanzania showing a link between gender workforce and geographically located facilities, whereas urban facilities are likely to have diverse genders, unlike rural facilities with fewer female professionals [ 21 ]. Moreover, due to the accessibility of basic social services and desirable infrastructural facilities, most of the qualified professionals 69% are concentrated in urban areas [ 30 ].

Therefore, the study involved four hospitals located in Dar es Salaam, named as Hospital 1, Hospital 2, Hospital 3, and Hospital 4. In detail, Hospital 1 has the bed capacity 1,500, with 2,000 outpatients attending per day, and with 2,800 employees. Meanwhile, Hospital 2 has 362 beds and provides additional daily care for 800-1,200 outpatients, with an estimated total of employee 435. Furthermore, Hospital 3 in 2018 had a bed capacity of 230, serving 1.4 million population, while Hospital 4 serving a population of more 2.2 million people, has a bed capacity of 254, with a bed occupancy of 317, and attends 1,500 up to 1,800 patients per day. The study involved licensed nurses working at healthcare facilities, non-nurse healthcare providers (physicians, laboratory technicians, and pharmacists), and clients who attended healthcare facilities to seek medical attention at the time of the study.

Inclusion and exclusion criteria

Nurses, and non-nurse healthcare providers who are licensed and currently working at the healthcare facilities were included in the study, but those unwilling to participate and absent during data collection were excluded. Meanwhile, clients who were able to speak Swahili native language or English were recruited, but those who did not complete informed consent and with severe illnesses to impaired their responses were excluded from the study.

Sample size and sampling procedures

The sample size was determined based on data saturation. When no new matters/issues were emerging from Focus Group Discussions (FGDs), the data were considered saturated. Enough participation from each member in each focus group session and exploring exhaustively in each focus group was performed to ensure no new ideas were coming out. Therefore, there were four FGDs for nurses, four FGDs for non-nurse healthcare providers, and four FGDs for clients. Regarding the sampling procedure, a purposive method was used to recruit participants.

Data collection procedures and tools

The data were collected between August 2022 to January 2023 by the principal investigator and one research assistant. The assistant was a licensed registered nurse who worked as ward-in-charge at a hospital in Dar es Salaam. Twelve Focus Group Discussions (FGDs) were carried out in the four hospitals with three FGDs in each hospital which comprised of nurses, non-nurse healthcare providers, and clients respectively. Each FGD comprised 5–6 participants who shared their perspectives, encounters, and choices about nursing gender in Tanzania. This number of participants per single FGD is based on the recommended minimum number of five participants needed to conduct a single Focus [ 31 ].

To formulate the FGDs of nurses at different facilities, the directors of nursing services were physically met and asked for a list of nurses with the required criteria. The selected nurses were contacted physically or through a mobile phone, and were informed about the study, completed consent, and scheduled the date and time for interviews. For non-nurse healthcare providers (NN-HCPs), the directors of medical services, directors of pharmacy, and directors of laboratories at different facilities were also asked to provide a list of potential participants with the required criteria to participate in the study. After getting a list, the proposed participants were contacted and asked to participate in the study. The FGDs were formulated and all participants were informed of the time for an interview. For all FGDs across three populations, the balance of gender was deliberately ensured to promote diversity.

Reflexivity and bracketing

Team members were mixed of female and male academicians, with diverse backgrounds in nursing care, the nursing workforce, nursing management, public health, and global health. One team member (RMM) was an early career researcher (2 years experience) and Two of the team members (SMK & GMM) had more than 10 years of experience in nursing qualitative research. This experience was valuable in the design of the study, recruitment of participants and data collection. During the analysis we used an inductive approach which was grounded in the data, to minimise the impact of the researchers on the findings. All authors had demographics that would have influenced the findings. However, researchers self-consciously critique, appraise, and evaluate how their subjectivity and context influence the research processes helped to mitigate the effect. Moreover, methodological cohesion, working inductively, and acquiring adequate and appropriate samples further prevented the researcher’s characteristics from influencing the results [ 32 ].

Data collection tools

The same interview guide for different populations was used to guide the interview sessions. The English interview guide was developed by a principal investigator based on literature and study objectives. The validation was performed by an expert in qualitative studies, who reviewed the interview guide and provided comments for revision. The final English interview guide contained three main questions (1) What is your perspective of nursing gender in Tanzania? (2) What is your opinion about nursing gender in Tanzania? (3) What can you say about your preference for nursing gender when you are seeking medical attention?. The final English version was translated into Swahili native language and interview sessions were conducted in Swahili native language, for convenience of participatns. The probing questions during interview sessions were based on the information from participants, such as “Can you explain more about what you have just said?” “Can you give an example of what you have mentioned?” “Do you think there are still other issues you want to speak about?” “Has anything important been left out or forgotten that you would like to share?” Meanwhile, the audio recorder was used to capture the conversations that conveniently helped during data analysis. Refer to supplementary Data 1 .

Data analysis

The collected data were transcribed verbatim into text by the principal investigator. The transcripts were translated forward and backward by a linguist, working as an English lecturer at St. John’s University of Tanzania. A principal investigator and one co-author coded the data independently. Every coded data was supposed to have an agreement between two coders, but a third co-author was consulted upon lack of agreement between two coders. Qualitative Content Analysis was used to analyze the data through the following steps; familiarizing oneself with the data, dividing up the text into meaning units and condensing meaning units, formulating codes, and developing categories and themes [ 33 ]. The coding data can be referred to Supplementary Data 2 – 4 .

Ethics approval and consent to participate

The study ethical clearance letter was obtained from the University of Dodoma Institution Research Review Committee (IRREC), with reference number: MA 84/261/02. The permission to conduct the study in four hospitals was obtained from the Regional Administrative Secretary (RAS). The written and verbal informed consent was completed by each participant before participating in the study. None of the participants was under 16 years of age, and therefore no guardian completed the informed consent on behalf of the participants. Participants had the freedom to participate voluntarily and withdraw from the study at any time they felt so. Since the study involved FGDs, full confidentiality could not be fully guaranteed [ 34 ], but permission to record and transcribe the data was obtained. Moreover, participants have explained procedures for how their recordings will be kept confidential, such as avoiding exposing participants’ identities, deleting the recordings and destroying transcripts six months after analysis, and securing devices containing recording files by passwords and encryption.

The researcher assistant had a greater chance of encountering conflicts of interest, since she is working in one of the studied hospitals. The conflict could have been raised when she was required to decide whether to defend the interest of her hospital or be led by study objective. The agreement with the research assistant before carrying out the study was the interview sessions should be guided by the interview guide and principles.

Trustworthiness

The credibility which deals with how congruent are the findings with reality was ensured through triangulation [ 35 ] and member checks. Two type of trianglulation that helped to make sure that the research findings are robust, rich, comprehensive, and well-developed ae; (i) triangulation of sources (collecting data from multiple sources of three populations) and (ii) analyst triangulation (having multiple analysists of qualitative data). Furthermore, the credibility was achieved through member checks, where the data, interpretations, and conclusions about nursing gender perspectives, encounters and choices were shared with the participants to enable them clarify what their intentions were, correct errors, and provide additional information if necessary. Detailed information was provided within the methodological section, including study setting, data saturation, sampling procedure, techniques of data collection, and tool development and validation to achieve transferability. Meanwhile, the dependability was ensured by involving multiple people in reading transcripts for face validity. Bracketing, reflexivity, and clear coding were used for confirmability.

Participants’ characteristics

The data were collected at four different hospitals, with a total of 12 Focus Group Discussions (FGDs). The total participants in the study were fifty-nine, distributed as 20 nurses, 16 non-nurse healthcare providers, and 23 clients.

Since FGD was an approach for data collection, a single FGD for each population was conducted at each hospital. The data collected from nurses in each hospital were; at Hospital 1: the FGD comprised five nurses (3 = female and 2 = males), with work experience ranging from 7 to 10 years. The FGD at Hospital 2 had six nurses (4 = males and 2 = females) who had worked for 2 to 8 years. Meanwhile, the FGD at Hospital 3 had five nurses (2 = males and 3 = females), having the working experience ranging from 5 to above 10 years. The FGD at Hospital 4 involved five nurses (3 = females and 2 = males) who had worked between 6 and beyond 10 years.

The data were also collected from non-nurse healthcare providers (NN-HCPs) who were medical doctors, laboratory technicians, and pharmacists. Four FGDs were carried out at four hospitals. At Hospital 1, a total of 4 participants were involved in FGD whereby there were two medical doctors (1 = male and 1 = female), one pharmacist (male), and one lab technician (male), with working experience ranging from 5 and over 15 years. At hospital 2, the FGD comprised four participants, two physicians (1 = male and 1 = female), one pharmacist (female), and one laboratory technician (female), with working experience of 7 years. Moreover, Hospital 3 had four participants comprising of, two medical doctors (1 = male and 1 = female), one pharmacist (female), and one medical laboratory scientist (male) who had worked in their careers between 5 and 7 years. At Hospital 4, four participants comprising of, two medical doctors (1 = male and 1 = female), one pharmacist (female), and one medical laboratory scientist (male) having working experience ranging from 10 to 22 years participated in the FGD.

Additionally, the data from clients were collected from four hospitals, with a total of four FGD and a single FGD per hospital. A total of 23 clients participated across all FGDs (14 = Female & 9 = Male). At Hospital 1 the FGD had six participants (4 = Female and 2 = Male) and at Hospital 2 the FGD had six participants (3 = Female and 3 = Male). Additionally, at Hospital 3 the FGD had six participants (3 = Female and 3 = Male), while at Hospital 4 the FGD had five participants (4 = Female and 1 = Male). Refer to Table  1 .

Through content analysis, ten themes and thirty-three subthemes emerged from the study. The following are the themes; ① Variations of male and female nurses in communication ② Differences of male and female nurses in carrying out leadership roles ③ Divergent clinical qualities and outcomes across nursing gender ④ Positive value of male nurses in clinical facilities from colleagues and patients ⑤ Different cooperation of male and female nurses at the clinical settings ⑥ Mixed perceptions towards clinical competencies across nursing gender ⑦ Perspective towards gender diversity in nursing ⑧ Preferences of nurse’s gender, reasons, and opinion towards gender preferences. Refer to Table 2 .

Theme 1: variations of male and female nurses in communication

Both populations including nurses, non-nurse health care providers, and clients reported noticed differences in communication between female and male nurses. They differ in the communication approaches they use, and vary when conveying information to clients, and when discussing with other non-nurse healthcare providers. However, communication differences among female and male nurses are not influenced by their gender but rather by individual personalities, communication skills, and experience. The first theme had three sub-themes (Table  2 ), which are elaborated on below.

Subtheme 1.1: the existing variations in communication between male and female nurses

It was mentioned by nurses in FGDs that female and male nurses differ in how they communicate

“Communication styles can vary between male and female nurses” (FGD1-N) .

Consistently, the clients confirm the existing variations of communication between male nurses and female nurses

“I’m acknowledging that there might be variations in communication styles and approaches for male and female providers” (FGD4-C) .

Subtheme 1.2: areas of difference in communication between male and female nurses

Non-nurse HCPs in different FGDs revealed the presence of variation in how female and male nurses communicate, especially when conveying information to clients, when discussing with team members, and when discussing medication-related issues. When conveying information to clients, the difference is noticeable during normal conversation or when discussing medication.

“I have observed differences in the communication styles between male and female nurses when conveying information about patient medications. Female nurses often tend to provide more detailed information, while male nurses tend to focus on the key points. Both are effective, but it’s interesting to note the variation” (FGD1-NN-HCP) . “The variations in communication styles among male and female nurses that I might have noticed is when they are discussing medication-related matters. Female nurses give rather long and detailed approach when explaining medication instructions to clients, whereas male nurses might be a little brief” (FGD3-NN-HCP) . “I have also observed that some and not all female nurses tend to be more empathetic and nurturing in their communication style, especially when discussing medication plans or side effects with clients. On the other hand, male nurses might focus more on factual information of which both of these approaches have their strengths, but these differences do impact patient interactions” (FGD4-NN-HCP) .

NN-HCPs reported their experience, particularly the communication difference between male and female nurses based on the communication approach they use.

“In my experience, there are occasional differences in communication styles between male and female healthcare providers. Female colleagues often bring a more empathetic and nurturing approach, which can be beneficial in certain patient interactions. On the other hand, male colleagues might sometimes adopt a more direct or assertive communication style although we also have some male colleagues who portray the stated empathetic approach” (FGD1-NN-HCP) . “There have been instances where male nurses have been more concise and to the point in communicating medication orders, whereas female nurses might provide more contextual information about the patient’s condition” (FGD2-NN-HCP) .

NN-HCPs also mentioned the existing differences in communication between male and female nurses when discussing with other healthcare providers.

“In my experience, gender dynamics can influence communication styles within the healthcare team. For instance, I’ve noticed that there might be variations in how male and female colleagues express their opinions or share information during team discussions” (FGD1-NN-HCP) . “I have noticed that sometimes, gender-related communication styles can impact how prescriptions or medication information are relayed and occasionally, there’s a difference in how male and female nurses approach discussing drug interactions or side effects with us” (FGD2-NN-HCP) . “A male nurse might come in with a prescription and request for drugs and leave while a female nurse might ask some specific details as what type of food the patient should be told to eat and other basic stuff regarding the drugs. But also, not all female nurses do that because some male nurses inquire too though the percentage is small” (FGD2-NN-HCP) .

Subtheme 1.3: factors for communication differences between male and female nurses

There are factors beyond nursing gender influencing how female and male nurses communicate, especially individual personalities, communication skills, and experience.

“It’s more about individual personalities and communication skills rather than a distinct difference based on gender” (FGD2-N) . “It’s more about individual personalities and experiences shaping communication (FGD3-N) . “Each individual brings their unique approach, influenced by personality and experience rather than being strictly gender-based” (FGD4-N) .

Theme 2: differences between male and female nurses in carrying out leadership roles

NN-HCPs revealed that nurse gender influences leadership capability. The variation is observed in the leadership style used by male and female nurses. Some use authoritative and others use democratic leadership style. The second theme had two sub-themes (Table  2 ), which are elaborated in detail below.

Subtheme 2.1: the existing variation in leadership between male and female nurses

NN-HCPs have indicated that nurses of different genders when in positions of leadership, differ in executing leadership roles.

“I have also noticed some slight variation in leadership styles between male and female nurses” (FGD3-NN-HCP).

Subtheme 2.2: different leadership styles used by male and female nurses

NN-HCPs mentioned that they have experienced seeing male nurses practicing an authoritative leadership style while female nurses assume a democratic leadership style. They added that the leadership style used by female nurses is good as it promotes staff involvement and enhances interaction.

“Sometimes, female nurses exhibit more collaborative leadership, while male nurses might take a more authoritative approach. This can influence how tasks are delegated and how teamwork unfolds within the healthcare unit” (FGD3-NN-HCP).

Theme 3: divergent clinical qualities and outcomes across nursing gender

Most nurses, NN-HCPs, and clients in different FGDs reported variations of clinical qualities for male and female nurses. As it is with male nurses possess positive and negative qualities in clinical settings, and female nurses do. Yet, some participants in different FGDs did not mention separate qualities for male or female nurses but rather put forth the shared qualities among nursing genders. The third theme had five sub-themes (Table  2 ), which are elaborated on below.

Subtheme 3.1: both male and female nurses’ positive qualities in clinical practice

Nurses in different FGDs indicated that male and female nurses have some common positive qualities in clinical areas, including being good at collaboration and exercising effective communication.

“I’ have also had positive experiences of good collaboration among nurses of different genders” (FGD2-N) . “I had a great experience where effective communication among team members, regardless of gender, led to a quick response to a critical situation” (FGD4-N).

Nevertheless, NN-HCPs confirmed that both male and female nurses do present positive characteristics in clinical settings, including empathy, communication, teamwork in nursing care, and commitment to patient well-being, both excel in their roles and dedication to delivering high-quality care.

“I’ve come to appreciate the importance of empathy, communication, and teamwork in nursing care, regardless of the nurse’s gender” (FGD1-NN-HCP). “I think nurses regardless of gender identity, demonstrate remarkable teamwork and dedication to patient care” (FGD2-NN-HCP). “What’s evident is the nurse’s shared commitment to patient well-being, which transcends any gender-related differences. Their collective focus on teamwork and patient-centered care is commendable” (FGD1-NN-HCP). “In my experience, nurses’ dedication to delivering high-quality care remains consistent regardless of gender identity” (FGD2-NN-HCP).

The clients also reported positive qualities of both male and female nurses in clinical practice, including attentiveness, good communication skills, sympathy, peacefulness, and response to clients’ needs

“The nurses, both male and female, were generally more attentive and communicative than the doctor in that particular instance” (FGD3-C). “It made me realize that nurses aside from them being either male or female show qualities like sympathy and communication well regardless of gender. I believe the majority of them possess that sense of peacefulness” (FGD3-C). “I found that nurses, regardless of gender, were often more attuned to clients’ needs and concerns” (FGD3-C).

Subtheme 3.2: male nurses’ positive qualities and impact in clinical practice

Nurses themselves mentioned several positive qualities in male nurses, including being expert, calm, empathetic, attentive to details, skilled in analyzing data, skilled in recognizing changes in the patient’s condition, tend to be more direct and concise in their communication, solution-oriented communication style, ability to connect with young clients and their families, and adaptability in nursing.

“He approached the situation with an orderly yet empathetic approach that immediately put all of us at ease and created a sense of trust and mutual respect. Our collaboration was perfect and I just loved his attention to detail regarding the patient’s condition. This nurse’s skill for analyzing data and recognizing any changes in the patient’s condition, was good which greatly contributed to the accuracy of our assessments and interventions” (FGD1-N).

NN-HCPs on the other hand described male nurses as being more direct, taking a more collaborative approach, calm and confident, using the empathetic approach, more of what the rules state, too much of protocol, kind, more trusted, more compassionate, more task-oriented, and focusing on efficient execution of care plans.

“Some male nurses being more direct and others taking a more collaborative approach” (FGD1-NN-HCP). “Male nurses, on the other hand, can bring a sense of calm and confidence, especially in high-pressure situations” (FGD1-NN-HCP). “Male nurses are more of what the rules state……too much of protocol” (FGD2-NN-HCP). “I have seen male nurses who are more compassionate” (FGD3-NN-HCP). “I think in working and collaborating with male nurses they show a more task-oriented approach, focusing on the efficient execution of care plans which sometimes eases our work” (FGD4-NN-HCP).

In the same way, clients mentioned the positive qualities of male nurses in clinical settings, including delivering comprehensive health education, competent, having good communication skills, promoting patient comfort, being attentive, introducing themselves to clients to be known, and communicating the procedure before doing it

“I am a hypertensive person with diabetes. As for me, a male nurse, in particular, stood out for the way he always attended to me when I came to the hospital. Truthfully speaking he answers all my concerns and explains my treatment plan clearly in a way that I feel so well understood and heard” (FGD4-C). “I can recall a particular incident with a specific nurse who attended to me when I came to the hospital. This nurse was a man and I loved how he attended to me. Since I was undergoing a challenging procedure, the nurse not only displayed practical skills during a challenging procedure but also maintained a kind and comforting approach when dealing with me. I loved his ability to effectively communicate and it seriously had a big impact on my overall experience” (FGD3-C). “Some male nurses were incredibly attentive and competent” (FGD3-C). “The good experience was this male nurse who when I arrived received me and happily introduced himself I later learned that he was a student. But the way he handled me and explained every procedure I was supposed to do made me feel good. He even allowed me to ask questions if I had any. I have never been handled that way before. It left me feeling good” (FGD4-C).

Nurses, NN-HCPs, and clients discussed the impact of the possessed positive qualities by nurses in the clinical areas. Having positive qualities result in positive effects. Nurses in different FGDs stated that when male nurses hold positive qualities in clinical facilities, it helps to put other nurses at ease, create a sense of trust, establish mutual respect, and promote the accuracy of assessments and interventions.

“He approached the situation with an orderly yet empathetic approach that immediately put all of us at ease and created a sense of trust and mutual respect” (FGD1-N). “This nurse’s skill for analyzing data and recognizing any changes in the patient’s condition, was good which greatly contributed to the accuracy of our assessments and interventions” (FGD1-N). NN-HCPs emphasized that when male nurses have positive characteristics in the clinical setting, create a spirit of collaboration within the team. “There have been instances where male nurses appeared more confident in voicing their opinions or suggestions during patient rounds which might sometimes affect the overall collaboration, especially when decisions need to be made collectively” (FGD2-NN-HCP). Clients also showed that the male’s positive qualities in clinical areas aid in preventing stress and promote good feelings among clients. “It seriously had a big impact on my overall experience. He removed my anxiety and I felt so peaceful” (FGD3-C).

Subtheme 3.3: male nurses’ negative qualities and effects on clinical practice

Nurses in different FGDs disclosed that male nurses are authoritative and with inappropriate comments on some issues that influence suboptimal outcomes in clinical settings. “Male nurses might be perceived as more authoritative” (FGD1-N). “I encountered a situation where a male nurse made inappropriate comments about my uniform which I think had suited me well and putting in mind I have a big body which created an uncomfortable working environment” (FGD2-N). Nevertheless, NN-HCPs reveal that male nurses are assertive, love to be addressed as doctors by clients, and tend to spread rumors and gossip. “Some male nurses might be thought to be assertive, leading the clients to respond differently to medication adherence discussion” (FGD3-NN-HCP). “Majority of male nurses would love to be addressed as doctors by clients and they do want to assume they are doctors and forget their roles as nurses who have specified roles and responsibilities” (FGD4-NN-HCP). “I tend to see male nurses as people who one has to be careful with as they have the .

tendency to spread rumors” (FGD4-NN-HCP).

Clients disclosed the negative qualities of male nurses in the clinical setting, especially their carelessness of patient’s pain during clinical procedures, lack of empathy, lack of caring habits, lack of professionalism, maintaining no privacy for clients, and dislike of being addressed as a nurse rather as a doctor

“I was once admitted because I had a wound on my right leg, as I was being cleaned my wound by a male nurse who regardless of telling him I was in severe pain when he was removing the bandages, did not listen and pulled them painfully and I ended up enduring the pain. Then the dressing time (laughs nervously) arrived, he cleaned the wound very very roughly without giving me medication to help and after he had finished cleaning, he told me to pick up the used bandages and dispose of them myself” (FGD1-C). “The nurse I interacted with, was a male, and I couldn’t help but wonder if his apparent lack of sympathy for my pain” (FGD1-C). “I was admitted for a minor surgical procedure, and while most of the nursing staff were fantastic, there was this one male nurse who seemed disinterested and indifferent from the moment he walked in. He was brusque in his mannerisms, displaying a lack of empathy or concern for my well-being. During one instance, when I was experiencing severe pain and requested pain relief, he brushed it off, saying, ‘It’s not that bad, you’ll manage.’ It felt dismissive and insensitive, especially considering the discomfort I was in. What made matters worse was his lack of professionalism in maintaining my privacy. He didn’t properly close the curtain around my bed when attending to me, exposing me to unnecessary views from other clients and passersby in the hallway. It was embarrassing and made me feel vulnerable” (FGD3-C). “Male seems more authoritative” (FGD3-C). “I also had a bad experience still with a male professional who at first I thought was a doctor but as I was admitted one of the doctors called out “call for me that nurse. I looked and saw that he was the one being called, when he came letter to give me medicine I jokingly said that “…so nowadays you males are nurses which is good” I was kind of happy to see him as a male nurse since all the time I had been referring to him as a doctor. Weeeee……. I have never seen that anger, he thought I was making fun of him, threw my drug on my bed, and told me to medicate myself. To be sincere, I felt bad and from then till I was discharged I was treated very badly by some nurses in that ward and if I don’t remind them to give me drugs they don’t give me” (FGD4-C).

Nurses, NN-HCPs, and clients reported that the negative qualities of nurses are linked to negative outcomes in the clinical setting. NN-HCPs indicated that when male nurses demonstrate negative qualities in clinical areas it affects clients, especially in medication adherence, and affects physicians in practice.

“Majority of male nurses would love to be addressed as doctors, but sometimes it hampers my work. There is this scenario in which I was treating a patient and I told him to be doing physical exercise due to his weight and when I came back to make a follow-up, he told me Dr X had been very helpful and was assisting him whenever he wanted to walk around. Looking for Dr X, I found out he was a nurse that was when I noticed all the clients were referring to all male nurses in that unit as doctors……Later when I instructed the patient to take a certain drug, he literary said he would counter check with Dr X” (FGD4-NN-HCP). “I also encounter the same problems in my unit and sometimes it hinders my work too. I think male nurses should accept that they are nurses and love their profession. Please note that not all male nurses have this character” (FGD4-NN-HCP). “Some male nurses might be thought to be assertive, leading the clients to respond differently to medication adherence discussion” (FGD3-NN-HCP). Clients expressed the negative consequences that result from negative characteristics possessed or demonstrated by male nurses. The effects include clients’ frustration, and scared, it erodes patient’s trust in the healthcare system, makes clients hesitate to seek medical help, and leaves clients feeling uncomfortable. “It was incredibly frustrating. I spent my entire hospital stay so scared for every time my wound was to be cleaned and the 4 days I was there it was always being cleaned by the male nurses who were just the same. I hated the hospital and specifically any male nurse as I know it’s like they were being forced to work in the hospital” (FGD1-C). “It eroded my trust in the healthcare system to some extent. I nowadays find myself hesitating to seek medical help unless necessary like today I have just come because I need the X-ray which I have been told is important to do it” (FGD1-C). “I had an unfortunate encounter with a male nurse during my recent hospital stay that left me extremely uncomfortable” (FGD3-C). “It felt dismissive and insensitive, especially considering the discomfort I was in” (FGD3-C). “He didn’t properly close the curtain around my bed when attending to me, exposing me to unnecessary views from other clients and passersby in the hallway. It was embarrassing and made me feel vulnerable” (FGD3-C). “I felt ignored, disrespected, and overall neglected under his care” (FGD3-C).

Subtheme 3.4: female nurses’ positive qualities and outcomes in clinical practice

Nurses in different FDGs acknowledged that female nurses possess positive qualities in hospitals. Several qualities were mentioned, including calmness, effective communication, team coordination, empathy, nurturing, detail in their communication, focus on emotional aspects during communication, building rapport, fostering open communication, and innovation in patient care.

“Female healthcare providers often display more empathy and tend to focus on emotional aspects during communication” (FGD1-N). “I’ve observed a different dynamic during patient consultations. Female healthcare providers, especially doctors and nurses, often excel in building rapport and fostering open communication” (FGD4-N).

Yet, NN-HCPs revealed that female nurses are more empathetic, in a nurturing manner. They seem more understanding, often assign tasks, seek assistance, build rapport, establish trust with clients, and put emphasis on team collaboration. Moreover, they are compassionate, use a holistic approach to care, prefer open communication, and create comfortable and supportive environments for clients.

“Female nurses I have interacted with show excellent teamwork skills, fostering collaboration and open communication within the healthcare team” (FGD4-NN-HCP). “Some female nurses might approach the same scenarios with a more empathetic or nurturing manner” (FGD1-NN-HCP). “Female nurses tend to excel in creating a comfortable and supportive environment for clients” (FGD2-NN-HCP). “Some female nurses being seen as more understanding, influencing how clients engage in these conversations” (FGD3-NN-HCP).

Clients in different FGDs had similar observations as nurses and NN-HCPs. They reported that female nurses deliver comprehensive education and navigation care to clients. They added that female nurses are sympathetic, empathetic, skilled, have good communication skills, involve clients in decision-making, compassionate

“She not only explained to me my sickness at the time she also took time to thoroughly explain what I was supposed to eat and even offered to direct me to a seller who sells the food. Aside from that, she offered me an opportunity to explain what she had taught me to see if I had understood. I felt good” (FGD1-C). “Female nurse would naturally be more sympathetic than a male nurse” (FGD2-C). “One nurse, in particular, stood out. She was exceptionally skilled at balancing technical skills with genuine understanding while attending to me. This nurse showcased qualities that I would value in any healthcare professional, regardless of gender. Her communication was clear, she took the time to listen to my concerns, and she actively involved me in decisions about my care. It made me realize that these qualities are not exclusive to a particular gender but are essential components of effective nursing practice” (FGD1-C). “One nurse, a female was good as she was a key part of my recovery after surgery. Her approach was remarkable. Not just in terms of ability to see my healing process but also in her ability to connect with me on a personal level” (FGD1-C). “The nurse went beyond the regular care routine. She took the time to explain each step of my recovery process, making sure I felt informed and involved. Moreover, her empathetic and compassionate behavior was good” (FGD1-C).

As it is with male nurses, nurses, NN-HCPs, and clients reported that the positive qualities possessed by female nurses corresponds to the positive outcomes at the clinical areas. Only one FGD for nurses appreciated the positive outcome from the positive qualities possessed by female nurses. They reported that female nurses enabled team dynamics during patient care.

“I have a positive experience working with a female nurse during a particularly challenging night shift where we have multiple accident victims and short staffed. Her calm demeanor and effective communication made a significant impact on the overall team dynamics” (FGD1-N).

On the other hand, NN-HCPs discussed that the positive qualities of female nurses remain the key factor influencing how clients engage in conversations.

“Female nurses being seen as more understanding, influencing how clients engage in these conversations” (FGD3-NN-HCP).

Similarly, Clients mentioned that the positive qualities of female nurses have resulted in clients feeling involved, supported, and comfortable.

“Her empathetic and compassionate behavior made the hospital environment feel more supportive for me” (FGD1-C). “I had a female nurse who made me feel comfortable during a sensitive exam. It made a big difference” (FGD2-C).

Subtheme 3.5: female nurses’ negative qualities and repercussions in clinical practice

Nurses in separate FGDs proclaimed that female nurses have negative characteristics in clinical areas that may have repercussions on patient care, such as being unable to correctly interpret clients’ instructions, having emotional reactions, and lacking confidence.

“I think she had misinterpreted the clients’ instruction regarding a prescribed drug. When I told her she had misinterpreted the records she was so angry for no reason and told me that I was also a mere male nurse and should not bossy her” (FGD1-N). “I’ve witnessed instances where we as female nurses are sometimes assumed to be less assertive or confident, especially in decision-making situations and it creates a challenging work environment, especially in cases where you make stern decisions regarding a staff behaviour” (FGD4-N).

Furthermore, NN-HCPs mentioned only that female nurses are too argumentative in a clinical setting

“Female nurses tend to be too argumentative” (FGD4-NN-HCP).

Clients also uncovered some negative qualities of female nurses in the clinical areas. They mentioned that female nurses don’t communicate the procedure before implementation, possess poor communication skills, especially listening skills, are disinterested in clients’ needs, are impatient, do not respond to clients’ needs, delay in responding to patient demands, inefficient, less attentive, lack caring spirit, possess anger, doing tasks hastily like having other things to attend, and appeared visibly stressed

“I had an unfortunate encounter with a female nurse that left me extremely uncomfortable. As someone who has always respected nurses, this experience shook my confidence. From the outset, the nurse appeared visibly stressed and overwhelmed. She didn’t announce herself when attending to me just ordered me to turn over and injected me not telling me what she had injected me with or whatever. I even didn’t want to ask her what it was (laughing) lest she rebuke me and seemed in a rush to attend to other tasks. Later when I tried to communicate my symptoms and concerns, she interrupted me multiple times, and it felt like she wasn’t even listening to me. I felt bad and here I was knowing that female nurses are more caring. This was my personal experience with this nurse though I have had better female nurses attending to me previously” (FGD2-C). “There was one incident that bothered me. I was feeling that I needed more effort to breathe and I could feel the difficulty in breathing, and when I called for assistance, it took a considerable amount of time for her to respond. When she finally arrived, she seemed annoyed and didn’t take the time to understand my situation. Instead, she administered medication without explaining what it was for or how it would help” (FGD3-C). “During my hospital stay, I noticed that this specific nurse was often impatient and seemed disinterested. Whenever I tried to ask questions about my treatment or express concerns about my symptoms, she brushed them off” (FGD3-C). “Few female nurses seemed inefficient and less attentive” (FGD3-C). “There was a female nurse who seemed like she did not care about my well-being, and the instructions regarding the drugs she had given me I did not well grasp and let me fill up the blanks. I tend to think maybe there were a lot of clients waiting to be attended but when I later saw that she was free, I went back to her for her to explain further but she angrily brushed me off. Luckily I went to a pharmacy shop and the shopkeeper explained to me” (FGD4-C). Clients disclosed the interdependence of female nurses’ negative qualities and negative impact at the clinical settings. Only clients in FGDs reported the negative outcomes that are likely to occur when female nurses possess negative qualities in clinical settings. Among the effects is clients feeling neglected and a burden. It also erodes clients’ trust in the healthcare system. “It made me feel like I was being a burden rather than someone in need of care” (FGD3-C). “It was disheartening. I came to the hospital seeking help and understanding, but I felt neglected and dismissed. It eroded my trust in the healthcare system and left me questioning the quality of care provided in such settings” (FGD3-C).

Theme 4: positive value of male nurses in clinical facilities from colleagues and clients

Male nurses seem to be much more valued compared to female nurses. They are valued by their colleague nurses and by clients cared for. The fourth theme had two sub-themes (Table  2 ), and the detailed information are provided below.

Subtheme 4.1: value of male nurses by colleague

It was reported that the suggestions given by male nurses are more likely to be acknowledged and accepted than what is suggested by female nurses. Moreover, the recovery of clients is associated with male nurse’s care despite the involvement of female nurses during the care.

“I’ve had instances where my suggestions are overlooked during team discussions, and if the suggestion comes from a male colleague who is a nurse it is accepted” (FGD3-N). “There have been instances where male colleagues were given more credit for successful patient outcomes, even when it was a collaborative effort. There was a time when we worked tirelessly on a patient who had an ulcerative wound cleaning and making sure the healing process was as per the standards. After 2 months, the patient started walking and the wound was healed. During the morning meeting., one male doctor openly praised a male staff in the same ward I was in for making sure the patient did not turn up with an infection” (FGD3-N). “I’ve had instances where my suggestions were sometimes overlooked during team discussions, and it seemed that my male colleagues received more immediate acknowledgment” (FGD4-N).

Subtheme 4.2: value of male nurses from clients

Male nurses are more trusted in the healthcare setting as compared to females and receive exceptional respect from their counterparts.

“I’ve had instances where my fellow male nurse colleagues received more immediate trust and respect from clients, even if we had similar qualifications. This behavior from the clients makes me so dissatisfied and see a need to educate them that whether male or female, a nurse is a nurse” (FGD2-N).

Theme 5: Different cooperation between male and female nurses in clinical settings

Nurses and clients in the FGDs discussed the interaction of male and female nurses in the clinical areas. Some mentioned the presence of good interaction and others reported poor interaction. They emphasized that the status of interaction among these nurses has a direct impact on nursing care. The fifth theme had two sub-themes (Table  2 ), which are elaborated on below.

Subtheme 5.1: Good interaction between male and female nurses .

Clients discussed their experiences and observations, mentioning that male and female nurses have good teamwork during nursing care and are in unity.

“I have noticed a sense of unity among nursing and it doesn’t seem to be influenced by gender. Especially in their social events and celebrations” (FGD2-C). “I’ve witnessed instances where nurses, regardless of gender, have shown great teamwork” (FGD3-C).

Subtheme 5.2: poor interaction of male and female nurses in clinical practice

There is poor interaction between male and female nurses especially when female nurses don’t want male nurses to provide any advice, which automatically distorts the whole coordination of care.

“I had when I was working with a female nurse in the ICU, thank God she is not among us here. I think she had misinterpreted clients the clients’ instructions regarding a prescribed drug. When I told her she had misinterpreted the records she was so angry for no reason and told me that I was also a mere male nurse and should not boss her Later our communication was strained, and it affected the overall coordination of care and luckily, I was transferred to the Medical Unit” (FGD1-N).

Theme 6: mixed perspectives towards clinical competencies across nursing gender

Through different FGDs by nurses, two subthemes emerged in the study including a negative perspective of male nurses’ clinical competency and a negative perspective of female nurses’ clinical competency. The sixth theme had two sub-themes (Table  2 ), which are elaborated on below.

Subtheme 6.1: negative perspective towards male nurses’ clinical competency

Female nurses have been holding negative perspectives of the competencies of male nurses as they doubt whether male nurses can deliver the needed care to the nursing mothers or even demonstrate empathy when giving care to clients.

“I know a lot of incidences where my ward in charge assumes that I can’t offer counseling, especially to nursing mothers simply because of my gender. I also remember during a team meeting, openly asked if I know how to display empathy, I felt bad although it sounded like a joke but still it had an underlying meaning” (FGD1-N).

Subtheme 6.2: negative perspective towards female nurses’ clinical competency

Even though female nurses are skilled, they are perceived to be unable to handle emergency issues, especially for clients in need of critical care.

“I can testify to this as I have personally witnessed an emergency at EMD and the female nurse was the second in charge as the in-charge male was not around, she was assumed to be less capable of handling emergencies simply because of her gender and a male nurse in charge of a particular unit was tasked to handle the situation. Despite the female nurse being experienced and skilled, there was an automatic assumption that a male nurse would handle critical cases better” (FGD1-N).

Theme 7: perspective towards gender diversity in nursing

Several participant nurses, NN-HCPs, and clients in different FGDs had different perspectives in regard to gender diversity in nursing. Their perspectives are categorized into; the need for diversity in nursing, the need to address gender biases in nursing, the relationship between nursing gender and competence, and the distribution of opportunities. The seventh theme had four sub-themes (Table  2 ), which are detailed elaborated on below.

Subtheme 7.1: the need for diversity in nursing

Nurses have indicated that diversity in nursing is good, and there is a need to embrace it. It is associated with the strength within the team and creates a suitable environment in the delivery of healthcare.

“It’s about embracing diversity as a strength within the team” (FGD1-N). NN-HCPs confirmed that there is a demand for gender diversity in nursing. It should be appreciated, respected, embraced, celebrated, and valued due to its benefits. “Nursing practices should prioritize a collaborative environment where diverse approaches are valued, focusing on delivering the best patient-centred care” (FGD4-NN-HCP). “I have also come to appreciate the diverse skill sets and approaches that both male and female nurses bring to patient care” (FGD3-NN-HCP). “The gender diversity within nursing should be celebrated” (FGD1-NN-HCP). “It is important to embrace and respect diverse styles and strengths from different healthcare providers regardless of gender” (FGD2-NN-HCP). “My limited interactions with nurses of different genders have shown me the significance of acknowledging and valuing diverse communication styles regardless of gender” (FGD2-NN-HCP). Meanwhile, clients supported the views of nurses and NN-HCPs by showing that having gender diversity in nursing is a good asset and brings different tastes to a clinical setting. “I also think the hospital needs to have both male and female nurses from different parts of Tanzania to bring in different tastes” (FGD4-C). “Both male and female in the nursing profession is an asset” (FGD4-C).

Subtheme 7.2: the demand to address gender biases in nursing

Due to the significance of gender diversity in nursing, the participants indicated that the effort to address challenges as gender diversity in nursing is inevitable. When gender bias is overcomed, patient care will be optimal.

“There is the need for continuous efforts to challenge and overcome gender biases in healthcare” (FGD1-N). “It emphasizes the importance of recognizing and addressing biases to ensure that every nurse, irrespective of gender, has the opportunity to contribute fully to patient care” (FGD1-N). “Address any concerns related to gender or other factors that might impact patient care” (FGD2-N).

Subtheme 7.3: the relation between nursing gender and competence

Te majority of nurses in different FGDs emphasized that nurse performance is not determined by nurse gender but rather by competence, professionalism, empathy, effective communication, expertise, dedication to work, and commitment.

“I believe competence and professionalism are crucial in healthcare, regardless of gender” (FGD1-N). “There is a need for a shift towards recognizing and valuing competence and skills over traditional gender roles” (FGD1-N). “Nursing excellence is not bound by gender (FGD1-N). “It is important to look beyond gender stereotypes in nursing. Positive collaborations . showcased that competence, empathy, and effective communication are essential qualities, irrespective of gender” (FGD2-N). “Qualities like empathy and adaptability are crucial in healthcare, and they are not bound by gender” (FGD2-N).

In the same line, NN-HCPs highlighted that expectations from nurses should be based on individual capabilities and skills rather than gender stereotypes. Moreover, NN-HCPs were of the opinion that qualities like compassion, expertise, effective collaboration, and understanding aren’t tied to any specific gender. The high level of professionalism and dedication from nursing personnel focuses more on competency rather than gender-specific traits. They emphasized that gender doesn’t determine competency but rather contributes to a rich diversity in nursing practice. Therefore, understanding the importance of individual strengths and skills rather than gender in nursing is essential.

“I’ve also learned that expectations should be based on individual capabilities and skills rather than gender stereotypes” (FGD1-NN-HCP). “I think we need to appreciate the diverse strengths of nurses, irrespective of gender and acknowledge individual skills and communication styles rather than categorizing based on gender as I expect a high level of professionalism and dedication from nursing personnel focusing more on competency than gender-specific traits” (FGD2-NN-HCP). “My experiences have shown me that nursing is a field where competence and compassion matter more than gender. While I acknowledge different communication styles, I’ve come to expect professionalism and dedication from nurses, irrespective of gender” (FGD3-NN-HCP).

The majority of clients in different FGDs show that gender in nursing does not predict excellence in the delivery of care. They insisted that good communication skills, caring, delivery of nursing services, quality of care, and compassion are not linked to gender, but rather individual competency.

“I’ve had positive experiences with both male and female nurses in the past, but it made me more aware of the need for providing good nursing service irrespective of gender” (FGD2-C). “I believe they have the qualities to take care of all clients, regardless of whether the nurse is male or female. It’s about the personal connection and the ability to understand the unique needs of the patient” (FGD2-C). “I came to see nursing practice as a profession where the emphasis is more on the individual’s skills, rather than their gender” (FGD3-C). “It’s about the individual’s ability to connect with me on a personal level that will make me feel comfortable that I am being properly attended to” (FGD4-C). “Positive interactions with nurses of both genders have shown me that competence and . communication are important irrespective of gender. We have heard how a male nurse was good and how another male nurse was bad and vice versa with the female. I think practice should not be tied to gender” (FGD4-C).

Subtheme 7.4: distinct importance of nursing gender diversity to patients and nurses

The availability of both male and female nurses at the healthcare facility has the benefits to clients, especially, creates a supportive environment, allowing clients to choose the preferred gender during the care. It influences the clients to express their needs freely, which promotes the patient’s comfortable experience.

“Most of the time and within our unit we have noticed that clients sometimes feel more comfortable discussing certain concerns with healthcare providers of the same gender. This awareness in our team allows us to ensure clients’ preferences are respected” (FGD1-N). “Creating a diverse and inclusive healthcare environment is important. Having a team with a variety of genders allows clients to have choices and may contribute to a more comfortable experience” (FGD1-N). “Regardless of gender identity, a collaborative approach ensures that diverse skills and perspectives are utilized for the benefit of the patient” (FGD1-N). “I’ve also encountered situations where clients, especially in diverse cultural contexts, had strong preferences for healthcare providers of the same gender. Being aware of and accommodating these preferences is crucial for providing patient-centered care” (FGD2-N). “I’ve seen instances where having a diverse team, including both male and female healthcare providers. Different perspectives contribute to more comprehensive and well-rounded patient care” (FGD4-N). “I want to highlight a positive experience where our team, consisting of both male and female nurses, collaborated exceptionally well during a challenging situation, and ended up saving the patient’s life. Indeed, without working together, we would have lost the patient” (FGD4-N). “Positive experiences have shown me the strength of diversity in improving patient outcomes” (FGD1-N).

Consistently, the NN-HCPs indicated that varied perspectives and diverse communication styles contribute significantly to patient care, contribute to a well-rounded and patient-focused care environment, address the diverse needs of clients, impact patient care, and promote a holistic approach to patient care.

“Witnessing the diverse strengths and approaches of both male and female nurses has reinforced my belief in the importance of a gender-diverse nursing workforce. It’s evident that these varied perspectives and communication styles contribute significantly to patient care” (FGD1-NN-HCP). “I think recognizing the unique strengths each gender brings to nursing practice has reinforced the importance of an inclusive and diverse nursing team as it’s with these varied approaches that contribute to a well-rounded and patient-focused care environment” (FGD1-NN-HCP). “Often results in comprehensive care plans that address the diverse needs of clients” (FGD2-NN-HCP). “Both male and female nurses bring unique perspectives and strengths that positively impact patient care regardless of their communication styles” (FGD3-NN-HCP). “Each nurse, regardless of gender, brings valuable perspectives that contribute to a holistic approach in patient care” (FGD3-NN-HCP). “Their ability to work together, leveraging individual strengths, fosters an environment conducive to excellent patient outcomes” (FGD2-NN-HCP).

Several nurses’ discussions in different FGDs indicate that gender diversity in nursing has many advantages for nurses themselves. It enhances the overall team dynamic, creates a supportive work environment, learn from each other, shares insights, promotes collaboration, enhances inclusive decision-making, influences personal comfort, and ease of communication and coordination. Moreover, gender diversity fosters problem-solving approaches and brings different perspectives.

“Having both male and female colleagues has created a supportive work environment. We learn from each other, share insights, and that friendship enhances the overall team dynamic” (FGD1-N). “Positive experiences have shown the benefits of inclusive decision-making, showcasing that everyone’s input matters” (FGD1-N). “In my experience, diverse teams with a mix of male and female nurses bring different perspectives and problem-solving approaches” (FGD2-N) . “Having diverse healthcare teams can contribute to a more understanding and inclusive environment” (FGD3-N) . “I’ve been part of teams where mutual respect and support, regardless of gender, created an enjoyable work environment” (FGD4-N) . Similarly, the NN-HCPs, reported that gender diversity in nursing enhances the overall team dynamic, better teamwork, enriching the overall healthcare delivery, ability to connect with clients, quality care, brings unique perspectives and strengths, enriches nursing practice, brings valuable perspectives, diverse skill sets and communication styles to their practice. “I think the gender mix among nurses can enhance the overall team dynamic” (FGD1-NN-HCP) . “Gender diversity in nursing can foster better teamwork and understanding” (FGD1-NN-HCP) . “Male and female nurses offer, enriching our overall healthcare delivery. It’s also good to note that gender can influence team dynamics among nurses” (FGD1-NN-HCP) . “I think from my experience, gender dynamics with nurses can indeed play a role in collaboration” (FGD2-NN-HCP) . “From my experience, I think that gender diversity among nurses enhances the collaborative nature of healthcare teams. Both male and female nurses bring unique perspectives and strengths” (FGD3-NN-HCP) . “I think nurses of different genders bring diverse skill sets and communication styles to their practice” (FGD4-NN-HCP) .

Theme 8: preferences of nurse’s gender, reasons, and opinion towards gender preferences

Nurses, NN-HCPs, and clients in different FGDs were asked about issues related to nursing gender preferences. NN-HCPs revealed their experiences on which clients had a preference of a specific nurse gender to be cared by. On the other hand, nurses in FGDs reported that when they sought medical attention, they had mixed reactions on which gender they prefer to care for them. Meanwhile, clients expressed their preferred gender nurse when seeking medical attention. Therefore, seven subthemes emerged in this area, including; having no gender preference for nurses, having a preference for nurses of a specific gender, having a preference for nurses of the same gender, having a preference for nurses of the opposite gender, reasons for gender preferences, the challenge of meeting clients’ preferences through nurse’s gender diversity, and different opinion about gender preferences. The eighth theme had seven sub-themes (Table  2 ), which are elaborated on below.

Subtheme 8.1: having no gender preference for nurses

One participant in a single FGD mentioned that clients had no preference for nurse gender rather they felt comfortable with any gender.

“I have observed situations where clients didn’t have a preference and were comfortable with healthcare providers of any gender” (FGD4-NN-HCP).

Some clients in FGDs indicated that they have never deliberately chosen to have a specific gender when seeking medical help.

“I have never had a conscious preference for a nurse of a specific gender. To me, it’s always been about the individual’s competence, communication skills, and ability to connect with clients. I believe these qualities are not confined to any particular gender” (FGD1-C). “No, gender has never been a deciding factor for me. I look for qualities such as kindness, attentiveness, and professionalism. These attributes can be found in nurses of any gender, and that’s what influences my comfort and trust in their care” (FGD2-C). “I haven’t had a specific preference for a nurse’s gender. For me, it’s always been about who is around to help me” (FGD3-C).

Consistently, the majority of nurses in the FGDs show no preference for gender nurses but rather accept any available nurse with the required competencies.

“I also have never had any preference for a nurse’s gender. I believe competence . and professionalism is crucial in healthcare, regardless of gender” (FGD1-N). “Now that I am a nurse it will seem funny if I have a preference because I know all or majority of us have gone through the same educational training. But as a patient, I think I never had a specific preference for a nurse’s gender. What matters most to me is their competence, communication skills, and ability to provide compassionate care” (FGD2-N). “I’ve never had a specific preference for a nurse’s gender as what I look for is competence, communication skills, and ability to provide compassionate care” (FGD3-N).

Subtheme 8.2: having a preference for nurses of a specific gender

Clients feel more at ease discussing sensitive topics with a nurse of the same gender and when they are receiving instructions or explanations about their medications.

“I’ve encountered clients who had preferences for a nurse of a specific gender while receiving instructions or explanations about their medications” (FGD1-NN-HCP). “I have come to understand that clients might sometimes express preferences for nurses of a specific gender” (FGD2-NN-HCP). “Clients feel more at ease or open to discussing certain health issues with nurses of their preferred gender, which can impact the overall care experience” (FGD3-NN-HCP).

One client mentioned being comfortable or understood when a nurse of a certain gender is available and providing care.

“I found myself paying more attention to the gender of the healthcare professionals involved in my care. It made me consider whether I felt more comfortable or understood when the nurse was of a certain gender. It’s not that I believe one gender is inherently better, but this experience has made me more attuned to the dynamics and the impact it might have on my experience” (FGD1-C).

Subtheme 8.3: having a preference for nurses of the same gender

NN-HCPs in different FGDs expressed their experiences where they have observed clients preferring to receive care from nurses of the same gender. Their preferences are based on when they have sensitive issues to share with healthcare provider

“Some female clients might feel more comfortable discussing certain personal or sensitive issues with female doctors or nurses” (FGD2-NN-HCP). “The clients may feel more at ease and communicate more openly with a nurse of the same gender” (FGD3-NN-HCP). “There were instances where clients seemed more persuaded to share personal details with nurses of the same gender, which could potentially impact the information conveyed to the medical team” (FGD3-NN-HCP). “I have encountered clients who felt more at ease discussing sensitive topics like personal hygiene or reproductive health with a nurse of the same gender” (FGD4-NN-HCP). “There might be a preference for same-gender care providers during intimate procedures or examinations due to modesty or religious reasons” (FGD4-NN-HCP).

Clients in different FGDs reported that they prefer nurses of the same gender when discussing personal issues. They feel comfortable and receive sympathy.

“As a female, during discussions about the more personal aspects of my well-being, I somehow felt more comfortable talking to female nurses. It was my understanding that they might be more open to these discussions” (FGD1-C). “As a male, I’ve sometimes felt more comfortable with male nurses during certain personal care situations. It’s not about competence, but more about feeling understood. Nevertheless, I’ve had exceptional care from nurses of both genders” (FGD3-C).

Nurses in FGDs revealed their preference and desire to have nurses of the same gender when seeking medical attention. They too mentioned their observation where clients deliberately ask the nurse of the same gender.

“I must admit that in certain situations, I’ve felt more at ease with healthcare providers of the same gender. It’s not a strict preference, but there are instances where discussing personal health matters feels more comfortable with someone of the same gender” (FGD3-N). “I’ve had female clients who explicitly requested a female nurse for intimate procedures she was undergoing and some discussions about personal health matters” (FGD3-N). “I recall a scenario where a female patient specifically requested a female nurse for a sensitive procedure. The patient expressed discomfort with a male nurse due to personal reasons. While it wasn’t a reflection on competency, the patient’s comfort was paramount” (FGD4-N).

Subtheme 8.4: having a preference for nurses of the opposite gender

Clients unzipped the fact that they prefer nurses of the same gender, making them feel at ease and comfortable for certain personal discussions.

“I would unconsciously seek out a female nurse when going to the hospital before opting for the available person to attend to me” (FGD1-C). “I do notice that I tend to feel more at ease with female nurses. Maybe it’s because I’m used to it” (FGD1-C). “If given an opportunity I choose female nurses” (FGD4-C).

It was identified that some nurses wish to be cared for by nurses of the opposite gender.

“On a personal level, if seeking medical help for me, even if I am a male nurse, I feel more comfortable discussing personal health issues with a female nurse. It just comes naturally for me” (FGD4-N).

Subtheme 8.5: reasons for gender preferences

Some clients said that their preferences for nursing gender are when they have personal discussions, sensitive issues to discuss, and during sensitive clinical procedures.

“Well, there was a time when I was going through a particularly sensitive health issue, and I found myself leaning towards having a female nurse. I think it was because I assumed she might understand the emotional aspect better” (FGD4-C).

Nurses in different FGDs discussed that nurses or clients who choose a certain gender whether similar or opposite, are in certain situations where discussing sensitive issues is involved, they seek comfort, looking for someone with whom it is easy to share their concerns and ask questions, and due to cultural issues.

“I can relate to having a preference, especially in certain situations where discussing sensitive issues is involved. I found that having a female nurse created a more comfortable environment for me to openly communicate about personal health matters” (FGD1-N). “As for me, regardless of being a male nurse, I have in some situations, felt more comfortable discussing personal health issues with a female nurse. It was more about personal comfort and ease of communication” (FGD1-N). “I’ve had female clients who explicitly requested a female nurse for intimate procedures she was undergoing some discussions about personal health matters” (FGD3-N). “Clients seem to feel more at ease sharing their concerns and asking questions with female providers” (FGD4-N).

The majority of clients discussed their nursing gender preference based on competency. They revealed that they prefer a nurse with the required competencies, caring elements, communication skills, confidence in delivering care, understanding clients’ needs, kind, attentive, professional, open in discussion, and available with empathy rather than gender.

“I don’t think I’ve ever had a preference based on gender. For me, it’s more about the nurses on duty and specifically how they communicate and care” (FGD1-C). “I don’t think I’ve ever had a preference based on gender. For me, it’s always been about the nurse’s competence and how comfortable they make me feel” (FGD4-C). Nevertheless, nurses in FGDs reported that those with no gender preference focus on professionalism, expertise, competence, communication skills, and ability to provide compassionate care. “The most important factors for me are their professionalism and expertise in delivering quality healthcare” (FGD2-N). “I look for competence, communication skills, and ability to provide compassionate care” (FGD3-N).

Most of the clients in different FGDs insisted that their preferences are tied to the service/care needed. For instance, preference may be tied to the demand for emotional support, a sense of security, caring service, the demand of peacefulness, help, empathy, and recovery services.

“I did and do have a preference. It was during a particularly sensitive situation, and I felt more comfortable with a female nurse. I think it was about emotional support” (FGD1-C). “It was a personal health issue, and I felt like a female nurse would understand the emotional aspect better. It wasn’t that I thought a male nurse couldn’t provide excellent care, but it was about connecting on a different level” (FGD1-C). “I guess I might have unconsciously preferred a male nurse in certain situations. Maybe because I associate their presence with a sense of security” (FGD1-C). “I tend to seek out female nurses if I am in the hospital because I believe they are sympathetic” (FGD4-C). “It’s about feeling understood on a deeper level. I assumed a female nurse might sympathize more with the emotional aspects of my situation” (FGD4-C). “I had surgery, and I felt more at ease having a female nurse during the recovery process. It just felt less awkward for me” (FGD4-C).

Clients mentioned culture as the factor motivating them to choose a nursing gender when seeking medical interventions. Some added that they grew up in an environment with gender sensitivity which has influenced their routine preference of nursing gender.

“I have grown up in a home where discussing personal matters with someone of the opposite gender can be uncomfortable, I’ve often preferred a nurse of the same gender” (FGD1-C). “I have found myself leaning towards female nurses because I grew up discussing . health matters primarily with women in my family. There’s a familiarity and comfort . in discussing personal issues with someone of the same gender” (FGD1-C). “I am from a conservative background, so I will always feel more comfortable with female nurses for certain personal discussions. It’s something about the cultural thing for me” (FGD3-C). NN-HCPs in different FGDs disclosed what influenced clients to have a preference for nursing gender (whether same or opposite gender), including cultural considerations and religious reasons. “I think the preference often arises due to cultural or personal reasons, where individuals might feel more comfortable discussing certain health issues with someone, they perceive may have an understanding from a shared gender perspective” (FGD4-NN-HCP). “I think it might be related to cultural considerations. For instance, in certain cultures, clients might feel more at ease discussing sensitive matters with healthcare providers of the same gender” (FGD4-NN-HCP).

Some NN-HCPs unzipped the fact that they prefer a certain gender in nursing because of the expectation of comfort.

“It seems these preferences are often linked to personal comfort levels and the nature of the information being shared” (FGD1-NN-HCP). “I have come to understand that clients might sometimes express preferences for nurses of a specific gender based on personal comfort” (FGD2-NN-HCP). “Maybe they may trust the person so they feel comfortable and with to share with them whatever that is bothering them” (FGD4-NN-HCP). NN-HCPs reported that clients who don’t choose a specific nursing gender are due to the fact they trust the healthcare system, making them not worry about any gender. “Some clients trust in the healthcare system and know that service is service regardless of the provider’s gender” (FGD4-NN-HCP). NN-HCPs said that the individual past experiences in seeking medical intervention might influence the person to have a preference for nurses a of certain gender. “I tend to think that it might depend on the individual’s patient’s personality and maybe some past experiences where he or she was either blamed for choosing a provider” (FGD4-NN-HCP).

Subtheme 8.6 the challenge of meeting clients’ preferences through nurse’s gender diversity

Nurses in FGD revealed that even though patient preference is significant, it is hindered by a shortage of nursing workforce.

“Clients’ preferences are respected although not always as sometimes with a hectic day and limited staff available, we sometimes fail to attain our goal” (FGD1-N).

Meanwhile, NN-HCPs supported that even though it has been reported that preferences of nursing gender by clients exist, it is challenged by a shortage of nursing workforce.

“Clients might request nurses of a specific gender for personal care, and if there’s a shortage of nurses of that gender, it could impact how responsibilities are distributed” (FGD4-NN-HCP). “I think addressing patient preferences related to gender requires a bigger approach putting in mind the scarcity of the workforce” (FGD1-NN-HCP).

Subtheme 8.7 different opinions about gender preferences

Different NN-HCPs in different FGDs gave their suggestions and opinions about clients’ preferences for nursing gender. They suggested that nurses should consider and respect clients’ preferences, and should create an environment for clients to express their demands for nursing gender.

“It’s crucial to respect these preferences when feasible without compromising the quality of care. I think we can facilitate this by having open discussions with clients, understanding their preferences, and making reasonable accommodations whenever possible” (FGD1-NN-HCP). “We as healthcare providers should prioritize a patient-centered approach by actively listening to patient’s preferences regarding the gender of their healthcare providers. We also need to create an environment where clients feel comfortable expressing their preferences without judgment” (FGD1-NN-HCP). “Respecting these preferences when feasible contributes to patient-centered care” (FGD2-NN-HCP).

Most nurses in different FGDs indicated the value of clients’ or nurses’ preferences of nursing gender. Most of them insisted that preference is a good thing, and several strategies should be reinforced to promote preference culture. Healthcare providers need to encourage clients to state their preferences and there should be an environment where clients may feel comfortable expressing their preferences.

“I think open communication is key. Providers should encourage clients to express their preferences and concerns regarding gender” (FGD-1). “I still believe that healthcare providers can initiate conversations with clients about . their preferences, ensuring a comfortable space for them to express any concerns or preferences related to the gender of their healthcare team” (FGD-2).

Most of the clients in different FGDs provided different opinions, suggestions, and comments about gender preferences. They mostly focused on strategies to encourage patient’s preferences for nurses. They emphasized that healthcare providers need to ask about clients’ preferences during admission, and healthcare providers and clients should be trained to understand the benefit of clients’ preferences in clinical areas, there is a need to create an environment for open communication and make clients comfortable to express their preferences. Moreover, they insisted that patient’s preferences need to be respected

“Maybe healthcare providers could ask about our preferences during intake or admit processes, allowing us to express our comfort zones” (FGD1-C). “I think the key is open communication. Healthcare providers can create an environment where clients feel comfortable expressing their preferences” (FGD1-C) . “The hospital should also create an environment where we feel comfortable expressing our preferences without judgment is important” (FGD2-C). “Training could be beneficial for healthcare professionals so that they can provide care effectively” (FGD1-C). “I believe the healthcare providers can communicate and provide education clearly emphasizing that all staff, regardless of gender, are trained to provide high-quality care. This will help build trust with us” (FGD2-C). “Education both us as clients and the healthcare providers to understanding that good care is not determined by gender, providers” (FGD2-C). “If clients are informed that they have the right to express gender preferences and that the healthcare team will do their best to accommodate, it could lead to more open discussions” (FGD1-C). “Perhaps asking clients about their preferences in a respectful way could be an option without making assumptions” (FGD2-C). “The healthcare providers should consider giving us the choice to specify our gender preferences for care, if possible without being pointed out as being bad” (FGD2-C).

The data were collected from 59 participants found at the four different hospitals in Dar es Salaam. A total of 12 FGDs. were conducted, comprised of nurses, non-nurse healthcare providers (physicians, laboratory technicians, scientists, and pharmacists)., and clients. The discussion is based on the identified themes.

① variations of male and female nurses in communication

It was found that male and female nurses differ in how they communicate, especially when communicating with clients and colleagues. Their difference is in the communication style adopted and is highly observed when discussing medications. For instance, when communicating with clients, female nurses tend to provide detailed information and demonstrate empathy and nurturing elements. While, male nurses are brief, concise, more direct, and assertive. It was reported whatever differences when discussing with clients, both communication styles are helpful and effective. The finding is supported by the study, which stated that male nurses are forthright and to the point, while female nurses consider the world as a network of connections and solidarity, leading their communication to be exhaustive and supportive [ 36 ]. Male nurses apply humor and establish mutual trust, but female nurses use touch during communication to demonstrate empathy and calm the patient [ 37 ]. Meanwhile, when female nurses are receiving instructions from colleagues they ask for more details, but male nurses don’t. While participants indicate that gender in nursing is the source of communication differences, others indicated that communication is not linked to nursing gender, rather personality, experience, and communication skills, majority. The previous study indicate that the communication difference is neither embedded to gender nor biological, but rather behavior, race, ethnicity, and socioeconomic background [ 38 ].

② differences between male and female nurses in carrying out leadership roles

It was found that male nurses use an authoritative leadership style while female nurses assume a democratic leadership style. Both leadership styles are good and recommended in the institutions. The previous study stated that an authoritarian style of leadership directs staff towards specific tasks they must obey and it promotes a highly structured work environment [ 39 ]. Male nurses seem to use an authoritative style because most of them are working in emergency demanding situations that require fast responses to clients, otherwise the delay may lead to a patient’s death. Therefore, in emergency cases decisions are made by fewer people and that makes authoritative an option. It is aligned with the literature, recommending that authoritarianism fits better in emergencies where quick action is required everyone works towards the same goal, and decisions do not need to be discussed at length [ 40 ]. In contrast, female nurses seem to use a collaborative style because most of them work in non-emergency units. Their cases do not demand quick decisions, that’s why they end up using a democratic leadership style. Adopting a certain style depends on personality, belief system, company culture, employee diversity, personality traits, level of control, organizational structure, and experience [ 41 ].

③ divergent clinical qualities and outcomes across nursing gender

Both male and female nurses reported having common positive qualities like good collaboration, communication skills, empathy, work commitment, attentiveness, sympathy, peacefulness, responding to clients’ needs, calmness, compassion, and promoting patient comfort. These shared qualities might have been obtained from their educations, which are well stipulated within nursing curricula. It is supported by previous literature denotes that nursing curricula contain different information to improve communication skills, teamwork, skills, attitude, and knowledge [ 42 ].

Nevertheless, male nurses have unique positive qualities that female nurses don’t have, including being expert, calm, attention to detail, skill for analyzing data, skill for recognizing any changes in the patient’s condition, tending to be more direct and concise in their communication, solution-oriented communication style, ability to connect clients and their families, confident, more of what the rules state, too much of protocol, kind, more trusted, more task-oriented, focusing on the efficient execution of care plans, delivering comprehensive health education, competent, attentive, introduce themselves to the patient to be known and communicate the procedure before doing it. The unique caring behavior of male nurses has been reported by previous literature that they are respectful, considerate, good listener, unbiased, and supportive [ 43 ]. Additionally, male nurses are polite and courteous during service delivery [ 44 ]. They also form trusting relationships in the clinical setting compared to their counterpart female nurses [ 45 ].

In contrast, female nurses reported to have their unique positive characteristics that are not found in male nursing, including nurturing, detail in their communication, focus on emotional aspects during communication, building rapport, fostering open communication, innovation in patient care, more understanding, often assign tasks, seek assistance, establish trust with clients, use a holistic approach to care, prefer open communication, create supportive environments for clients, deliver comprehensive education and navigation care to clients, and involve clients in decision making.

All positive qualities for female nurses and male nurses are good.Most of their qualities should have been learned from their professional education and clinical experiences, but some may have been rooted in their natural gender. For instance, some male nurse’s qualities are dominated by manhood like confidence, too many rules, and comprehensiveness, while female nurses are detailed in communication and deliver holistic care. Since all positive qualities in both genders are important, every nurse regardless of gender should possess them.

It has been found that positive qualities for both nursing genders have a positive outcome while their negative qualities influence negative effects in the clinical areas. For instance, the positive qualities of male nurses put other nurses at ease, create a sense of trust, establish mutual respect, promote the accuracy of assessments, promote effective interventions, create a spirit of collaboration within the team, prevent stress, and promote good feelings among clients. Moreover, the positive qualities of females enable team dynamics during patient care, a key factor influencing how clients engage in the conversations, and make clients feel involved, supported, and comfortable. Therefore, the positive qualities of whatever gender has an outcome on colleagues and clients, make clients able to receive optimal care and enhance team collaboration. The finding is supported by the previous study by Danwil [ 43 , 46 ].

Regarding negative qualities, no reported shared negative qualities for male and female nurses. It is found that every gender has unique negative characteristics. For instance, male nurses are reported to be authoritative, and assertive, love to be addressed as doctors by clients and dislike to be addressed as nurses rather as doctors, tend to spread rumors, and gossip, careless of patient’s pain during clinical procedures, lack of caring habit, and maintaining no privacy for clients. On the other side, female nurses are unable to correctly interpret clients’ instructions, have emotional reactions, lack confidence, are too argumentative in a clinical setting, don’t communicate the procedure before implementation, lack listening skills, are disinterested in patient’s needs, are impatient, not responding to clients’ needs, delay in responding to patient demand, inefficient, less attentive, lack caring spirit, possess anger, doing tasks hastily like having other things to attend, and appeared visibly stressed. All negative qualities from both genders have negative repercussions on patient care, there is a need for efforts to eradicate these negative qualities from both genders. Meanwhile, the negative qualities of male nurses affect clients during medication adherence, affect physicians in their practices, increase clients’ frustration, and scared, erode clients’ trust in the healthcare system, make clients hesitate to seek medical help, and leave clients feeling uncomfortable. For negative qualities of female nurses, they cause clients to feel neglected and burdened, and erode clients’ trust in the healthcare system. It has been found that regardless of gender, the negative qualities abrade patient’s trust in the healthcare system. The negative effects are more common to clients than colleagues.

④ positive value of male nurses in clinical facilities from colleagues and clients

Male nurses are reported to be more valued by clients and their colleagues. They are appreciated based on the suggestions they contribute and the patient’s recovery. Based on the history of nursing being regarded as a female profession, male nurses might have improved their education in the form of competency and clinical practices to mask the notion of a female-oriented profession and reverse the negative image of nursing by communities. This conforms to the previous documentation showing that ten years ago male nurses entitled as nurse practitioners increased by 108% [ 47 ], which can be an indicator of increasing their values.

⑤ different cooperation between male and female nurses in the settings

The majority of participants revealed the existing good teamwork between male and female nurses. This can be reflected in the organized patient care that results in patient recovery. The finding is consistent with a previous study that reported a positive correlation between nurses’ teamwork [ 48 ]. If male and female nurses don’t collaborate the disintegrated care will be observed and end up with suboptimal care to clients. For some participants who reported the poor interaction of male and female nurses, it may be due to some few nurses who are still led by the nursing history that a certain gender is inefficient for a certain performance and should not be involved.

⑥ mixed perspectives towards clinical competencies across nursing gender

Most of the participants reported their negative perspectives toward male and female nurses. Male nurses are considered unable to offer counseling to nursing mothers and female nurses are regarded as unable to emergency issues. All these perspectives are tied to social and cultural gender roles, assuming that men aren’t supposed to care for women with maternity or gynecological issues. The findings is aligned with the previous study indicating that male nurses are incapable or incompetent in providing intimate care, particularly to young female patients, and cannot adequately take care of female patients, as they are unable to control their sexual impulses and are at risk for sexually assaulting young women [ 49 ]. Meanwhile, women are not in a position to respond to emergencies like lifting clients in comas and making prompt decisions.

⑦ perspective towards gender diversity in nursing

Due to the demand for diversity in nursing, it is emphasized to eradicate anything hindering the growth of diversity. Moreover, most of the participants had the perspective that the performance of nurses is not determined by their gender, but rather by their competencies. This can be because all nurses regardless of gender are academically trained, molded, and equipped through structured curricula. All nurses are well-informed about the values and ethics of nursing and are encouraged to deliver care professionally. Therefore, their performance will always be based on professionalism rather than their gender personal elements. This is consistent with the previous finding reported that nurses of any gender with professional expertise and good virtues matter more than gender [ 50 ].

Diversity of nursing gender is reported to have benefits for clients and nurses themselves. It influences the clients to express their needs freely, promotes patient care, improves patient outcomes, saves the patient’s life, allows diverse skills to be utilized during patient care, promotes healthcare providers’ collaboration which is beneficial to clients, addresses the diverse needs of clients, and promote a holistic approach to patient care. Patient freedom is associated with an opportunity that the patient to choose the preferred gender to be cared for. Optimal patient care and good outcomes are the results of different nurse genders with different capabilities and critical thinking involved in assessment, diagnosis, and decision of care. Similar findings has been previously reported that gender diversity improves cultural competence and outcomes for patients [ 51 ].

Nevertheless, to nurses, diversity enhances the overall team dynamic, creates a supportive work environment, learn from each other, shares insights, promotes collaboration, enhances inclusive decision-making, influences personal comfort, and ease of communication and coordination. Moreover, gender diversity fosters problem-solving approaches and brings different perspectives. Having a diverse nursing gender may help some to choose who to work with that may promote a convenient environment for them to be comfortable in their performances. Additionally, the diversity of nursing helps nurses to identify multiple characteristics possessed by nurses and learn those that seem effective in nursing and discard undesirable ones. Consistently, the previous study reported that the diversity of nursing gender encourages nurses to learn from each other and appreciate different perspectives and life experiences [ 52 ].

⑧ preferences of nurses’ gender, reasons, and opinion towards gender preferences

Some participants indicated having no gender preference for nurses and others had a preference for nurses of specific gender. Meanwhile, some had a preference for nurses of the same gender. Their reasons for preferences were; when having personal discussions or sensitive issues, nurse’s competency, kind of needed service, cultural issues, expectation of comfort, trusting the healthcare system, and past experiences in medical issues. Therefore, gender diversity in nursing is inevitable as it accommodates the different needs of clients. It is advised to embrace diversity and create a cultural environment of promotes diversity.

Study limitation

Even though the study had a sufficient number of FGDs at different hospitals, it was only confined to a single region out of 28 regions in Tanzania. Therefore, the findings lack a representation of participants from different angles of the country. The study also lacks nursing gender perspectives from student nurses, nursing faculty, employers, and policymakers.

Male nurses and female nurses differ in how they communicate, execute leadership roles, and have positive clinical qualities. However, their variations don’t mean one gender is underrated than the other, but every gender has unique communication styles, leadership styles, and positive clinical qualities that both lead to effective outcomes. Since all styles, approaches, and qualities are beneficial, every nurse needs to possess all of them, and in contrast, since all negative qualities from both genders have negative repercussions on patient care, there is a need for efforts to eradicate these negative qualities from both genders. Diversity in nursing gender is very important and should be strategized as it is essential to patient recovery and promotes teamwork. Preferences of nursing gender should be encouraged because it enhances somebody’s freedom and creates an environment where a person can discuss sensitive issues. The study has introduced uncertainties that call for further quantitative studies to assess several variables of nursing gender.

The implications of the study

These results build on existing evidence that gender diversity in nursing has a clinical implication as it improves patients care. Both genders in nursing have negative qualities that calls for innovative strategies to combat these negativities. Moreover, the variation in communication and leadership among nursing gender does not affect the delivery of healthcare services.

Data availability

The supplementary materials including raw data in the analysis are available upon request.

Abbreviations

Focus Group Discussions

Focus Group Discussions of Nurses

Focus Group Discussions of non-nurse healthcare providers

Focus Group Discussions of clients

Doctor of Nursing Practice

Tanzania Nursing and Midwifery Council

Tanzania Commission for Universities

Muhimbili National Hospital

Institution Research Review Committee

Regional Administrative Secretary

Non-nurse healthcare providers

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Acknowledgements

The authors acknowledge the School of Nursing and Public Health for creating a conducive research environment. The authors would like to appreciate the invaluable efforts of Dr Zawadi Richard who assisted during the transcription process and Upendo Munuo who translated the transcripts. We thank the management of St. John’s University of Tanzania for funding the current study, as it smoothed the data collection process and helped to obtain the data as per established protocol. We also extend our acknowledgment to some individuals’ contributions, especially the data collectors who exercised honesty and avoided fabrication and falsification of data.

The study is funded by Saint John’s University of Dodoma, which is located in Dodoma City, Tanzania.

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RMM: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review & Editing, Visualization, Supervision, and Project administration. SMK and GMM: Formal Analysis and Review & Editing.

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Masibo, R.M., Kibusi, S.M. & Masika, G.M. Nurses, non-nurse healthcare providers, and clients’ perspectives, encounters, and choices of nursing gender in Tanzania: a qualitative descriptive study. BMC Nurs 23 , 353 (2024). https://doi.org/10.1186/s12912-024-02027-3

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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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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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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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• Introduction

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. [1] Instead of collecting numerical data points or intervening or introducing treatments just like in quantitative research, qualitative research helps generate hypothenar to further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a standalone study, purely relying on qualitative data, or part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and applications of qualitative research.

Qualitative research, at its core, asks open-ended questions whose answers are not easily put into numbers, such as "how" and "why." [2] Due to the open-ended nature of the research questions, qualitative research design is often not linear like quantitative design. [2] One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. [3] Phenomena such as experiences, attitudes, and behaviors can be complex to capture accurately and quantitatively. In contrast, a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a particular time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify, and it is essential to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore "compete" against each other and the philosophical paradigms associated with each other, qualitative and quantitative work are neither necessarily opposites, nor are they incompatible. [4] While qualitative and quantitative approaches are different, they are not necessarily opposites and certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated.

Qualitative Research Approaches

Ethnography

Ethnography as a research design originates in social and cultural anthropology and involves the researcher being directly immersed in the participant’s environment. [2] Through this immersion, the ethnographer can use a variety of data collection techniques to produce a comprehensive account of the social phenomena that occurred during the research period. [2] That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc, through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.

Grounded theory

Grounded Theory is the "generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior." [5] Unlike quantitative research, which is deductive and tests or verifies an existing theory, grounded theory research is inductive and, therefore, lends itself to research aimed at social interactions or experiences. [3] [2] In essence, Grounded Theory’s goal is to explain how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

Phenomenology is the "study of the meaning of phenomena or the study of the particular.” [5] At first glance, it might seem that Grounded Theory and Phenomenology are pretty similar, but the differences can be seen upon careful examination. At its core, phenomenology looks to investigate experiences from the individual's perspective. [2] Phenomenology is essentially looking into the "lived experiences" of the participants and aims to examine how and why participants behaved a certain way from their perspective. Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources. In contrast, Phenomenology focuses on describing and explaining an event or phenomenon from the perspective of those who have experienced it.

Narrative research

One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called a "thick" or "rich" description and is a strength of qualitative research. Narrative research is rife with the possibilities of "thick" description as this approach weaves together a sequence of events, usually from just one or two individuals, hoping to create a cohesive story or narrative. [2] While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be "opportunities for innovation." [2]

Research Paradigm

Research paradigms are the assumptions, norms, and standards underpinning different research approaches. Essentially, research paradigms are the "worldviews" that inform research. [4] It is valuable for qualitative and quantitative researchers to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontologies and epistemologies. Ontology is defined as the "assumptions about the nature of reality,” whereas epistemology is defined as the "assumptions about the nature of knowledge" that inform researchers' work. [2] It is essential to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a complete understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, researchers must understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.

Positivist versus postpositivist

To further understand qualitative research, we must discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social and natural sciences. [4] Essentially, positivist thinking insists that the social sciences should use natural science methods in their research. It stems from positivist ontology, that there is an objective reality that exists that is wholly independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.

Conversely, postpositivists argue that social reality can never be one hundred percent explained, but could be approximated. [4] Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world,” and therefore, postpositivist philosophy is often associated with qualitative research. [4] An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.

Constructivist

Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are also constructivist, meaning they think there is no objective external reality that exists but instead that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. "Constructivism contends that individuals' views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality.” [6]  constructivist thought focuses on how "reality" is not a fixed certainty and how experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike positivist views, that there is not necessarily an "objective"reality we all experience. This is the ‘relativist’ ontological view that reality and our world are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.” [4]

So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have. It can even change the role of the researchers. [2] For example, is the researcher an "objective" observer, such as in positivist quantitative work? Or is the researcher an active participant in the research, as in postpositivist qualitative work? Understanding the philosophical base of the study undertaken allows researchers to fully understand the implications of their work and their role within the research and reflect on their positionality and bias as it pertains to the research they are conducting.

Data Sampling 

The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors. The following are examples of participant sampling and selection: [7]

• Purposive sampling- selection based on the researcher’s rationale for being the most informative.
• Criterion sampling selection based on pre-identified factors.
• Convenience sampling- selection based on availability.
• Snowball sampling- the selection is by referral from other participants or people who know potential participants.
• Extreme case sampling- targeted selection of rare cases.
• Typical case sampling selection based on regular or average participants. 

Data Collection and Analysis

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

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or the participants' environment, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed, which may then be coded manually or using computer-assisted qualitative data analysis software or CAQDAS such as ATLAS.ti or NVivo. [8] [9] [10]

After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data. [11] Results could also be in the form of themes and theory or model development.

Dissemination

The healthcare team can use two reporting standards to standardize and facilitate the dissemination of qualitative research outcomes. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups. [12] The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a more comprehensive range of qualitative research. [13]

Applications

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

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

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

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

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

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

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

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

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

The researcher could try to have the parks department reassess the shady areas to make them less conducive to smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk populations their perceptions of the changes and what factors are still at play, and quantitative research that includes teen smoking rates in the community and the incidence of new teen smokers, among others. [14] [15]

Qualitative research functions as a standalone research design or combined with quantitative research to enhance our understanding of the world. Qualitative research uses techniques including structured and unstructured interviews, focus groups, and participant observation not only to help generate hypotheses that can be more rigorously tested with quantitative research but also to help researchers delve deeper into the quantitative research numbers, understand what they mean, and understand what the implications are. Qualitative research allows researchers to understand what is going on, especially when things are not easily categorized. [16]

• Issues of Concern

As discussed in the sections above, quantitative and qualitative work differ in many ways, including the evaluation criteria. There are four well-established criteria for evaluating quantitative data: internal validity, external validity, reliability, and objectivity. Credibility, transferability, dependability, and confirmability are the correlating concepts in qualitative research. [4] [11] The corresponding quantitative and qualitative concepts can be seen below, with the quantitative concept on the left and the qualitative concept on the right:

• Internal validity: Credibility
• External validity: Transferability
• Reliability: Dependability
• Objectivity: Confirmability

In conducting qualitative research, ensuring these concepts are satisfied and well thought out can mitigate potential issues from arising. For example, just as a researcher will ensure that their quantitative study is internally valid, qualitative researchers should ensure that their work has credibility. 

Indicators such as triangulation and peer examination can help evaluate the credibility of qualitative work.

• Triangulation: Triangulation involves using multiple data collection methods to increase the likelihood of getting a reliable and accurate result. In our above magic example, the result would be more reliable if we interviewed the magician, backstage hand, and the person who "vanished." In qualitative research, triangulation can include telephone surveys, in-person surveys, focus groups, and interviews and surveying an adequate cross-section of the target demographic.
• Peer examination: A peer can review results to ensure the data is consistent with the findings.

A "thick" or "rich" description can be used to evaluate the transferability of qualitative research, whereas an indicator such as an audit trail might help evaluate the dependability and confirmability.

• Thick or rich description:  This is a detailed and thorough description of details, the setting, and quotes from participants in the research. [5] Thick descriptions will include a detailed explanation of how the study was conducted. Thick descriptions are detailed enough to allow readers to draw conclusions and interpret the data, which can help with transferability and replicability.
• Audit trail: An audit trail provides a documented set of steps of how the participants were selected and the data was collected. The original information records should also be kept (eg, surveys, notes, recordings).

One issue of concern that qualitative researchers should consider is observation bias. Here are a few examples:

• Hawthorne effect: The effect is the change in participant behavior when they know they are being observed. Suppose a researcher wanted to identify factors that contribute to employee theft and tell the employees they will watch them to see what factors affect employee theft. In that case, one would suspect employee behavior would change when they know they are being protected.
• Observer-expectancy effect: Some participants change their behavior or responses to satisfy the researcher's desired effect. This happens unconsciously for the participant, so it is essential to eliminate or limit the transmission of the researcher's views.
• Artificial scenario effect: Some qualitative research occurs in contrived scenarios with preset goals. In such situations, the information may not be accurate because of the artificial nature of the scenario. The preset goals may limit the qualitative information obtained.
• Clinical Significance

Qualitative or quantitative research helps healthcare providers understand patients and the impact and challenges of the care they deliver. Qualitative research provides an opportunity to generate and refine hypotheses and delve deeper into the data generated by quantitative research. Qualitative research is not an island apart from quantitative research but an integral part of research methods to understand the world around us. [17]

• Enhancing Healthcare Team Outcomes

Qualitative research is essential for all healthcare team members as all are affected by qualitative research. Qualitative research may help develop a theory or a model for health research that can be further explored by quantitative research. Much of the qualitative research data acquisition is completed by numerous team members, including social workers, scientists, nurses, etc. Within each area of the medical field, there is copious ongoing qualitative research, including physician-patient interactions, nursing-patient interactions, patient-environment interactions, healthcare team function, patient information delivery, etc. 

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Disclosure: Steven Tenny declares no relevant financial relationships with ineligible companies.

Disclosure: Janelle Brannan declares no relevant financial relationships with ineligible companies.

Disclosure: Grace Brannan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

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Parental experiences of caring for preterm infants in the neonatal intensive care unit, Limpopo Province: a descriptive qualitative study exploring the cultural determinants

• Madimetja J. Nyaloko 1 ,
• Welma Lubbe 1 ,
• Salaminah S. Moloko-Phiri 1 &
• Khumoetsile D. Shopo 1  

BMC Health Services Research volume  24 , Article number:  669 ( 2024 ) Cite this article

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Parent-infant interaction is highly recommended during the preterm infant hospitalisation period in the Neonatal Intensive Care Unit (NICU). Integrating culturally sensitive healthcare during hospitalisation of preterm infants is critical for positive health outcomes. However, there is still a paucity of evidence on parental experience regarding cultural practices that can be integrated into preterm infant care in the NICU. The study explored and described the cultural determinants of parents that can be integrated into the care of preterm infants in the NICU.

A descriptive qualitative research design was followed where twenty ( n =20) parents of preterm infants were purposively selected. The study was conducted in the NICU in Limpopo using in-depth individual interviews. Taguette software and a thematic analysis framework were used to analyse the data. The COREQ guidelines and checklist were employed to ensure reporting standardisation.

Four themes emerged from the thematic analysis: 1) Lived experienced by parents of preterm infants, 2) Interactions with healthcare professionals, 3) Cultural practices concerning preterm infant care, and 4) Indigenous healthcare practices for preterm infants.

Conclusions

The study emphasised a need for healthcare professionals to understand the challenges parents of preterm infants face in NICU care. Furthermore, healthcare professionals should know indigenous healthcare practices to ensure relevant, culturally sensitive care.

Peer Review reports

Introduction and background

Parenting is an intricate process involving the upbringing and caring for a child from infancy to adulthood through promoting and supporting the child’s physical, emotional, social, and intellectual development [ 1 ]. This process becomes challenging, particularly when it involves preterm infants admitted to the hospital [ 2 ]. The birth of a preterm infant can be an epoch-making, evocative, and occasionally devastating parental experience [ 3 ]. A preterm infant is defined as a child born before the 37 th week of pregnancy is completed [ 4 ]. Annually, approximately 15 million preterm births are documented out of 160 million live births, accounting for an 11.5% global preterm birth rate [ 5 ]. Between 2010 and 2020, more than 60% of global preterm births occurred in South Asia and Sub-Saharan Africa [ 5 ]. One in every seven infants in South Africa was born before their due date and required NICU admission [ 5 ].

The NICU is typically a foreign and intimidating environment for parents, due to the need for continuous monitoring and medical intervention for infants who are fragile and sick. Parents can experience stress, guilt, anxiety, and sadness due to the infant's uncertain health prognosis [ 6 ]. The active involvement of parents in preterm infant care activities in the NICU is crucial for infant developmental outcomes [ 7 ]. Healthcare professionals should comprehend the parental experience of caring for a preterm infant in the NICU to address parental needs and enhance parent-infant interaction and attachment [ 8 ]. This interaction may in turn increase parental satisfaction, thus promoting more appropriate parent-infant interaction, including attachment and bonding [ 9 ].

Although parent-infant interaction is beneficial, cultural variables need to be acknowledged. Parenting is deeply rooted in a culture characterized by ideologies concerning how an individual should act, feel and think as an in-group member [ 10 ]. Therefore, the parental involvement and parent-infant interaction might be disrupted if the parental cultural practice is not considered. Cultural practices influence the parents' infant care approach [ 11 , 12 ]. The values and ideals of culture are conveyed to the next generation through child-rearing practices, which implies that cultures are contextually sensitive parenting guidelines [ 13 ].

Parents of preterm infants in Limpopo Province, South Africa, come from various cultural backgrounds, which may influence how they understand and react to the care provided to their preterm infant in the NICU. Various childrearing practices associated with culture influence the health of preterm infants [ 14 ]. These practices include massaging the baby, applying oil to the eyes and ears, burping the baby, applying black carbon to the eyes, and trimming the nails. Parental involvement in preterm infant care in the NICU may also be influenced by culture [ 15 ]. The cultural views and ideas of healthcare professionals can potentially affect the standard of care offered to preterm infants and their parents in the NICU. These cultural views and ideas are health beliefs that explain the cause of illness, its prevention or treatment methods, and the appropriate individuals who should participate in the healing process [ 16 ].

Healthcare professionals who have a comprehensive understanding of the parental cultural determinants can facilitate the nurturing and promoting of adequate parental-infant care and interaction, which is the foundation for developing preterm infants [ 17 ]. Lack of support from healthcare professionals regarding the cultural aspects of parent-infant interaction may negate parents' cultural practices, and increase negative perceptions and dissatisfaction with the healthcare service provided in the NICU [ 17 ]. Consequently, this may result in a lack of parental awareness or responsiveness to the infant, associated with delayed infant cognitive development and multiple behavioural problems [ 18 ].

Despite the recognition of the importance of parental involvement in NICU care and the documented emotional challenges experienced by parents, there is a gap in the literature regarding the specific experiences and cultural practices of parents caring for preterm infants which can be integrated in NICU in settings, such as Limpopo Province in South Africa. The province has seen a significant increase in the number of newborn babies weighing under 2,500 grams in recent years [ 19 ]. The study aimed to explore and describe the cultural determinants of parents that can be integrated into the care of preterm infants admitted to the NICU in Limpopo Province to ensure culturally sensitive care. This study is unique due to its focus on South Africa, specifically Limpopo Province, which is the centre of cultural practices due to its rurality. The main research question was: 'What are the cultural determinants which influence the parental experience that can be integrated into the care of preterm infants in the NICU in Limpopo Province?

The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed to ensure standardisation in reporting the study type, design, execution, analysis, and results [ 20 ].

The study applied a qualitative research design following a descriptive approach [ 21 ]. In-depth individual interviews were used to explore and describe the experiences of parents of preterm infants admitted to the NICU in Limpopo Province through a cultural determinant lens.

The current study was conducted in the NICU of a tertiary hospital in Limpopo Province, South Africa. Limpopo Province was selected based on two grounds: 1) Cultural practices are more evident in rural villages than in semi-urban or urban settings [ 22 ], 84.2% of the study population live in rural areas [ 23 ]; and 2) one in every seven infants is born before its due date in South Africa [ 5 ], the Limpopo Province accounts for high preterm birth rates [ 19 ].

Participants and sample

The population comprised mothers of a preterm infant admitted to the NICU. For this study, a parent was defined as the mother of a preterm infant in the NICU. Purposive sampling was used to select twenty ( n =20) participants from the NICU in a tertiary hospital [ 24 ]. The inclusion criteria required that 1) the participant be the parent of a preterm infant; 2) the parent had a preterm infant in the NICU for a minimum of two weeks (As set out by the researcher, the contextually relevant time for an immersive experience was two weeks); 3) the parent be able to speak either Sepedi, Xitsonga, Tshivenda, or English (the common local languages). Mothers of preterm infants who were in critical condition were excluded. There were no refusals to participate. The sample size was determined based on data saturation, which was reached with n =20 participants [ 25 ].

Recruitment

The first author (Ph.D.) and an independent person recruited the participants face-to-face by distributing recruitment material such as flyers and asynchronously by displaying posters on the noticeboards in the selected hospital's NICU and a place where the mother lodge in the hospital. Recruitment was conducted after ethical approvals and permission from the hospital were granted. Participants who expressed interest in the study notified the first author through a phone call, SMS, or WhatsApp text message. The first author then contacted the potential participants to provide detailed information regarding the study aim and data collection method, including audio recordings of interviews, confidentiality agreements, written informed consent, and voluntary participation. Potential participants who showed interest were given an informed consent form and a minimum of 48 hours to consult and inform their partners or family members. The first author was accessible telephonically for any clarity-seeking questions. The first author contacted the agreed participants to schedule the hospital-based interviews on the agreed-upon dates. All consented mothers participated and there were no withdrawals.

Data collection

The interview guide was developed for this current study in English, and translated to local languages (Sepedi, Xitsonga, and Tshivenda) by assistant researchers who are fluent with these respective languages. Three bilingual speakers (Sepedi, Xitsonga, and Tshivenda) checked the translations from English to these local languages for accuracy, which was endorsed. Furthermore, the interview schedule was piloted with two participants to assess its effectiveness and suitability (See supplementary document 1). Pilot study was instrumental in refining the interview guide and ensuring that it would yield the desired data during the primary study. The in-depth interview began with an open-ended question, as shown in Table 1 below.

The data was collected between August and September 2022. In-depth individual interviews were conducted by the first author and assistant researcher using Sepedi, Xitsonga, Tshivenda, or English in a private room in the hospital to ensure confidentiality. COVID-19 precautionary measures were followed to protect the health and safety of participants and interviewers. Furniture was wiped with a 70% based-alcohol solution before and after each interview, chairs were spaced 1.5 meters apart to ensure adequate social distance and researchers and participants sanitised their hands before entering and exiting the room. Participants and the interviewer wore a surgical facial mask covering the nose and mouth throughout the interview.

The first author served as the lead interviewer, the assistant researcher functioned as a support system in case of a language barrier. The interviews were conducted in the participant's preferred language (Sepedi, Xitsonga, Tshivenda, or English). The interviewer used probing questions to encourage the participants to elaborate, and all other questions arose from the dialogue. The duration of each interview was between 45 and 65 minutes.

With the participants' permission, two audio recording devices were used to record each interview, whereby one served as a backup in case the main one defaulted. During each interview, the first author compiled field notes regarding the context, non-communication cues, and impressions to complement the recorded audio. Data collection continued until no new data emerged, whereby data saturation was declared. All the interviews were conducted at the hospital.

After data collection, the first author and assistant researchers transcribed the data verbatim, including field notes in English. The researchers' subjective experiences regarding the explored phenomenon were described to avoid influencing data analysis: a process termed bracketing [ 26 ]. Three bilingual speakers (Sepedi, Xitsonga, and Tshivenda) checked the translations to English transcriptions for accuracy against the audio recordings. Additionally, two transcripts (10% of the sample) were back translated, and accuracy was verified by an independent co-coder and two co-authors [SSM, KDS]. No substantial linguistic issues were identified during the translation process.

Data analysis

Giorgi's data analysis method [ 27 , 28 ] was applied to comprehend the essence of the experiences of parents of preterm infants in the NICU. The data analysis process constituted five steps: understanding raw data, constructing a constituent profile, forming a theme index, merging participants' theme indexes, and searching the thematic index to develop interpretive themes.

Trustworthiness

The four criteria of Lincoln and Guba [ 29 ] were applied to establish the trustworthiness of the current study. Credibility was established by member checking with 10% of the sample ( n =2) by sending the transcript and developed themes. The supervisors (experts) conducted a confirmability audit of the study project by checking and rechecking the collected raw-, coded- and interpreted data to affirm neutrality. Additionally, the study followed a rigorous descriptive qualitative method and underwent a peer review process that confirmed the consistency of the data, and the findings ensured dependability, while data saturation and a detailed description of the methodology ensured transferability.

Demographic data

Twenty ( n =20) mothers of preterm infants admitted to the NICU in a tertiary hospital participated in this study. The participants’ ages ranged from 18 to 39 years, with the majority being between 18 and 25. The majority of parents had three children. Regarding education, nine participants had a secondary-level education, and 11 had a tertiary education. Of the 20 participants, nine were unemployed, two were self-employed, one was fully employed, one was employed part-time, and seven were students (Refer to Table 2 ).

Emerging themes and sub-themes

Four main themes emerged from the data analysis. These were: lived experienced by parents of preterm infants, interactions with healthcare professionals, cultural practices concerning preterm infant care, and indigenous healthcare practices for preterm infants. These themes, supported by sub-themes, are outlined in Table 3 .

Theme 1 lived experienced by parents of preterm infants

The current study's first theme emerged as the lived experienced by parents of preterm infants. Parents experienced considerable challenges while caring for the preterm infants in the NICU. Lived difficulties experiences by parents are further explored through the sub-themes: stress and exhaustion, and longing for home.

Sub-theme 1.1 stress and exhaustion

Participants felt an overwhelming sense of exhaustion and stress, as they cared for their infants in the NICU. Participant responses revealed a pervasive fear of the unknown, coupled with emotional turmoil and physical strain. The uncertainty surrounding the health of their infants exacerbates their distress, leading to heightened anxiety and feelings of helplessness. This emotional burden is compounded by the challenges of navigating complex medical information and coping with unexpected health complications. Participants expressed shock, describing the unexpected event of preterm birth and the overwhelming emotions following the delivery of a preterm infant.

One participant reported:

We are always scared when we go to see babies because we don't know what it is, especially when you leave the baby without the tube; you think she may vomit when you are not around, and the next thing you will be receiving a call saying your baby is no more. (P1, 18-year-old)

Participant 1's expression of fear illustrates the constant apprehension experienced by mothers in the NICU, highlighting the emotional strain of anticipating potential emergencies and adverse outcomes. Another participant indicated the overwhelming uncertainty faced by the mothers upon entering the NICU, emphasizing the need for clear communication and reassurance from healthcare providers. The following quote supports the participant’s experience:

What if they tell me the situation is like this when I enter there? Honestly speaking, it frightens us. We just wish that it didn't ring so that when you get there, they tell you that they needed you so and so . (P2, 25-year-old)

Another participant highlighted the shock and fear induced by the sight of an extremely premature infant, illustrating the emotional toll of witnessing their vulnerability.

This baby, she was too small, like it was the first time seeing a small child like this. I once saw premature, but it was not like this, this one was so small, so I was scared. (P4, 24-year-old)

Another participant described her emotional response to distressing news about her baby's health which underscores the profound impact of medical uncertainties on maternal well-being, emphasizing the need for sensitive communication and support.

When they told me that my baby was like this and this, I even cried. (P10, 39-year-old)

Additionally, other participant’s narrative reflected the overwhelming fear and uncertainty experienced by mothers in the NICU, highlighting the emotional toll of constantly anticipating adverse outcomes and navigating complex medical situations. The following quotes reflect the participants’ experiences:

What I'm dealing with, because I was very broken and did not know what it is, will the baby survive, what will she do, what's going to happen. The answer is not right, as, for us, we are always afraid, we don't know what it is when you are here. (P17, 23-year-old)

Sub-theme 1.2 longing for home

The emotional strain and challenges faced by mothers while caring for their infants in the hospital setting evoke a profound yearning for the sense of security, comfort and belonging that home provides. The participants described their experience of not getting enough rest and sleep while caring for their preterm infant in the NICU which would not happen if they were home. Contributing factors include the time required to visit the NICU for the infant’s care routine, time spent walking from the mother's lodge to the NICU and back, and the separation of mother and infant.

The participant reflected on the contrast between hospital practices and what would have been done if she were at home:

Yes, here in the hospital, they want you to bathe the baby like this while at home they want you to do this and this or at home, you would do this when you see him doing that. It's things I want to know. (P5, 38-year-old)

This quote encapsulates the longing for the familiar routines and comforts of home amidst the unfamiliarity of hospital protocols. It highlights the sense of control and autonomy associated with home, where individuals adhere to their own customs and practices, as opposed to the regulated environment of the hospital. Another participant reminisces about cultural practices that would have been observed in her home environment:

Yeah, like mostly, like back at home, in our culture, we believe that a baby less than a month old must be bathed by the mother or grandmother... If I was at home, I will be feeding her with soft porridge without giving her any medications because this medication makes her defecate twice a day or so and this makes her lose weight. (P7, 32-year-old)

This excerpt emphasises the role of cultural traditions and familial support in shaping caregiving practices. It underlines the interconnectedness between home and cultural identity, where adherence to traditional customs provides a sense of security and belonging, particularly in the context of new-born care. Furthermore, another participant described the traditional approach to newborn care back home:

No, after birth when I come home, we don’t bathe the baby right away, we dampen the cloth in lukewarm water and just wipe the baby where he is dirty. We wash the head because the hair traps a lot of dirty things (blood and birth secretions), we avoid the full bath so that we don’t expose the baby to flu. (P18, 20-year-old)

Other participants compared hospital feeding methods with traditional practices at home. The participants reported that:

Here we feed the baby with breast milk using pipes (NG tubes and syringes) but at home, we do a light and very soft porridge. (P16, 38-year-old)

This comparison highlights the adaptation to different environments and the longing for familiar routines. It shows how home serves as a sanctuary where individuals adhere to their preferred methods of infant care, reinforcing the notion of home as a place of comfort and familiarity. Other participants expressed a longing for the comforts of home and the familiar routines:

So, the first challenge is that we wake up. We only sleep two hours. Most of the time we spend on the way, we do not have time to rest. Like when you are going that way, you may find that you are going for a long time in the baby’s room. When you are coming here, and you try to sleep, time is gone, you must go back. (P14, 39-year-old)

This statement reflects the desire for a sense of normalcy and routine amidst the challenges of hospitalisation. It highlights the idea that home represents a heaven of rest and recuperation, where individuals can adhere to their preferred practices and routines, particularly during significant life events such as childrearing.

Theme 2 interactions with healthcare professionals

In this study, interaction is perceived as communication and involvement in preterm infant care among healthcare professionals and parents of preterm infants in the NICU. The sub-themes included NICU care, communication, and healthcare professional attitudes.

Sub-theme 2.1 care in NICU

This sub-theme concerns how healthcare professionals cared for preterm infants and their parents in the NICU. Some indicated that they received adequate care from nurses and doctors in the NICU.

One participant indicated that:

The doctors are mostly here; they used to come only to check and update [us] about the baby's condition. The people who take part mostly are the nurses. Okay, looking at the ICU there is no problems, all is right. (P02, 25-year-old)

A similar view was echoed by another participant who stated:

Yes, they help me take care of the baby, and the doctors are nearby if there is something the doctor and nurses can help with. (P13, 22-year-old)

Another participant shared that she had only seen good things and is at peace with the care that she is receiving in the NICU:

In [N]ICU I have not seen any bad things; I only noticed the good things. My baby was in troubles, but she is not well, nurses are checking her every time so does the doctors. So up to so far, I never had any problems with nurses and doctors. I am at peace. (P18, 20-year-old)

However, one participant expressed dissatisfaction with the care she received in the NICU. The following quote confirms this:

They end up swearing at us and to be treated this way, been shouted, it ends up affecting our minds since I already have a problem with my baby’s condition. (P12, 28-year-old)

The participants’ responses highlight that they experienced positive and negative care while looking after their preterm infants in NICU; it appears that they appreciated the care, although some were unhappy.

Sub-theme 2.2 communication in NICU

Nearly all parents mentioned the importance of healthcare professionals practising effective communication as clinicians. In this context, communication is the exchange of information between parents of preterm infants and healthcare professionals in the NICU. The parents indicated that they had experienced satisfactory communication with healthcare professionals while caring for their preterm infant in the NICU. This includes comprehensive explanations; for instance, the doctor offered information regarding the baby's weight decrease in terms that parents could comprehend, giving them relief. The following quotes support the experience:

Yes, is not it that when we come here, we are under stress? So, if we want to say sister (nurse), may I ask, how is my baby doing? She can answer me; if she does not know, she must go and ask or tell me that I do not know about this one. I can ask someone who knows, like have good communication. (P17, 23-year-old)

Yes, the same doctor that I ask him regarding the baby’s weight loss. He explained to me well and now I understand, am free because the weight is no longer 0.8 kg, it is now around 1.0 kg. The support is good because when you ask something they quickly actioned it, so there is support. (P18, 20-year-old)

The above participants highlighted the importance of efficient communication in interactions between parents and healthcare professionals in the NICU and its positive effects on parents’ experiences and well-being. Nevertheless, other participants expressed dissatisfaction with the communication they received from the healthcare professionals in the NICU. One of the cited reasons for their dissatisfaction was that healthcare professionals discussed the infant's condition in a language the parents did not understand.

One participant mentioned that:

They asked me if I knew why my baby went to the theatre? What is the reason he came here? I said yes; I just heard them saying it is the authority which I do not know what they meant. (P06, 23-year-old)

Similarly, other participants expressed disappointment that healthcare professionals were not informing them about the interventions/procedures before implementation. The following quotes support the parental disappointment:

We do want to know because when we arrive in the ward, we just see that intravenous lines were inserted, and blood sample were collected, and we also see that the infant was pricked several times on the extremities hence do not even know where the samples are taken to. (P16, 38-year-old)

It is the same as when he was in high care because after labour, my baby was sent to high care, and the next morning he was in ICU without informing me. (P19, 23-year-old)

Moreover, another participant mentioned feeling confused because of the conflicting communication from healthcare professionals. The following quote supports this confusion:

The other one enters tells you the baby should change sides and give you reasons. When you tell them one said I should not change sides, they end up swearing at us end up confusing us. (P12, 28-year-old)

Participants highlighted the negative impact that poor communication could have on their experience in the NICU, as well as the significance of simple and consistent communication with healthcare professionals. They expressed a desire for precise, reliable information to understand what was happening to their preterm infants and to feel more involved in the care of their infants.

Sub-theme 2.3 attitude of healthcare professionals in NICU

The participants in the study expressed dissatisfaction with the attitudes of healthcare professionals in the NICU, as illustrated by the two quotes below:

When you go to the nurse and tell her that the tube is disconnected from the baby and the secretions are coming out through the nose, so the response will be like, what do you want me to do because your baby did that (mother rolling the eyes)? (P01, 18-year-old)

Okay there was this nurse who was on a night shift yesterday and she was busy with files, and when we wanted to ask her to collect some of the things for us, and she would say to us that we must go collect those things for ourselves because she is busy. So, when we got there to collect for ourselves, we found another nurse who asked us as to where our nurse is because we should not be doing this for ourselves. So, when we called her, she showed to me that she does not like her job. (P08, 31-year-old)

Another participant further mentioned that:

There is a nurse that seemed to have an advanced age, whenever we ask her to assist our babies, or asking some supplies to help our babies she is rude. She once told me that [my] babies are ugly such like me. (P20, 19-year-old)

More so, some mothers lamented the lack of communication from the nurses. For example

Their communication is not good because they hide things from us, sometimes you will find that they had taken your baby’s blood and not tell you about the results or what the results implies, and even when you ask the nurses, they would tell you that they are doing what they have been instructed to do. Sometimes you also find your baby inserted with drip, and when you ask, they do not say or explain the reason for all of these. (P08, 31-year-old)

Even though other participants expressed their dissatisfaction regarding the attitude of the healthcare professionals, other participants felt the opposite. One participant mentioned that she had a satisfactory relationship with the healthcare professionals expressed in the quote:

I am pleased with how the hospital is providing her with milk, yes, I am happy they help. (P12, 28-year-old)

Similarly, another participant added that she has only observed good things concerning the level of service provided to her infant:

In [N]ICU I haven’t seen any bad things; I only noticed the good things. (P18, 20-year-old)

Most parents expressed satisfaction with the level of support provided by the healthcare professionals in the NICU. The participants describe the support as encouraging and helping them to understand that challenges are a normal part of the process, as indicated by the below quotes:

Yes, their support is good. It is the kind of support that encourages you to understand that things like this are there and there are these kinds of challenges. (P07, 32-year-old)

Additionally, another participant alluded that:

The support from the nurses is very good, each one of them know me because I have been here for a long time. When they arrive, they call and ask how is the baby [doing]? Initially it was scary because my baby was the smallest one in the unit, and I was new but now am used to the nurses and the unit. (P18, 20-year-old)

Theme 3 cultural practice concerning preterm infant care

The third main theme was the cultural practices concerning preterm infant care. This study's concepts associated with this theme include practices and behaviours conducted after childbirth. This includes the infant naming practice, infant access restrictions, family involvement, and religious practice observance.

Sub-theme 3.1 infant naming by senior family members

Participants indicated that they adhere to the cultural practices of naming the preterm infant after birth. These cultural practices include understanding who is responsible for naming the infant, introducing the infant to the ancestors, and the meaning associated with the name given. The quotes show that senior family members, particularly grandmothers, are responsible for naming the infant and performing ancestral veneration to introduce the infant to the ancestors after birth.

One participant shared that:

If the granny [was] still alive, she [would be] the right [person] to appoint my parent to name the infant. (P02, 25-year-old)

Another participant supported the preceding statement by stating:

Well, when I call them at home regarding the name, my grandmother would want her name to be passed down to the child. (P08, 31-year-old)

The above data highlight that the grandmothers are responsible for naming the infants. This is because naming a preterm infant in Limpopo Province is culturally associated with the practice of ancestral communication, which grandmothers perform. Furthermore, one participant indicated that the infants are named based on various events in life. The following quotation illustrates this:

Because they used a dead person's name, so they are informing the owner of the name that there is someone who will use it. (P02, 25-year-old)

The above quote highlights the belief that a preterm infant is given the name of a deceased person to keep their memory alive and to ensure the continuation of a family legacy. Also, ancestral communication rituals should be performed to inform the name's owner. In addition, another participant indicated that infant naming is culturally essential and that a misnamed infant will continuously cry. The following quotation evidences this belief:

They do that; for example, they can call a baby by name like Sara, and if the baby stops crying, it means that is the name she wanted. And these things happen because they can call her by her name; the baby then stops crying and is healed instantly. (P01, 18-year-old)

The above data suggest that naming a preterm infant may positively affect the infant’s health and well-being when culturally informed. The beliefs and practices related to naming a preterm infant reflect the cultural values and traditions of the parents, which are essential considerations in providing culturally sensitive care in the NICU.

Sub-theme 3.2 infant access restrictions

Participants indicated that everyone is not permitted access to the room where the preterm infant is kept. Access restrictions include funeral attendees, pregnant women and individuals who recently engaged in sexual activities. The following section further explores how participants perceived these restricted individuals as harmful to the infant through a cultural lens based on their experiences during preterm infant care. A common experience for many participants was that individuals who participated in funeral services should perform cultural rituals with ashes and some aloes when entering, as illustrated in the following quotes.

They [those attended the funeral] enter the baby's room, they bath the baby with aloe and ashes a little bit and even on the joints so that she must never get sick. (P01, 18-year-old)

Usually, when they are from a funeral, they take ashes, apply them to the baby and make her swallow a bit of it so that they do not suppress her. (P02, 25-year-old)

An additional participant concurred with the preceding participants and elaborated that:

According to culture all babies from newborn to a child aged 6 to 7, when one person at home goes to the funeral, when that person comes back home takes ashes and rub it on the tummies of all these age group so that none of them can get suppressed or have negative auras. (P20, 19-year-old)

The data highlight the cultural belief that there are diseases and negative auras that can be acquired from funeral services and that precautionary measures must be taken to prevent the spread of these harmful elements to the preterm infant. In addition to the precautionary measures highlighted above, other participants explained that people who attend funerals should be isolated from the infant for some period before regaining access to the infant's room, as illustrated by the two quotes below:

I am staying with my grandmother, but if they are from the funeral, it means only I will nurse the baby. They will take seven days without entering the baby's room. (P04, 24-year-old)

She [person attended the funeral] must stay there for seven days before she returns, and after that, she can come back and help me with the baby. (P11, 27-year-old)

The above quotes indicate that isolating individuals who attended the funeral service for seven days will allow the acquired diseases and negative auras from the funeral to clear up and minimize the chances of transmission to the infant. Pregnant women were the second restriction. The following quotes illustrate beliefs and practices surrounding the presence and interactions of preterm infants and pregnant women:

Traditionally, we think she will suppress the baby. If a pregnant person carries the baby, she will delay the baby's growth. You find that at around six months, the baby is still unable to sit, so they believe it is because a pregnant person carried the baby. She is not supposed to enter the baby's room until the baby gets out. (P02, 25-year-old)

Another participant said:

If someone is pregnant, she is not supposed to hold a baby in such a way that the legs of the baby are on [her-pregnant woman] abdomen because we believe that if the baby's legs are stepping on top of the pregnant person's abdomen, the baby won't walk until the pregnant woman give birth, she will wait for the unborn baby to be born before she can walk. (P01, 18-year-old)

The first quote highlights the complete restriction of pregnant women from gaining access to the infant due to the negative impact (slow growth) that she can have on the infant. However, the second quote indicated that a pregnant woman can be granted access to the infant’s room and can even carry the infant, although with precautions not to allow the infant’s leg to come in contact with the abdomen. Through this analysis, it becomes clear that cultural beliefs and practices play a substantial role in shaping the experiences of pregnant women and their interaction with preterm infants. The final restriction was holding the infant after sexual intercourse. Most participants revealed a common belief that sexual intercourse could lead to the transfer of a negative aura to the infant. The following quote exemplifies this belief:

When the cord has not yet fallen, my grandmother is the only person who is allowed to enter because she has passed that stage of sexual intercourse. The rest of them are not allowed because we are trying to avoid negative aura to be passed on to the child, and if that happen, he will cry a lot. So, no one is allowed except my grandmother. (P08, 31-year-old)

Other participants stated, in support of the preceding statement:

They [siblings] might be coming from their partners and you would find that they were intimate in a way, so their energies will affect the baby negatively. (P09, 30-year-old)

Because they [grandmothers] do not have sexual intercourse anymore and they have experience. Culturally, it is believed that people who had sexual intercourse had negative aura. (P16, 38-year-old)

The data suggest that the role of grandmothers in caring for preterm infants is essential and safe as they are free of negative energies due to their age, experience, and abstinence from sexual intercourse. Furthermore, the data highlights that individuals who engage in sexual intercourse bring negative auras to the baby and are, therefore, not allowed to be in close proximity to the newborn. This cultural practice aims to ensure the well-being and health of the preterm infant by avoiding contact with individuals who have recently engaged in sexual intercourse.

Sub-theme 3.3 family involvement

Cultural practices concerning preterm infant care restrict infant access and allow family members to assist in caring for the infant. The following quotations illustrate participants' experience regarding family involvement while caring for the infant.

One participant stated that:

When I am here, the nurses help me, which is the same when you are at home. There is no difference. (P11, 27-year-old)

Another participant expressed a similar view:

It is very important because when you get help as a new mom you also get time to rest, in my family they would bathe the infant and massage you. (P12, 28-year-old)

In support of the above participants, another participant added that:

At home it is better because we have people who are assisting us, and we have time to rest (P16, 38-year-old)

The conclusion that can be drawn from these findings is that the involvement of family members in caring for the infant enabled the mothers to rest rather than continuously caring for the infant alone, which may be exhausting.

Sub-theme 3.4 religious practices observance/beliefs

In context of this study, most parents were religious and observed religious practices in terms of prayer and using ditaelo (church prescriptions - the church practices believed to be effective in curing the patient and preventing misfortune). This is connected to the belief that their infants would be protected from illness and be healthy, parents would be strengthened, and healthcare professionals would be granted wisdom to care for the infants. Most parents prayed to God for their preterm infant to get better and be healed. The following quotes illustrate this:

I just thought my baby is going to die but because God is present, I prayed I got baby boy. Now I thank God because of my faith and even the doctors had confidence that the baby will be okay. (P18, 20-year-old)

I pray every time I go to the ward for God to give her life and when I leave, I do not know what they will do to her, to not be affected when a lot of activities are done to her body. (P02, 25-year-old) Furthermore, parents also prayed for themselves and drew strength from their spiritual anchor to overcome the challenges they experienced while caring for their preterm infant in the NICU.

I have a way of overcoming my fears and sadness through prayer so that I can be able to receive strength . (P11, 27-year-old)

Other participants also highlighted this. For example, one participant indicated that:

When I am down, I pray for 2 minutes and ask God for strength. Then after, I feel okay. (P02, 25-year-old)

Moreover, participants did not only pray for themselves and their infants but also for healthcare professionals to have wisdom while caring for their infants. The following quotes demonstrate this intercession:

I believe that is the reason I prayed, because evil spirits can block the doctors view for them not see anything. (P12, 28-year-old)

Until now I just pray to God to give wisdom to doctors so that they treat my baby well then, I can go home. (P18, 20-year-old)

Lastly, one participant believed that prayer is more effective when performed in person, in the presence of others, rather than done alone. The participant stated that:

I prefer that when I pray, I must be there with two or more people because the prayer becomes more powerful when you are many. (P11, 27-year-old)

These findings highlights that the communal aspect of religious practices is vital for some individuals and that they believe that the power of prayer is amplified when performed with others. The quotes in this analysis indicate that the participants view prayer as connecting with a higher power, seeking strength, wisdom, and healing for themselves and the preterm infant in their care. Another aspect of religious practice, observance/practice called ditaelo , was also used to protect their infants from evil spirits and heal them.

Theme 4 indigenous healthcare practices for preterm infants

The final theme from the data analysis was “indigenous healthcare practices for preterm infants,” which parents described as the beliefs, knowledge, and habits about health passed down from generation to generation in a specific community. This theme is further explored through the following four subthemes.

Sub-theme 4.1 cultural practices used for cleaning the umbilical cord

Most participants believed that the indigenous care method for the umbilical cord is a vital cultural practice related to preterm infant care. Although the participants used surgical spirit in the NICU, they expressed the practices of using various herbal formulations that they would like to incorporate in the NICU during umbilical cord care. The following quotes reflect this.

I take table salt with that powdered wood soot and apply it [umbilical cord] on the cord every time you bathe the baby until it dries. (P10, 39-year-old)

We took soil from termite mound, chickens’ manure and placed them there for it to fall. (P12, 28-year-old)

Additionally, the same view was echoed by other participants, explaining that:

The herbs will shrink the cord, which will eventually fall off. After that, they will give you herbs to spread over the cord area, which will help the cord to close from inside. I was using the ashes to mix with Vaseline, then spread the mixture over the cord. (P15, 32-year-old)

We clean the cord with surgical spirit. Then we also use the head from the ‘matches’ stick and mix with the mouse poo and crush it down until is a fine powder. Then we apply the fine powder on the cord area. (P20, 19-year-old)

In addition to the various preferred herbal formulations, other participants mentioned that they apply breastmilk on the umbilical cord to increase the rate at which it dries. This is evident in the following quotes:

We do a full bath after two days with warm water, then clean the cord with the spirit, and apply breast milk so that the cord can dry and fall fast. (P18, 20-year-old)

They say we pour breast milk on the cord, like basically the newborn baby we need to apply the breast milk when I wake up in the morning, on the belly button. (P17, 23-year-old)

Furthermore, despite using surgical spirit in the NICU, participants were dissatisfied with its effectiveness. Most mothers felt that the delayed umbilical cord drying, and detachment were caused using surgical spirits.

One participant mentioned:

The way of taking care of children here is different; for instance, the surgical spirit is not so effective in cleaning and making the cord dry. The cord would have fallen by now if I was home. (P05, 38-year-old)

Another participant expressed that:

With home remedies it takes up to three days but with the surgical spirit, it takes seven days. It is fast if you do it traditionally. (P13, 22-year-old)

In support of the above participant, another participant further explained that:

We are staying with elderly people at our homes, so immediately after the baby is born, we start by treating her umbilical cord, which, culturally or religion-wise, is much faster than what we use here at the hospital, because even here at the hospital, they treat the cord by spreading spirit on the cord, but it takes time. (P14, 39-year-old)

Sub-theme 4.2 treatment of dehydration “ phogwana or lebalana ”

Some illnesses experienced by newborns are deemed to be not-for-hospital treatment but require indigenous healthcare practices or treatment. For example, dehydration is an indigenous childhood illness called phogwana, which traditionalists treat through herbal formulations. Other participants were concerned that their infant might suffer from phogwana while admitted to the NICU.

Maybe if I do things the way I am used to doing on the baby, he might recover, or maybe the baby has phogwana, and the doctor thinks it is something they can treat. (P06, 23-year-old)

The following participant echoed a similar notion in support:

When the baby is sick with lebalana, you do not take the baby to the hospital because they do not know how to treat that. You take her to someone. In Tshivenda, we say when the baby has lebalana, they must cut, burn things that came out of it, and then come to the baby… then the baby heals at the same time. (P17, 23-year-old)

Furthermore, participants shared that phogwana needs to be treated by a traditional healer or with traditional medicine. This is evident in the following quote.

If the phogwana is not beating well, there is a traditional medicine that we apply to make sure that it does not affect the baby. (P16, 38-year-old)

Sub-theme 4.3 care of eyes, ears, and nose

The subtheme of "care of eyes, ears, and nose " within the major theme of indigenous healthcare practices for preterm infants is represented by traditional methods of addressing issues related to the eyes, ears, and nose. Most participants reported using breast milk to clean and treat minor ailments of the eyes, ears, and nose.

Most of the time we use breast milk to take care of their eyes, and that even allows them to sleep peacefully, we take few drops of our breast milk and pour them inside his eyes. (P08, 31-year-old)

Another participant added that:

If the eyes are having discharge, we express breast milk inside the eyes and wipes it using the tongue to remove the discharges. (P16, 38-year-old)

In addition to using breast milk for eyes, it was reported to treat blocked nostrils and common flu and clean the umbilical cord, as reflected in the following quotes.

Breast milk works especially when the eyes are white or having the discharges. Same as the nose, when the baby is having a flu, we put few drops of breast milk that is our culture. (P18, 20-year-old)

Participants believe that the non-nutritional use of breast milk as a remedy or treatment for minor ailments of the eyes, sinuses, and ears is effective. This traditional belief may be because breast milk contains antibacterial and anti-inflammatory properties.

Sub-theme 4.4 infant bathing practices

The current study further revealed that preterm infant bathing was not only done for hygiene-related reasons but was also seen as serving to stimulate weight, for physical strengthening, and to protect the infant against evil spirits. These reasons are reflected in the following quotes.

Traditionally we bathe her with sehlapišo (traditional medicine) used to bathe infants to stimulate weight gain. (P13, 22-year-old)

Another participant also shared that:

We use leaves from the Baobab tree to bathe the baby; it is a medication. It is responsible for making the baby strong. (P10, 39-year-old)

In addition to herbal medicines that stimulate infant weight, other participants reported using herbal formulations to protect the infant against evil spirits and negative auras. The usage of herbal formulations is evident in the following quotes:

They use mogato (a traditional form of medicine to protect the baby from being suppressed) for bathing her. They put mogato inside the water and then just bath her, more especially if there is someone from the extended family coming to visit. (P02, 25-year-old)

I use the mixture, add it to the water, and bathe the baby to remove the negative spirits and aura, and some is for weight-gaining stimulation because young babies are difficult to hold due to their size. (P14, 39-year-old)

Lastly, other participants also shared the same notion; however, they indicated that this kind of herbal formulation called sehlapišo should not be used on the infant’s head during bathing as it is believed that the infant’s head will grow at an expedited rate should it come in contact with sehlapišo . The following quotes demonstrate this point:

When we use ‘sehlapišo’ for two days, we keep the water and then the next day we dilute it with hot water so that it becomes warm, and then after bathing we rinse him. we only bath his arms and legs because if we bath his head and neck they will grow too as this is used for growing or gaining weight. (P08, 31-year-old)

You do not touch the baby’s head when using ‘sehlapišo’ you only bath him from the neck to his toes, because they say if it happens that you touch the baby’s head while bathing him, [otherwise] the head and face becomes swollen and changes size. (P09, 30-year-old)

This study highlights parents' experiences caring for their preterm infants and the cultural determinants that can be integrated into preterm care to ensure culturally sensitive care. Four major themes and related sub-themes emphasise the importance of healthcare professionals respecting and acknowledging cultural practices, beliefs, and customs relevant to parents of preterm infants admitted to their facilities.

Participants in the current study experienced a range of negative feelings, including shock, fear, and anxiety, concerning the unexpected event of preterm birth, consistent with the literature. For instance, studies conducted in Sweden [ 30 ] and Denmark [ 31 ] reported that the abruptness of preterm birth, combined with the physical environment of the NICU, evokes feelings of shock and overwhelm in parents. Furthermore, the fear and anxiety experienced by the participants in this study while caring for their preterm infant in the NICU corroborate the findings in existing literature [ 32 , 33 ]. Both studies reported that parents often oscillate between hope and fear, particularly regarding their infant's survival and the possible long-term health complications associated with preterm birth. This correlation could be explained by the fact that preterm birth is traumatic and a potential stressor because it occurs mostly under emergency conditions, often threatening both the parents and the infant's well-being.

The current study's findings revealed that most participants acknowledged receiving satisfactory care from the nurses and doctors, as they were regularly present and helpful in tending to the infants' needs. This finding mirrors those of a study which noted that parents appreciate the quality of care provided by healthcare professionals in the NICU [ 34 ]. However, some participants felt that the nurses were often not friendly and mistreated them in the NICU. The findings are similar to the study which reported that some parents were dissatisfied with the care they received, which often stemmed from perceived rude behavior or negligence [ 35 ]. While technical, medical treatment and care are vital, the current data highlight how such care significantly influences parents' experiences in the NICU.

Communication, both in content and manner, is essential in the NICU setting, as it profoundly impacts parental experiences [ 36 ]. In addition, communication was also identified as a critical component in providing quality care to a diverse population concerning incorporating culturally competent care [ 37 ]. The current findings showed that many parents were satisfied with the communication they received from healthcare professionals, particularly when they were given clear explanations about their infants' condition. However, specific communication issues, including using incomprehensible medical jargon, insufficient intervention information, and conflicting advice from different professionals, were pointed out. These issues align with previous research, highlighting the need for improved communication strategies in the NICU to better inform and support parents [ 38 ].

Regarding the attitude of healthcare professionals, our findings revealed a mixed perception among parents. Some parents expressed dissatisfaction with the perceived negative attitudes of healthcare professionals, echoing similar findings by Shields et al. [ 39 ]. Negative attitudes from healthcare professionals can lead to mistrust and increased stress among parents [ 40 ]. Conversely, other parents in our study reported positive attitudes and felt well-supported and valued by the NICU staff. This positive perception aligns with the previous study which suggested that positive interactions with healthcare professionals can improve parental satisfaction [ 41 ]. While the current findings corroborate existing literature, the heightened perception of both positive and negative aspects of care, communication, and attitude might be attributed to cultural diversity in Limpopo Province.

The current study found that naming preterm infants is the domain of senior family members, particularly grandmothers. This finding aligns with previous work which asserted that grandmothers play a crucial role in naming infants and performing associated rituals in African cultures [ 42 ]. This role could be because the naming process is closely related to ancestral communication, which grandmothers frequently facilitate. Furthermore, the study indicates that infants' names often carry important cultural meanings or memorials, reflecting events or individuals in the family's history. The belief in the power of naming to affect an infant's well-being corroborates with the previous study’s assertion that names in most African cultures bear profound significance, carrying the family's hopes, aspirations, and legacies [ 43 ]. Additionally, names help individuals understand who they are and the community to which they belong. Such findings underscore the importance of cultural considerations concerning naming preterm infants in the NICU to promote culturally sensitive care and enhance parents' experiences.

In this study, three cultural restrictions on infant access aimed at safeguarding preterm infants' health were revealed. These restrictions primarily concern those who attended funerals, pregnant women, and people who recently engaged in sexual intercourse. First, funeral attendants: participants believed they could introduce diseases or negative auras to preterm infants, so precautionary measures needed to be taken before access could be granted again. The precautionary measure, which includes isolating funeral attendants for several days and having them wash their hands with aloe and ashes before touching the infant, aligns with a study by McAdoo [ 44 ], which reported similar customs among various African cultures. The use of aloe and ashes might stem from the fact that they contain some antibacterial properties, which may kill or lessen bacteria.

Second, according to our findings, pregnant women were also viewed as potentially harmful to preterm infants. This finding is unique as no other similar study could be located regarding the harm that could be brought by pregnant women. Third, individuals who recently engaged in sexual intercourse were deemed to have negative auras that could harm infants, particularly from parents' perspectives. This restriction echoes findings of previous study which revealed that newborns are isolated from young girls who engage in sexual activities as they can delay umbilical cord falling off [ 45 ]. This finding highlights the need for open dialogue and understanding regarding sexual practices in NICU care.

This study's findings underline the key role of family members in caring for preterm infants, which aligns with previous research in the field. Particularly, participant responses corroborated the evidence of family involvement as crucial to maternal well-being and infant care, as shown in a study conducted in the United States [ 46 ]. The responses reflect an appreciation for the support offered by extended family, primarily in providing mothers with rest and recovery time, mirroring previous findings [ 47 ]. The significance of family engagement in this study can be linked to cultural norms and values in the Limpopo Province and South Africa.

Most South African tribes, particularly indigenous ones, strongly believe in communal assistance and interdependence, particularly at significant life events such as childbirth. This is frequently characterised by extended family members stepping in to aid and support the new mother, allowing her time to relax and heal while contributing to the infant's care. Additionally, the similarity in support between NICU nurses and family members emphasized by participants resonates with the notion of family-centred care advocated by other scholars [ 48 ]. This approach, which suggests that healthcare providers can emulate a sense of familial support, highlights the importance of aligning clinical practices with the socio-cultural context of care.

Most participants expressed a reliance on prayer for the health of their infants, personal strength, and wisdom for healthcare professionals, which aligns with other studies that demonstrated the importance of spiritual beliefs in health outcomes and coping mechanisms [ 49 , 50 , 51 ]. Moreover, the idea of communal prayer being more potent than individual prayer, as pointed out by one participant, echoes classic sociological theory on the collective effervescence and emotional energy generated in communal religious rituals [ 52 ]. This finding accentuates the importance of understanding and integrating spiritual needs and beliefs in the NICU environment.

Interestingly, participants in the current study also invoked ' ditaelo ', or church prescriptions, in protecting and healing their infants. This practice, not extensively documented in the existing literature, appears to be a distinct element of religious observance in this cultural context. It may relate to African traditional healing practices, as discussed in the previous studies which indicated a unique fusion of Christianity and indigenous beliefs [ 53 , 54 ]. This practice underscores the cultural and spiritual complexity surrounding NICU care in the Limpopo Province and calls for further research to better comprehend these practices and their implications for infant care.

The participants’ experiences in the current study regarding umbilical cord care revealed that most parents reported using and believing in traditional cord care practices. These participants further described using ashes, powdered wood soot, breast milk, and soil from termite mounds topically to dry off and heal the umbilical cord. The use of herbs to treat and care for the umbilical cord was not unique to the participants in this study. In Sub-Saharan countries including South Africa [ 45 ], Zambia [ 55 ], Nigeria [ 56 ], Pakistan [ 57 ], and Uganda [ 58 ], the topical application of substances to the umbilical cord to hasten its detachment has been reported. It is important to acknowledge that while these traditional practices hold cultural significance and have been used for generations, their efficacy and safety may differ. In some cases, such practices may carry risks, such as infection or irritation. Healthcare providers should be aware of these cultural practices and engage in open and respectful conversation with families to understand their beliefs and preferences while also providing safe evidence-based care.

Moreover, participants also expressed dissatisfaction with modern procedures, such as surgical spirits, which they perceived as less effective than traditional practices because it makes the cord detach after seven days. This perception echoes the findings of study which revealed that some cultures believe traditional practices provide superior results compared to modern medical care, particularly for infants [ 59 ]. Although the herbal formulation was preferred over modern medical care, it has not been scientifically evaluated and studied; therefore, there is a potential risk of infection and other complications. Further research is needed to understand the scientific functionality of herbal formulations used to treat and dry off the umbilical cord.

This study showed that there are perceptions that certain medical conditions affecting newborns do not necessitate hospital care but rather require indigenous healthcare practices or treatment. For instance, phogwana was mentioned as a condition that needs out-of-hospital treatment by traditionalists. Similarly, this finding supports the previous literature which documented that the treatment of phogwana requires a traditional healer [ 44 , 60 ]. In addition, the literature indicated that the characteristics, prevention, and treatment of phogwana correspond to specific cultural contexts [ 61 ]. Providing medical care for premature infants outside of the hospital, under the guidance of traditionalists, may pose result risks, such as adverse responses to herbal therapy and metabolic poisoning. The immature organs of preterm newborns may have limited ability to efficiently remove metabolites of herbal medicines, which could potentially cause more health complications and death [ 62 ].

Furthermore, regarding the care of eyes, ears, and nose, participants reported using breast milk as a treatment for minor ailments. The belief in the antibacterial effects and healing properties of breast milk in traditional medicine is further substantiated by this finding, aligning with existing literature. These studies reinforce the multifunctional uses of breast milk beyond nutrition, including its application in treating eye infections [ 63 ] and alleviating nasal congestion, among others [ 64 ]. Although the benefits of breast milk are recognised, it is crucial to follow proper hygiene protocols when dealing with it. This includes washing your hands before handling breast milk and using sterile containers and applicators. Neglecting to maintain good hygiene can potentially introduce infections to the ears, nose, and eyes.

The participants in the current study reported that infant bathing was performed with different herbs for several purposes, such as stimulation of weight, warding off the evil spirit, and strengthening and protecting the infant. Herbal formulations used for bathing included sehlapišo , mogato , and baobab tree leaves. This study's findings agree with several studies on the African continent. In Uganda, infants were bathed with kyogero to attract fortunes [ 65 ], and in South Africa [ 44 ], India [ 66 ] and Nigeria [ 67 ], herbal medicine was also used during infant bathing for strengthening and spiritual protection purposes. One possible reason for the similarity could be that all studies reporting indigenous infant bathing were conducted on the African continent, which has overlapping cultural practices. It is clear from this finding that bathing practices are not merely physiologically functional but are often symbolic, serving various socio-cultural purposes and highlighting the intersection of cultural belief and healthcare. Preterm infants are vulnerable to health risks such as hypothermia, skin irritation, and infection due to their underdeveloped thermoregulatory system, delicate skin, and immature immune system [ 68 ]. Ritual bathing, particularly if not performed carefully, has the potential to worsen these health risks. It is recommended that healthcare professionals should ensures measures to guarantee that the ritual bathing environment for preterm newborns is secure, hygienic, and at a suitable temperature to reduce these dangers.

Limitations and strengths of the study

This study explored the cultural determinants of parents that can be incorporated into preterm infant care to ensure culturally sensitive care as part of maternal and childcare routine in the NICU in Limpopo Province. Although the qualitative design was the most appropriate to explore the phenomenon in this study, it limited the study's findings as it was not generalizable. Additionally, the primary investigator’s unconscious biases and perceptions could have influenced data analysis, however bracketing was applied to limit bias. Furthermore, to limit biases, the experts conducted a confirmability audit of the study project by checking and rechecking the collected raw-, coded- and interpreted data. The current study was conducted in a public hospital in Limpopo Province to explore the experiences of parents of preterm infants in the NICU, which may differ substantially from those in private hospitals and other provinces. Therefore, future research is recommended to explore this phenomenon in private hospitals and other provinces in South Africa.

The current study provides an understanding of parents' experiences caring for preterm infants in the NICU. The study offered meaningful insights into indigenous healthcare practices, emphasizing their crucial role in preterm infant care in specific cultural contexts. The cultural determinants included various topics, such as caring for the umbilical cord, treating phogwana , caring for the eyes, ears, and nose, and infant bathing customs. These practices showed a deeply ingrained belief system and a rich cultural heritage that have a meaningful impact on healthcare behaviours. However, these cultural determinants might have both positive and negative implications.

The findings demonstrated a strong reliance on traditional methods and herbal formulations in caring for preterm infants. Parents emphasised the advantages of these practices over current medical procedures, notably in treating disorders not frequently recognised by modern medicine and the care of the umbilical cord. This discontent with contemporary practices, highlights the need for culturally sensitive healthcare which can be conducted by conducting cultural assessments to understand the beliefs, values, and practices of the families in the NICU.

Overall, the findings of this study highlight the profound role of indigenous healthcare practices for preterm infants, reinforcing the need for a culturally sensitive approach in healthcare.

Availability of data and materials

The dataset materials generated and analysed during this study are accessible upon justified request from the corresponding author [MN].

Abbreviations

Neonatal Intensive Care Unit

North-West University

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Acknowledgements

The authors would like to extend their gratitude to all the parents of preterm infants who participated in this study and the assistant researchers who assisted in collecting the data.

Open access funding provided by North-West University. This manuscript was extracted from a funded research project by the NWU postgraduate bursary and Faculty of Health Sciences bursary (Funding code/number: not applicable).

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Madimetja J. Nyaloko, Welma Lubbe, Salaminah S. Moloko-Phiri & Khumoetsile D. Shopo

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M.N. conceptualised and developed the research protocol, conducted research (gathered, analysed, interpreted, and managed the data), and wrote the initial draft. W.L., S.S.M., and K.D.S. supervised the research and provided inputs and guidance for the research protocol development, data collection, analysis, and interpretations. All authors have read and approved the manuscript.

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Correspondence to Madimetja J. Nyaloko .

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The current study was executed in accordance with the Declaration of Helsinki and approved by North-West University Health Research Ethical committee [NWU-00267-21-S1]. Limpopo Province [LP-2021-08-027] granted permission to conduct the study through the National Health Research Database website. The management of the tertiary hospital granted goodwill permission for the study to be undertaken in their NICU. All the parents of preterm infants who participated in the study provided written informed consent. Participants were informed that participation in the study was voluntary and that they could withdraw anytime without penalty.

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Nyaloko, M.J., Lubbe, W., Moloko-Phiri, S.S. et al. Parental experiences of caring for preterm infants in the neonatal intensive care unit, Limpopo Province: a descriptive qualitative study exploring the cultural determinants. BMC Health Serv Res 24 , 669 (2024). https://doi.org/10.1186/s12913-024-11117-6

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Received : 11 October 2023

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DOI : https://doi.org/10.1186/s12913-024-11117-6

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Understanding the Stigma Experience of Men Living with HIV in Sub-Saharan Africa: A Qualitative Meta-synthesis

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• Sarah E. Janek   ORCID: orcid.org/0009-0002-1213-2791 1 ,
• Sandy Hatoum   ORCID: orcid.org/0009-0002-3618-9733 2 ,
• Leila Ledbetter   ORCID: orcid.org/0000-0002-5206-8002 3 &
• Michael V. Relf   ORCID: orcid.org/0000-0002-4951-8869 1 , 2  

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Men living with HIV (MLWH) in sub-Saharan Africa experience poor health outcomes and increased AIDS-related deaths due to stigma influencing testing and treatment uptake and adherence. PRISMA 2020 was used to report a meta-synthesis of the stigma experiences of MLWH in SSA. With the help of an expert librarian, a search of six databases was formulated and performed to examine the available qualitative and mixed method studies with qualitative results relevant to the research question. Studies focused on adult men living with HIV, with five studies specifically examining the HIV experience of men who have sex with men. Study themes were synthesized to describe MLWH’s perceived, internalized, anticipated, enacted, and intersectional stigma experiences. Most studies included masculinity as a key theme that affected both testing and treatment adherence upon diagnosis. Future research is needed to better understand subpopulations, such as men who have sex with men living with HIV, and what interventions may be beneficial to mitigate the disparities among MLWH in SSA.

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Acknowledgements

The manuscript was supported by the Fogarty International Center/National Institutes of Health through Award Number R21TW011247 (M. Relf, Contact MPI/L. Nyblade, MPI) and the Duke University Center for AIDS Research (CFAR), an NIH funded program (5P30AI064518). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Research reported in this publication was supported by the Fogarty International Center of the National Institutes for Health under award R21TW012007 and by the Duke Center for AIDS Research, a National Institutes of Health funded program under award number 5P30AI064518. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

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Janek, S.E., Hatoum, S., Ledbetter, L. et al. Understanding the Stigma Experience of Men Living with HIV in Sub-Saharan Africa: A Qualitative Meta-synthesis. AIDS Behav (2024). https://doi.org/10.1007/s10461-024-04329-8

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