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Research Methods in Nursing

Qualitative, quantitative, observational, correlational, quasi-experimental, experimental, mixed-methods, triangulation, ask a librarian.

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QUALitative research "is best suited for research aimed at rich description or in-depth understanding of a phenomenon, rather than determining causality; it is particularly useful in understanding the relevance of contextual features in the expression of the phenomenon. Qualitative approaches are most often chosen when little is known about a topic or when new perspectives are needed; other functions of qualitative approaches include generating hypotheses, refining theory, providing illustrative examples, creating taxonomies, and generating items for instrument development.

Relying primarily on inductive rather than deductive processes, qualitative studies generally share several “ground-up” features that differentiate them from “top-down” quantitative research. These features are driven by two central tenets: an orientation to cases rather than variables, as well as a preference for emergent rather than fixed designs."

More Information from Encyclopedia of Nursing Research

Four types of qualitative research design often applied to nursing research are:

Phenomenology - the study of human life experiences and how they appear in human consciousness
Grounded Theory - seeks to explain variations in social interactional and social structural problems and processes
Ethnography - As a research process, ethnography is a comparative method for investigating patterns of human behavior and cognition through observations and interactions in natural settings
Narrative Inquiry - the analysis of meaning in context through interpretation of persons' life experiences

For more details , look up these research designs in:

Encyclopedia of Nursing Research

Dictionary of Nursing Theory and Research

QUANtitative research "consists of the collection, tabulation, summarization, and analysis of numerical data for the purpose of answering research questions or hypotheses. The term quantitative research is of recent origin and is distinguished from qualitative research in design, process, and the use of quantification techniques to measure and analyze the data. The vast majority of all nursing studies can be classified as quantitative.

Quantitative research uses statistical methodology at every stage in the research process. At the inception of a research project, when the research questions are formulated, thought must be given to how the research variables are to be quantified, defined, measured, and analyzed. Study subjects are often selected for a research project through the statistical method of random sampling, which promotes an unbiased representation of the target population among the sample from whom generalizations will be made. Statistical methods are used to summarize study data, to determine sampling error, and in studies in which hypotheses are tested, to analyze whether results obtained exceed those that could be attributed to sampling error (chance) alone."

Quantitative Research Design can be Non-Experimental (Descriptive or Correlational) or Experimental (including Quasi-Experimental).

" Observational designs are nonexperimental, quantitative designs. In contrast to experimental designs in which the investigator manipulates the independent variable and observes its effect, the investigator conducting observational research observes both the independent and dependent variables. In observational studies, variation in the independent variable may be due to genetic endowment, self-selection, or occupational or environmental exposures."

" Correlational research examines the relationships between variables, but unlike experimental or quasi-experimental studies, correlational studies lack active manipulation of the independent variable(s). Therefore, postulation of relationships among study variables in causal terms is risky. Discussion of associations in correlational studies, however, sometimes gives an indication of how likely it is that a cause-and-effect relationship might exist."

More Information from Dictionary of Nursing Theory and Research

" Quasi-experimental research is similar to experimental research in that there is manipulation of an independent variable. It differs from experimental research because there is no control group, no random selection, no random assignment, and/or no active manipulation. Quasi-experimental research is a useful way to test causality in settings when it is impossible or unethical to randomly assign subjects to treatment and control groups or to withhold treatment from some subjects."

Experimental research "involves manipulation of the principal independent variable, i.e., the actual administration of treatments or interventions that comprise the categories of the independent variable. An investigation is made of the effect of the independent variable on the dependent variable.

A true experiment is characterized by random assignment of individual subjects to the treatment conditions and a high degree of control over unwanted influence of extraneous variables and other factors that could bias the results of the study."

"True experiments have the potential to provide strong evidence about the hypothesized causal relationship between independent and dependent variables. Experiments are characterized by manipulation, control, and randomization. The quality of experiments depends on the validity of their design."

" Mixed methods research is a term associated with research that uses a combination of methods that are usually identified with qualitative research and methods that are usually identified with quantitative research. It should not be confused with the terms mixed models or mixed effects that are used in other contexts such as the analysis of variance.

It is important to understand that the use of a mixed methods approach does not make research better or more valid than the use of either a qualitative or a quantitative approach."

"In nursing research, triangulation refers to the use of multiple sources to validate findings by the nursing researcher. It involves the combination of both quantitative and qualitative research methods within a single study."

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Evidence Based Nursing Practice

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Levels of Evidence

As the different study designs have different strengths, and weakness, they have been ranked in levels of evidence. Simply put, the strongest designs are at the top, the weakest at the bottom. The pyramid is a convenient symbol for this, as there are usually fewer randomized trials say, than case reports.

For an interactive version, go to: https://library.muhealth.org/evidencepyramid/

Click on the image to see larger version.

Study Types/Designs

Case Report - a write up of the case of an individual patient; a clinical presentation. Often the first report of a new disease or disease trend.

Case Series - a write up of the cases of several patients all undergoing similar treatment.

Case-Control Study - a comparison of study subjects with a particular disease/risk factor (cases) to those without (controls). These have also been called retrospective studies. A good design for rare diseases but easy to get poor data.

Clinical Trial - an experimental study in which subjects receive an intervention. Preferably subjects are assigned to either treatment or no treatment/placebo (see Controlled Clinical Trial). Some trials compare multiple treatments, e.g. the subjects could be assigned to: Treatment A, Treatment B, No treatment/placebo. The different groups are called arms. This is the best study design for testing effect of interventions.

Cohort Study - a group of subjects followed through time. Cohort studies can be used to track effect of an exposure, e.g. all subjects had been exposed to lead in their housing, or they can track a cohort not exposed. They have also been called prospective studies. This is a strong design for determining risk and incidence.

Controlled Clinical Trial - a Clinical Trial where there is a control group receiving a comparison treatment or no treatment/placebo.

Cross Sectional Study - a descriptive study that documents the number of people with a particular disease or risk factor.

Randomized Controlled Trial - Same as Controlled Clinical Trial, with the added benefit of the subjects being randomly assigned to treatment/no treatment arms. This avoids selection bias as all subjects have an equal chance of being assigned to any one of the treatment/no treatment arms. Random assignment can be accomplished using machine generated random number tables. Assigning subjects using methods such as coin tosses or assigning even-odd numbers is considered pseudo-randomization.

Review articles are not considered evidence . One exception to this are Systematic Reviews - including their subset, Meta-Analysis .

Why are Systematic Reviews included in the evidence based pantheon? They aim for documented, exhaustive and comprehensive searching for all research on a specified topic. Most other types of reviews either do not document their search and collection of the research nor do they verify that they have completed an exhaustive and comprehensive search.

All things random

In evidence based practice, much is made of Randomized Control Trials (i.e. clinical trials where participants are randomized assigned to an interventions, including a control group.) Why? Randomized Control Trials - RCTs - can show cause and effect not just association.

However, they are not the only study design available. This page provides a glossary (left column) of some of them. For more info & a nifty chart, check out CEBM's Study Design site.

Making sense of it all

Study designs can be classified as descriptive or analytical . The analytical studies have more power, or ability to predict, than descriptive studies and therefore rank higher in the evidence based world.

Descriptive studies give us a snap shot of what is happening. Surveys, case reports, cross sectional studies (using surveys) are descriptive. They cannot show cause and effect, but they can show prevalence or incidence. They can also be useful in spotting trends.

Analytical studies measure the relationship between factors. Cohort studies and randomized control trials are analytical. They show cause and effect.

For more information or in depth definitions, see College of Veterinary Medicine, Washington State University.

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Evidence-based nursing is about applying the best available evidence to a specific clinical question. Different clinical questions require evidence from different research designs. No single design has precedence over another, rather the design chosen must fit the particular research question. 1 Questions focused on the cause, prognosis (course), diagnosis, prevention, treatment, or economics of health problems are best answered using quantitative designs, whereas questions about the meaning or experience of illness are best answered using qualitative designs. Many different quantitative and qualitative research designs exist, each with a specific purpose and with strengths and limitations. In this editorial, the most rigorous quantitative designs to address questions of prevention or treatment, causation, and prognosis will be outlined. The next editorial will describe the use of qualitative designs to address questions of meaning or experience.

Questions about the effectiveness of prevention and treatment interventions

The randomised controlled trial (RCT) is the strongest design for questions of whether healthcare interventions are beneficial (ie, do more good than harm). An RCT is a true experiment in which people are randomly allocated to receive a new intervention (experimental group) or to receive a conventional intervention or no intervention at all (control group). Because it is the play of chance alone that determines the allocation, the only systematic difference between the groups should be the intervention. Investigators follow participants forward in time (follow up) and then assess whether they have experienced a specific outcome (fig 1 ⇓ ). The 2 most important strengths of RCTs are (1) the random allocation of participants to groups, which helps to ensure that the groups are similar in all respects except exposure to the intervention, and (2) the longitudinal nature of the study, whereby exposure to the intervention precedes the development of the outcome. These 2 features ensure that any differences in outcome can be attributed to the intervention. The …

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Choosing and Implementing the Right Study Design

Study Designs Short article from the Centre for Evidence-Based Medicine gives a brief guide to the different study types and a comparison of the advantages and disadvantages.
Research Design Checklist Research Design Checklist from Graziano & Raulin's Research Methods (9th Edition).
Research Design Checklist Tutorial Tutorial with examples on how to use the Research Design Checklist to verify that all key decisions have been made during the design and preparation phases of research. From Graziano & Raulin's Research Methods (9th Edition).
What is the appropriate study design? Questions to ask yourself to match a study design to a PICO or research question. From BMJ Open.
Checklist for Experimental Design From the Essential Guide to Doing Your Research Project, 3rd Edition, by Zina O'Leary.
Checklist for Achieving Credibility in Qualitative Studies From The Essential Guide to Doing Your Research Project, 3rd Edition, by Zina O'Leary.
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NURSING: Research Designs

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Research Design Resources

The following links provide definitions and information on research designs.

Study Types & Designs - University of Missouri Health Sciences Library Definitions of study types/designs and tips for understanding research designs and EBP
Centre for Evidence Based Medicine - Study Designs A brief guide to the different study types and a comparison of the advantages and disadvantages of the different types of study.
University of Alabama at Birmingham - Lister Hill Library of Health Sciences - Top Ten Things You Need to Know About EBP Go to the sections on EBP and Research Fact Sheets to locate tips on EBP.
Indiana State University Cunninham Memorial Library - EBP Terminology Definitions related to EBP, including case and cohort studies.
American Association of Colleges of Nursing - Evidence Based Practice by Karen N. Drenkard, PhD, RN, NEA-BC, FAAN QSEN Workshop presentation.
University of Minnesota Health Sciences Library - Understanding Research Designs Basic definitions and examples of study designs.

Additional Definitions and Sample Articles

Definitons of research designs from Introduction to Evidence Based Practice: A Practical Guide for Nursing by Lisa Hopp and Leslie Rittenme yer .

Case Controlled studies are where researchers conduct a comparison of cases with a particular outcome and cases without a particular outcome to evaluate the participants’ exposure.

Case Series/Case Report is a research design that track patients with a known exposure given similar treatment or examines their medical records for exposure and outcome.

Cohort studies with a control group are those where a group of people with something in common (a cohort) are followed. This group is compared to another group with similar characteristics/circumstances, with the exception of the factor being investigated.

Cross-sectional studies involve data collected at a defined time, providing a snapshot of a disease in the population (observational studies).

Meta-analysis uses statistical methods to pool the results of independent studies (quantitative). Meta-synthesis is a qualitative analysis of a group of individual studies in which the finding of the studies are pooled.

Randomized Clinical Trial is an experiment using human beings in which the investigator randomly assigns participants in the trial either to a treatment or control (no treatment) group.

Systematic Reviews attempt to synthesize and summarize evidence from existing primary studies. They use explicit and transparent methods to include/exclude studies on a topic, and rigorously analyze the results to form a conclusion.

Example of Case Control Study
Example of Case Report
Example of Case Series
Example of Cohort Study
Example of Cross-Sectional Study
Example of Randomized Controlled Trial
Example of a Systematic Review
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Introduction to qualitative nursing research

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

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

Research 101: Descriptive statistics

Differentiating research, evidence-based practice, and quality improvement

How to appraise quantitative research articles

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

What is qualitative research?

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

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

Qualitative research designs

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

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

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

Sampling approaches

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

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


Action research	Education	Conducted by and for those taking action to improve or refine actions	What happens to the quality of nursing practice when we implement a peer-mentoring system?
Case study	Many	In-depth analysis of an entity or group of entities (case)	How is patient autonomy promoted by a unit?
Descriptive	N/A	Content analysis of data
Discourse analysis	Many	In-depth analysis of written, vocal, or sign language	What discourses are used in nursing practice and how do they shape practice?
Ethnography	Anthropology	In-depth analysis of a culture	How does Filipino culture influence childbirth experiences?
Ethology	Psychology	Biology of human behavior and events	What are the immediate underlying psychological and environmental causes of incivility in nursing?
Grounded theory	Sociology	Social processes within a social setting	How does the basic social process of role transition happen within the context of advanced practice nursing transitions?
Historical research	History	Past behaviors, events, conditions	When did nurses become researchers?
Narrative inquiry	Many	Story as the object of inquiry	How does one live with a diagnosis of scleroderma?
Phenomenology	Philosophy Psychology	Lived experiences	What is the lived experience of nurses who were admitted as patients on their home practice unit?

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

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

Data collection and analysis

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

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

Evaluating a qualitative study

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

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

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

Application to nursing practice

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

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

Successful implementation

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

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



o What is the report title and composition of the abstract? o What is the problem and/or phenomenon of interest and study significance? o What is the purpose of the study and/or research question?	→ Clear and concise report title describes the research topic and design (e.g., grounded theory) or data collection methods (e.g., interviews) → Abstract summarizes key points including background, purpose, methods, results, and conclusions → Problem and/or phenomenon of interest and significance is identified and well described, with a thorough review of relevant theories and/or other research → Study purpose and/or research question is identified and appropriate to the problem and/or phenomenon of interest and significance

o What design and/or research paradigm was used? o Is there evidence of researcher reflexivity? o What is the setting and context for the study? o What is the sampling approach? How and why were data selected? Why was sampling stopped? o Was institutional review board (IRB) approval obtained and were other issues relating to protection of human subjects outlined?	→ Design (e.g., phenomenology, ethnography), research paradigm (e.g., constructivist), and guiding theory or model, as appropriate, are identified, along with well-described rationales → Design is appropriate to research problem and/or phenomenon of interest → Researcher characteristics that may influence the study are identified and well described, as well as methods to protect against these influences (e.g., journaling, bracketing) → Settings, sites, and contexts are identified and well described, along with well-described rationales
o What data collection and analysis instruments and/or technologies were used? o What is the method for data processing and analysis? o What is the composition of the data? o What strategies were used to enhance quality and trustworthiness?	→ Sampling approach and how and why data were selected are identified and well described, along with well-described rationales; participant inclusion and exclusion criteria are outlined and appropriate → Criteria for deciding when sampling stops is outlined (e.g., saturation) and rationale is provided and appropriate → Documentation of IRB approval or explanation of lack thereof provided; consent, confidentiality, data security, and other protection of human subject issues are well described and thorough → Description of instruments (e.g., interview scripts, observation logs) and technologies (e.g., audio-recorders) used is provided, including how instruments were developed; description of if and how these changed during the study is given, along with well-described rationales → Types of data collected, details of data collection, analysis, and other processing procedures are well described and thorough, along with well-described rationales → Number and characteristics of participants and/or other data are described and appropriate → Strategies to enhance quality and trustworthiness (e.g., member checking) are identified, comprehensive, and appropriate, along with well-described rationales; trustworthiness framework, if identified, is established from experts (e.g., Lincoln and Guba, Whittemore et al.) and strategies are appropriate to this framework

o Were main study results synthesized and interpreted? If applicable, were they developed into a theory or integrated with prior research? o Were results linked to empirical data?	→ Main results (e.g., themes) are presented and well described and a theory or model is developed and described, if applicable; results are integrated with prior research → Adequate evidence (e.g., direct quotes from interviews, field notes) is provided to support main study results

o Are study results described in relation to prior work? o Are study implications, applicability, and contributions to nursing identified? o Are study limitations outlined?	→ Concise summary of main results are provided and thorough, including relation to prior works (e.g., connection, support, elaboration, challenging prior conclusions) → Thorough discussion of study implications, applicability, and unique contributions to nursing is provided → Study limitations are described thoroughly and future improvements and/or research topics are suggested

o Are potential or perceived conflicts of interest identified and how were these managed? o If applicable, what sources of funding or other support did the study receive?	→ All potential or perceived conflicts of interest are identified and well described; methods to manage potential or perceived conflicts of interest are identified and appear to protect study integrity → All sources of funding and other support are identified and well described, along with the roles the funders and support played in study efforts; they do not appear to interfere with study integrity

o What is the report title and composition of the abstract?

o What is the problem and/or phenomenon of interest and study significance?

o What is the purpose of the study and/or research question?

→ Clear and concise report title describes the research topic and design (e.g., grounded theory) or data collection methods (e.g., interviews)

→ Abstract summarizes key points including background, purpose, methods, results, and conclusions

→ Problem and/or phenomenon of interest and significance is identified and well described, with a thorough review of relevant theories and/or other research

→ Study purpose and/or research question is identified and appropriate to the problem and/or phenomenon of interest and significance

o What design and/or research paradigm was used?

o Is there evidence of researcher reflexivity?

o What is the setting and context for the study?

o What is the sampling approach? How and why were data selected? Why was sampling stopped?

o Was institutional review board (IRB) approval obtained and were other issues relating to protection of human subjects outlined?

→ Design (e.g., phenomenology, ethnography), research paradigm (e.g., constructivist), and guiding theory or model, as appropriate, are identified, along with well-described rationales

→ Design is appropriate to research problem and/or phenomenon of interest

→ Researcher characteristics that may influence the study are identified and well described, as well as methods to protect against these influences (e.g., journaling, bracketing)

→ Settings, sites, and contexts are identified and well described, along with well-described rationales

o What data collection and analysis instruments and/or technologies were used?

o What is the method for data processing and analysis?

o What is the composition of the data?

o What strategies were used to enhance quality and trustworthiness?

→ Sampling approach and how and why data were selected are identified and well described, along with well-described rationales; participant inclusion and exclusion criteria are outlined and appropriate

→ Criteria for deciding when sampling stops is outlined (e.g., saturation) and rationale is provided and appropriate

→ Documentation of IRB approval or explanation of lack thereof provided; consent, confidentiality, data security, and other protection of human subject issues are well described and thorough

→ Description of instruments (e.g., interview scripts, observation logs) and technologies (e.g., audio-recorders) used is provided, including how instruments were developed; description of if and how these changed during the study is given, along with well-described rationales

→ Types of data collected, details of data collection, analysis, and other processing procedures are well described and thorough, along with well-described rationales

→ Number and characteristics of participants and/or other data are described and appropriate

→ Strategies to enhance quality and trustworthiness (e.g., member checking) are identified, comprehensive, and appropriate, along with well-described rationales; trustworthiness framework, if identified, is established from experts (e.g., Lincoln and Guba, Whittemore et al.) and strategies are appropriate to this framework

o Were main study results synthesized and interpreted? If applicable, were they developed into a theory or integrated with prior research?

o Were results linked to empirical data?

→ Main results (e.g., themes) are presented and well described and a theory or model is developed and described, if applicable; results are integrated with prior research

→ Adequate evidence (e.g., direct quotes from interviews, field notes) is provided to support main study results

o Are study results described in relation to prior work?

o Are study implications, applicability, and contributions to nursing identified?

o Are study limitations outlined?

→ Concise summary of main results are provided and thorough, including relation to prior works (e.g., connection, support, elaboration, challenging prior conclusions)

→ Thorough discussion of study implications, applicability, and unique contributions to nursing is provided

→ Study limitations are described thoroughly and future improvements and/or research topics are suggested

o Are potential or perceived conflicts of interest identified and how were these managed?

o If applicable, what sources of funding or other support did the study receive?

→ All potential or perceived conflicts of interest are identified and well described; methods to manage potential or perceived conflicts of interest are identified and appear to protect study integrity

→ All sources of funding and other support are identified and well described, along with the roles the funders and support played in study efforts; they do not appear to interfere with study integrity

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

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

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

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

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

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

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

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

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

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

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

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

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

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Nurses build coalitions at the Capitol

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Reflections: My first year as a Magnet® Program Director

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Research Study Design

Nursing Research, Step By Step - Series from American Journal of Nursing

This series coordinated by the Heilbrunn Family Center for Research Nursing at Rockefeller University is designed to give nurses the knowledge and skills they need to participate in research, step by step. Each column will present the concepts that underpin evidence-based practice—from research design to data interpretation. Some articles are accompanied by a podcast offering more insight and context from the author. Articles from the series are listed below.

Capili, B. (2020). How does research start? The American Journal of Nursing, 120 (10), 41–44. 10.1097/01.NAJ.0000718644.96765.b3

This article focuses on how to start the research process by identifying a topic of interest and developing a well-defined research question.

Capili, B. (2021). Selection of the study participants. Th e American Journal of Nursing, 121 (1), 64–67. 10.1097/01.NAJ.0000731688.58731.05

This article is an introduction to designing study eligibility criteria and recruiting study participants.

Curtis, & Keeler, C. (2021). Sampling design in nursing research. The American Journal of Nursing , 121 (3), 53–57. https://doi.org/10.1097/01.NAJ.0000737304.14564.51

This column continues with a discussion of sampling design and includes a consideration of probability and nonprobability sampling methodologies.

Curtis, A. C., & Keeler, C. (2021). Measurement in nursing research. The American Journal of Nursing, 121 (6), 56–60. 10.1097/01.NAJ.0000753668.78872.0f

In this article, we explore measurement in quantitative research. We will also consider the concepts of validity and reliability as they relate to quantitative research measurement.

Capili, B. (2021). Selection and implementation of outcome measurements . The American Journal of Nursing, 121 (8), 63–67. 10.1097/01.NAJ.0000767840.30291.31

This column continues the discussion of outcome measures, focusing on questionnaire formats and guidelines for selecting and administering these measures in clinical research.

Capili, B. (2021). Cross-sectional studies. The American Journal of Nursing, 121 (10), 59–62. 10.1097/01.NAJ.0000794280.73744.fe

This article describes one type of observational study, the cross-sectional study, examining its strengths and weaknesses and discussing methods for reporting the study results.

Capili, B., & Anastasi, J. K. (2021). Cohort studies. The American Journal of Nursing , 121 (12), 45–48. https://doi.org/10.1097/01.NAJ.0000803196.49507.08

This article describes prospective (following a group from the present into the future) and retrospective (studying a group from the past through to the present) cohort designs, examines their strengths and weaknesses, and discusses methods for reporting the study results.

Keeler, & Curtis, A. C. (2022). Case-control studies. The American Journal of Nursing , 122 (2), 51–56. https://doi.org/10.1097/01.NAJ.0000820584.29051.80

Like cohort studies, case–control studies connect a health outcome with a specific exposure, allowing researchers to compare the association between the two. Here, we compare cohort and case–control studies, discuss the selection of cases and controls, describe how one might evaluate whether an association exists between them, and outline potential sources of bias. We end by discussing when a case–control study might be appropriate.

Keeler, & Curtis, A. C. (2022). Secondary data in nursing research. The American Journal of Nursing , 122 (4), 58–61. https://doi.org/10.1097/01.NAJ.0000827360.84863.f1

This article discusses the alignment of research goals with secondary data sources, explores sources of publicly available secondary data that might be of interest to nurse researchers, and outlines the costs and benefits of using secondary data.

Curtis, & Keeler, C. (2022). Diagnostic studies: Measures of accuracy in nursing research. The American Journal of Nursing, 122 (6), 44–49. https://doi.org/10.1097/01.NAJ.0000833928.06431.8e

This article reviews the use of diagnostic and screening tests and tools in nursing research and clinical practice.

Curtis, A. C. (2022). An introduction to qualitative methods for the nurse researcher. The American Journal of Nursing , 122 (8), 52–56. https://doi.org/10.1097/01.NAJ.0000854992.17329.51

This article provides an introduction to qualitative methods in nursing research.

Curtis, A. & Keeler, C. (2022). Interpretive methodologies in qualitative nursing research. The American Journal of Nursing, 122 (10), 45-49. doi: 10.1097/01.NAJ.0000890224.65902.0a .

This article, one in a series on clinical research by nurses, explores the rich tradition of interpretive qualitative research practices, including phenomenology, grounded theory, ethnography, and case study

Capili, B., & Anastasi, J. K. (2023). Improving the validity of causal inferences in observational studies. The American Journal of Nursing , 123 (1), 45–49. https://doi.org/10.1097/01.NAJ.0000911536.51764.47

This article focuses on understanding causal inferences and methods for improving their use in observational studies.

Capili, B., & Anastasi, J. K. (2023). Efficacy randomized controlled trials. The American Journal of Nursing , 123 (3), 47–51. https://doi.org/10.1097/01.NAJ.0000921808.23646.01

This article describes the process of selecting the intervention, choosing experimental and control groups, determining study outcomes, and applying blinding and randomization.

Keeler, C., & Curtis, A. C. (2023). The architecture of a research study. The American Journal of Nursing , 123 (5), 59–62. https://doi.org/10.1097/01.NAJ.0000933952.08188.67

This article describes the development of a research study from research question to empirical strategy.

Keeler, C., & Curtis, A. C. (2023). Introduction to statistical hypothesis testing in nursing research. The American Journal of Nursing , 123 (7), 53–55. https://doi.org/10.1097/01.NAJ.0000944936.37768.29

This article focuses on hypothesis testing—and outlines the following five elements: (1) stating the null and alternative hypotheses, (2) calculating the appropriate test statistic, (3) interpreting the P value of the test statistic, (4) assessing statistical significance, and (5) interpreting the results.

Capili, B., & Anastasi, J. K. (2023). The cluster randomized trial study design. The American Journal of Nursing , 123 (9), 57–60. https://doi.org/10.1097/01.NAJ.0000978168.48569.72

Randomized clinical trials are among the highest levels of evidence researchers can use in evaluating new therapeutics or interventions. Besides classic parallel, two-group comparisons between an experimental condition and a control, another type of randomized trial is the cluster randomized trial. This study design helps evaluate the usefulness of an intervention at the population or public health level.

Curtis, A. C., & Keeler, C. (2023). Sample size planning in quantitative nursing research. The American Journal of Nursing , 123 (11), 42–46. https://doi.org/10.1097/01.NAJ.0000995360.84994.3b

Building on previous articles in this series on sampling design1 and hypothesis testing, the current installment describes how to determine an appropriate sample size for a quantitative research project, and introduces the concepts of error, power, and effect size.

Keeler, C., & Curtis, A. C. (2024). Descriptive and inferential statistics in nursing research. The American Journal of Nursing , 124 (1), 48–52. https://doi.org/10.1097/01.NAJ.0001004944.46230.42

This article addresses the distinction between parameters and statistics; reviews sample populations, general populations, and validity; and defines descriptive and inferential statistics.

Capili, B., & Anastasi, J. K. (2024). Ethical research and the Institutional Review Board: An introduction. The American Journal of Nursing, 124 (3), 50–54. https://doi.org/10.1097/01.NAJ.0001008420.28033.e8

This article discusses the role and origins of the institutional review board, the independent research ethics committee that approves or denies research involving human subjects.

Capili, B., & Anastasi, J. K. (2024). An introduction to implementing and conducting the study. The American Journal of Nursing , 124 (5), 58–61. https://doi.org/10.1097/01.NAJ.0001016388.26001.50 This article focuses on implementing the study.
Capili, B., & Anastasi, J. K. (2024). Methods to Disseminate Nursing Research: A Brief Overview. The American Journal of Nursing , 124 (7), 36–39. https://doi.org/10.1097/01.NAJ.0001025644.87717.4c This article provides an introduction to disseminating research findings to other research professionals, clinicians, policymakers, and funders or sponsors.

Understanding Nursing Research

Primary Research
Qualitative vs. Quantitative Research

Experimental Design

Randomization vs random selection, randomized control trials (rcts), how do i tell if my article is a randomized control trial, how to limit your research to randomized control trials.

Is it a Nursing journal?
Is it Written by a Nurse?
Systematic Reviews and Secondary Research
Quality Improvement Plans

Correlational , or non-experimental , research is research where subjects are not acted upon, but where research questions can be answered merely by observing subjects.

An example of a correlational research question could be, "What is relationship between parents who make their children wash their hands at home and hand washing at school?" This is a question that I could answer without acting upon the students or their parents.

Quasi-Experimental Research is research where an independent variable is manipulated, but the subjects of a study are not randomly assigned to an action (or a lack of action).

An example of quasi-experimental research would be to ask "What is the effect of hand-washing posters in school bathrooms?" If researchers put posters in the same place in all of the bathrooms of a single high school and measured how often students washed their hands. The reason the study is quasi-experimental is because the students are not randomly selected to participate in the study, they just participate because their school is receiving the intervention (posters in the bathroom).

Experimental Research is research that randomly selects subjects to participate in a study that includes some kind of intervention, or action intended to have an effect on the participants.

An example of an experimental design would be randomly selecting all of the schools participating in the hand washing poster campaign. The schools would then randomly be assigned to either the poster-group or the control group, which would receive no posters in their bathroom. Having a control group allows researchers to compare the group of students who received an intervention to those who did not.

How to tell:

The only way to tell what kind of experimental design is in an article you're reading is to read the Methodologies section of the article. This section should describe if participants were selected, how they were selected, and how they were assigned to either a control or intervention group.

Random Selection means subjects are randomly selected to participate in a study that involves an intervention.

Random Assignment means subjects are randomly assigned to whether they will be in a control group or a group that receives an intervention.

Controlled Trials are trials or studies that include a "control" group. If you were researching whether hand-washing posters were effective in getting students to wash their hands, you would put the posters in all of the bathrooms of one high school and in none of the bathrooms in another high school with similar demographic make up. The high school without the posters would be the control group. The control group allows you to see just how effective or ineffective your intervention was when you compare data at the end of your study.

Randomized Controlled Trials (RCTs) are also sometimes called Randomized Clinical Trials. These are studies where the participants are not necessarily randomly selected, but they are sorted into either an intervention group or a control group randomly. So in the example above, the researchers might select had twenty high schools in South Texas that were relatively similar (demographic make up, household incomes, size, etc.) and randomly decide which schools received hand washing posters and which did not.

To tell if an article you're looking at is a Randomized Control Trial (RCT) is relatively simple.

First, check the article's publication information. Sometimes even before you open an article, you can tell if it's a Randomized Control Trial. Like in this example:

If you can't find the information in the article's publication information, the next step is to read the article's Abstract and Methodologies. In at least one of these sections, the researchers will state whether or not they used a control group in their study and whether or not the control and the intervention groups were assigned randomly.

The Methodologies section in particular should clearly explain how the participants were sorted into group. If the author states that participants were randomly assigned to groups, then that study is a Randomized Control Trial (RCT). If nothing about randomization is mentioned, it is safe to assume the article is not an RCT.

Below is an example of what to look for in an article's Methodologies section:

If you know when you begin your research that you're interested in just Randomized Control Trials (RCTs), you can tell the database to just show you results that include Randomized Control Trials (RCTs).

In CINAHL, you can do that by scrolling down on the homepage and checking the box next to "Randomized Control Trials"

If you keep scrolling, you'll get to a box that says "Publication Type." You can also scroll through those options and select "Randomized Control Trials."

If you're in PubMed, then enter your search terms and hit "Search." Then, when you're on the results page, click "Randomized Controlled Trial" under "Article types."

If you don't see a "Randomized Controlled Trial" option, click "Customize...," check the box next to "Randomized Controlled Trial," click the blue "show" button, and then click on "Randomized Controlled Trial" to make sure you've selected it.

This is a really helpful way to limit your search results to just the kinds of articles you're interested in, but you should always double check that an article is in fact about a Randomized Control Trial (RCT) by reading the article's Methodologies section thoroughly.

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Types of Research within Qualitative and Quantitative

Nursing Resources : Types of Research within Qualitative and Quantitative

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Aspects of Quantative (Empirical) Research

♦ Statement of purpose—what was studied and why.

♦ Description of the methodology (experimental group, control group, variables, test conditions, test subjects, etc.).

♦ Results (usually numeric in form presented in tables or graphs, often with statistical analysis).

♦ Conclusions drawn from the results.

♦ Footnotes, a bibliography, author credentials.

Hint: the abstract (summary) of an article is the first place to check for most of the above features. The abstract appears both in the database you search and at the top of the actual article.

Types of Quantitative Research

There are four (4) main types of quantitative designs: descriptive, correlational, quasi-experimental, and experimental.

samples.jbpub.com/9780763780586/80586_CH03_Keele.pdf

Types of Qualitative Research

	Attempts to shed light on a phenomena by studying indepth a single case example of the phenomena. The case can be an individual person, an event, a group, or an institution.
	To understand the social and psychological processes that characterize an event or situation.
	Describes the structures of experience as they present themselves to consciousness, without recourse to theory, deduction, or assumptions from other disciplines
	Focuses on the sociology of meaning through close field observation of sociocultural phenomena. Typically, the ethnographer focuses on a community.
	Systematic collection and objective evaluation of data related to past occurrences in order to test hypotheses concerning causes, effects, or trends of these events that may help to explain present events and anticipate future events. (Gay, 1996)

http://wilderdom.com/OEcourses/PROFLIT/Class6Qualitative1.htm

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Next: Cohort vs Case studies >>
Last Updated: Sep 4, 2024 3:12 PM
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Case Study Research Design in Nursing

Siedlecki, Sandra L. PhD, RN, APRN-CNS, FAAN

Author Affiliation: Senior Nurse Scientist, Department of Nursing Research and Innovation, Cleveland Clinic, Ohio.

Dr Siedlecki is a senior nurse scientist at the Cleveland Clinic who maintains her own program of research and serves as a consultant and mentor to clinical nurses who are planning and conducting bedside research.

The author reports no conflicts of interest.

Correspondence: Sandra L. Siedlecki, PhD, RN, APRN-CNS, FAAN, Department of Nursing Research and Innovation, Cleveland Clinic, 9500 Euclid Ave T 046, Cleveland, OH 44195 ( [email protected] ; [email protected] ).

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Building qualitative study design using nursing's disciplinary epistemology

Affiliations.

1 School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada.
2 Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada.
PMID: 26412414
DOI: 10.1111/jan.12822

Aim: To discuss the implications of drawing on core nursing knowledge as theoretical scaffolding for qualitative nursing enquiry.

Background: Although nurse scholars have been using qualitative methods for decades, much of their methodological direction derives from conventional approaches developed for answering questions in the social sciences. The quality of available knowledge to inform practice can be enhanced through the selection of study design options informed by an appreciation for the nature of nursing knowledge.

Design: Discussion paper.

Data sources: Drawing on the body of extant literature dealing with nursing's theoretical and qualitative research traditions, we consider contextual factors that have shaped the application of qualitative research approaches in nursing, including prior attempts to align method with the structure and form of disciplinary knowledge. On this basis, we critically reflect on design considerations that would follow logically from core features associated with a nursing epistemology.

Implications for nursing: The substantive knowledge used by nurses to inform their practice includes both aspects developed at the level of the general and also that which pertains to application in the unique context of the particular. It must be contextually relevant to a fluid and dynamic healthcare environment and adaptable to distinctive patient conditions. Finally, it must align with nursing's moral mandate and action imperative.

Conclusion: Qualitative research design components informed by nursing's disciplinary epistemology will help ensure a logical line of reasoning in our enquiries that remains true to the nature and structure of practice knowledge.

Keywords: applied research; epistemology; methodology; nursing knowledge; qualitative research; theoretical framework.

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Clinical Research Nursing

Clinical Research Nursing Landmark Documents

Domain of Practice | Model of Care

Background and Overview

In January 2007, Clinical Center Nursing at the National Institutes of Health launched a four-year strategic plan to lead an international effort to define the specialty practice of clinical research nursing. The goal was to take this definition to the level of detail and consensus required to create a certification process for nurses practicing in clinical research. This initiative is called Clinical Research Nursing 2010 , or CRN 2010 .

Clinical research nursing is nursing practice with a specialty focus on the care of research patients. In addition to providing and coordinating clinical care, clinical research nurses have a central role in assuring patient safety, ongoing maintenance of informed consent, integrity of protocol implementation, accuracy of data collection, data recording and follow up. Care received by research patients is driven by study requirements and the collection of research data as well as clinical indications. Study procedures may include administration of investigational drugs, performance of an experimental or investigational surgical or radiological procedure, detailed clinical assessment or phenotyping to characterize the natural history and etiology of a disease, or delivery of a psychosocial intervention. Additional nursing care may be necessitated by the response of the participant to the study intervention.

The scope of CRN 2010 included two the main roles assumed by nurses practicing in clinical research settings.

Clinical research nurses are clinical staff nurses with a central focus on care of research patients. They support study implementation within the context of the care delivery setting and are primarily located in dedicated clinical research settings, such as the NIH Clinical Center and clinical research units located in academic medical centers across the country. These clinical nurses are part of the permanent infrastructure of the research unit and are available to any investigator accessing the facility.
Research nurse coordinators are primarily responsible for study coordination and data management, with a central focus on managing subject recruitment and enrollment, consistency of study implementation, data management and integrity, and compliance with regulatory requirements and reporting. Research nurse coordinators are often hired by and report to a principal investigator for support of a specific study or group of studies. They may rely on clinical staff to deliver “hands on” care including administration of investigational drugs or interventions.

Developing tools to support the specialty practice of clinical research nursing included two parallel efforts:

A careful and thorough documentation and clarification of the practice of clinical research nursing here at the Clinical Center, and
The formal development and consensus around steps leading to possible national certification.

Both efforts used a team structure that included all leadership members of the Nursing Department Leadership as well as nursing Shared Governance chairs and co-chairs. Examination of the Clinical Center practice of clinical research nursing began with a clarification of our model of nursing care delivery, roles across the department and several key processes of clinical care such as research patient education and clinical documentation. Development of a specialty identity, which can lead to certification, began with a clarification of the domain of practice. This is similar to the steps taken by various specialty groups ranging from oncology nursing to informatics nursing. The CRN domain includes 5 dimensions and about 50 individual activities which make up the full range of practice of both clinical nurses providing research-based patient care and study coordinators managing studies.

This domain description was validated in 2008 with the assistance of a consensus panel representing Clinical Center and Institute nurses as well as nurses in clinical research from across the country.

In 2016, the American Nurses Association recognized Clinical Research Nursing as a specialty practice and published the Clinical Research Nursing: Scope and Standards of Practice.

Clinical Research Nursing Documents

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http://orcid.org/0000-0002-7080-830X Frank H O Verbeek 1 ,
Elvira S Nouwens 1 ,
http://orcid.org/0000-0001-8346-1379 Marleen Hermien Lovink 2 ,
Getty Huisman-de Waal 3 ,
Cornelia R M G Fluit 4 ,
http://orcid.org/0000-0002-8826-3352 Miranda Laurant 1 ,
http://orcid.org/0000-0002-4266-744X Anneke J A H van Vught 1
1 Organisation of Care and Services , HAN University of Applied Sciences , Nijmegen , The Netherlands
2 Radboud Institute for Health Sciences, Department of Primary and Community Care , Radboud University , Nijmegen , The Netherlands
3 IQ Healthcare, Department of Nursing Sciences , Radboud University , Nijmegen , The Netherlands
4 Research on Learning and Education , Radboud University , Nijmegen , The Netherlands
Correspondence to Frank H O Verbeek; Frank.verbeek{at}han.nl

Objective Insights about what actions contributed to the development of an interprofessional learning and working culture were lacking for nursing homes. This study aimed to provide insight into the context and actions that trigger mechanisms for the development of an interprofessional learning and working culture in nursing homes.

Study design Realist evaluation action research was conducted from 2019 to 2023.

Setting and participants 11 teams in 6 Dutch nursing homes.

Primary and secondary outcome measures Questionnaires, focus group interviews and observations were used to identify actions, context factors and mechanisms. We used retroductive analysis to discuss how actions were related to the development of the culture. Actions were evaluated in terms of context and manner in which they contribute to the development.

Results 21 actions were identified and clustered into two themes. Theme 1: improving person-centred care. Actions activated the mechanisms of critical reflective behaviour and collective ownership in a context of, among other things, clear roles and tasks, a stable and competent team, the presence of case managers and facilitating organisational factors such as time for reflection. Theme 2: getting to know and understand each other’s expertise. Actions activated respectful relationships, collective ownership of goals and feeling appreciated for your work in a context of, among other things, team members who meet regularly and management supporting interprofessional working.

Conclusions This research sheds light on how and in what manner-specific actions contribute to the development of an interprofessional learning and working culture in nursing homes. Depending on the context, the actions triggered the following mechanisms: critical reflective behaviour, collective ownership of goals, respectful/caring relationships and feeling appreciated for your work. These mechanisms are the underlying drivers of an interprofessional learning and working culture. This study provides valuable guidance for fostering collaborative and effective interprofessional dynamics in nursing homes.

Interprofessional Relations
Patient-Centered Care
Quality Improvement

Data availability statement

Data are available on reasonable request. Descriptive data from the questionnaires (pre/post) are available from the first author on reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjopen-2024-085096

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The design realist action research allowed the teams to select and create actions tailored to their specific context and needs.

A founder of the realist evaluation approach was consulted to discuss the study’s methodology and proper data analysis.

Due to the COVID-19 measures, it was not always possible to be physically present in the nursing homes for coaching on the job.

The questionnaires probably lacked sufficient power to detect significant differences between the beginning and the end of the study.

Introduction

In the Netherlands, most older people receive care at home from primary healthcare professionals and informal caregivers. When it is no longer possible to receive this care at home, people with more complex needs are admitted to nursing homes. 1 2 To meet more complex needs, it is important to work together in an interprofessional way to provide the best quality of person-centred care for nursing home residents. 3 In person-centred care, the residents and their families become partners with professionals in their own care. The focus is on shared decision-making, emotional well-being and personal goals of the resident, rather than on the illness.

Delivering person-centred care requires intensive collaboration between the resident, their relatives, their informal network and the usually many professionals involved. In the Netherlands, professionals in a nursing home are organised into separate teams, the nursing professionals and allied/medical healthcare professionals. Nursing teams are a mix of nurse aides, nurse assistants, licensed practical nurses, vocationally trained registered nurses and baccalaureate-educated registered nurses at levels 1–6 of the European Qualifications Framework (EQF). 4 Allied/medical healthcare professionals include physiotherapists, dieticians, speech therapists and general or elderly care physicians. Each professional has their own expertise and competencies in the care of residents. Previous studies have found that the development of an interprofessional learning and working culture enhances the quality of person-centred care of residents. 5–8 An interprofessional learning and working culture is defined as a culture in which different healthcare professionals work intensively and learn together, share an integral vision, set common goals and have responsibilities that cross over into each other’s field. 9–12 However, due to the organisation of daily care or lack of time, we see that most healthcare professionals work within their own field, rely on their own expertise, share little knowledge with colleagues and are not always aware of each other’s expertise in daily practices. 13 To address these challenges and improve the quality of person-centred care in nursing homes, it is important to facilitate and stimulate interprofessional learning and working.

Recent reviews of interprofessional learning and working cultures in different healthcare settings show that there are many interventions, actions and facilitators to improve interprofessional learning and working. Interprofessional learning and working leads to high standards of care of residents, exemplified by an increase in optimal processes, motivated professionals and involvement of residents and their families in care. 3 However, there is a gap of knowledge about what works, in what context and in what manner it works in daily nursing home practices. There is, therefore, a need to identify which actions contribute to the development of an interprofessional learning and working culture in nursing homes and to what extent. It is not yet clear what works, in what context and manner it works in daily nursing home practices. This study, therefore, aims to provide insight into the context and actions that trigger mechanisms for the development of an interprofessional learning and working culture in nursing homes.

Methods and analysis

In order to gain more insight into the context of different nursing homes, what actions and mechanisms are used to develop an interprofessional learning and working culture in nursing homes, the realist evaluation approach was combined with action research. 14 This realist action research was carried out from September 2019 to July 2023 and consisted of four steps: (1) formulating theory, (2) insights about cultural elements, (3) act and observe and (4) reflect (see figure 1 ). More details of these steps can be found in the published study protocol. 15 We used the Rameses II reporting standards for realist evaluation. 16

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Overview of the four steps in this research.

11 interprofessional healthcare teams participated in this research. The teams worked at six nursing homes: three nursing homes with one participating team, two nursing homes with two teams and one nursing home with four teams. The participating nursing homes, located in the south-east of the Netherlands, specialised in providing healthcare in the area of psychogeriatrics, gerontopsychiatry, rehabilitation, Huntington’s disease, Korsakov syndrome and short stay or observation for older residents.

Participants

The interprofessional teams consisted of nursing team professionals and allied/medical professionals from levels 2–8 of the EQF. 4 The number of professionals in the teams varied widely between the units. In the Netherlands, each unit in a nursing home, such as a geriatric rehabilitation unit, has a nursing team. Usually, only allied/medical healthcare professionals work on more than one unit. The allied/medical healthcare professionals were included in the study when they provided care to residents in the participating unit.

Step 1: formulating theory

Initial theory of interprofessional learning and working culture in nursing homes.

This study started with the formulation of the initial theory, which could be further developed during the research. This theory was formulated with experts on interprofessional learning and working, the project leader, the researcher and two external coaches. The theory consisted of the description of context-related factors, mechanisms and outcomes. 17 In each context, mechanisms could be triggered to develop an interprofessional working and learning culture in nursing homes (outcome). In this study, we were interested in the actions that interact with the context and trigger mechanisms to develop the interprofessional working and learning culture. An action is defined as an activity, task or movement that contributes to the main goal, the development of an interprofessional learning and working culture in nursing homes. This initial theory was based on a comprehensive literature search and a previous action research in nursing homes about the development of an evidence-based nursing culture in nursing teams. 13

Summary of the initial theory

To develop an interprofessional learning and working culture, it is important to have insights into the conditions (the context) that are relevant to the operation of the mechanism. 18 The interprofessional learning and working culture is a culture in which at least two healthcare professionals collaborate and learn together. Innovating, communicating, keeping each other informed, being aware of each other, sharing compliments, sharing successes and collaborating with the residents and their families are needed in this culture. Outcomes could affect at resident, team and organisational level. 14 15 17 Important conditions are the individual professional factors, team factors, organisation factors, factors of the resident and research/social, political or legal factors. For example, the nursing professionals collaborate with allied and medical healthcare professionals. Each team of professionals (nursing, allied or medical team) has its own culture and mostly works independently of other teams. This could hinder interprofessional collaboration. Furthermore, we identified three mechanisms that enhance the effect of the interprofessional learning and working culture. These are (1) critically reflective work behaviour, (2) collective ownership and (3) respectful/caring relationships. For example, in order to work intensively with each other, it is important to reflect on daily work processes or to respect each other. 19 More in-depth information is presented in our published research protocol. 15

Step 2: insight about cultural elements

First, we created an overview of the presence of the interprofessional cultural elements in each participating team at the start of the research. The insights were discussed in each team in a kick-off meeting and during the team coaching.

Measuring the interprofessional cultural elements

To gain an initial overview of the culture, we sent two questionnaires to all healthcare professionals in the interprofessional teams at the starting point of the study. To get more in-depth details, we performed interviews.

Questionnaires

The Critically Reflective Work Behaviour Survey 20 and the Interprofessional Collaboration Measurement Scale 21 were used. The questionnaires were conducted online with Lime Survey V.3.22.17. The link to the questionnaire was distributed by the contact person in the nursing homes. The questionnaires, including the demographic data of the participants, were descriptively analysed with IBM SPSS Statistics V.27.

We performed 47 individual interviews with healthcare professionals from the different interprofessional teams to gain an initial overview of the interprofessional learning and working culture at the start of the research. The development of the topic guide was based on relevant outcomes from the earlier action research 13 and discussions with experts in interprofessional collaboration. Each interview was only summarised by the researcher (FHOV). Highlights of these summaries were recorded to provide an overall picture of the interprofessional learning and working culture in each participating team. These highlights were only used to present and discuss in the kick-off meetings in each participating team (see step 3).

Step 3: act and observe

Highlights of the questionnaires and interviews were discussed in a kick-off meeting in each participating team. This meeting was the starting point for each team to develop the interprofessional learning and working culture within their own unit. Each team was supported by at least one internal coach, that is, a healthcare professional from within the team. The internal coaches were employees of the nursing team, the allied/medical healthcare team or a combination of both teams. The internal coach or coaches per participating team were selected for their motivation, leadership skills and reflective capacity to coach an interprofessional team in working and learning together in an interprofessional way. The internal coach was coached by two external coaches who were members of the research team and employees of HAN University of Applied Sciences in the Netherlands. The external coaches were experienced lecturers in nursing and allied/medical healthcare and had expertise in culture change, the nursing home setting and interprofessional learning and working. These coaches worked with the practice development approach (PD) to support and encourage professionals to work together and to involve residents and family members. Residents and family members, together with professionals, selected and performed the actions to encourage interprofessional work contributing to person-centred care. The PD approach focused on creating working and learning cultures and on developing person-centred cultures. The PD approach consisted of nine principles, for example, focusing on microlevel and working with short cyclic innovation processes in the workplace. 22 23 Highlights of the questionnaires, interviews and the discussion in the kick-off meeting were subsequently used to identify topics for the development of an interprofessional learning and working culture. The internal coaches followed a cyclic process at the team level, which means that they started by identifying topics for developmental action. 23 The cyclic process consisted of six processes (called PDDOEN in Dutch): (1) creating an overview of a subject, the need, the why and who is involved, (2) setting a goal to improve interprofessional learning and working, (3) selecting or creating the needed actions, (4) sharing and collecting new insights, (5) evaluating and (6) selecting/creating actions or selecting a new topic. 23 During this cyclic process, internal and external coaches and the researcher (FHOV) observed and identified actions occurring in the participating teams. Observations were recorded in a logbook. During the action and observation period, we had several meetings with the internal coaches, the external coaches and the researcher (FHOV) to share ideas, inspiration and discuss the process.

Step 4: reflect

This step was about getting insights into what works (actions), and in what context and what manner (mechanism). We used the outcomes of the two questionnaires that were repeated at the end of the study (described in step 2), the logbooks (described in step 2) and the focus group sessions per participating team at the end of the study.

All the questions in the two questionnaires were categorical and were tested with the χ 2 test to analyse whether the statements (agree–disagree) changed between the start and the end of the study. The level of significance was established at p=0.05.

The aim of the focus group sessions was to create insight into the actions, the influence of the context and how these actions worked. A total of 4–10 professionals participated in each focus group; nursing team members and allied/medical healthcare professionals were mixed together. The focus group sessions were audio-taped and transcribed. The transcriptions were deductively analysed using the subjects from the initial theory with Atlas TI by two researchers (FHOV and ESN). Findings from the analysis were discussed between these two researchers and with the project leader (AJAHvV). We created a summary text for each participating team for members to check.

For the overall analysis, we used iterative steps based on retroductive analysis; identification of the actions; exploration of what works, in what context and how actions influenced mechanisms in a specific context that contribute to the outcome; and lastly formulation of the relationship between context, mechanism and outcome. 24

Identification of the actions

Actions were identified by screening the logbooks and discussing the identified actions in the focus group sessions. After identification, the actions were clustered into themes of actions through the discussions with the researchers (FHOV, ESN), external coaches (ESN, AW) and the project leader (AJAHvV).

Exploration

To explore how these actions were related to the development of the culture, FHOV and ESN deductively analysed the focus group transcripts independently for the performed actions, the context factors, which mechanisms were triggered and what outcomes were seen. After that, FHOV, ESN and AJAHvV explored and reported which patterns in terms of context, mechanism and outcome on the interprofessional learning and working culture were seen in the themes of actions.

Formulation

Lastly, we discussed the patterns of what works, in what context and how with a group of experts on interprofessional collaboration in healthcare and with the internal coaches who participated in the study. These discussions were held by means of an online meeting and bilateral conversations. Such broad discussion enabled us to formulate and refine the relationship between the context, mechanism and outcome in the themes of actions.

Demographic data

The demographic data from the questionnaires and focus groups are presented in table 1 . In total, 128 professionals completed the two questionnaires at the start of the research and 66 at the end of the research. Of these, 58.6% (pre) and 65.2% (post) were members of a nursing team and most were female (93% pre, 87% post) and with a mean age of 40–42 years. In addition, 34 healthcare professionals were interviewed in 7 focus group sessions with a mean duration of 70 min. 19 professionals were members of a nursing team and 32 professionals were female, mean age was 42 years.

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Demographic data of participants, questionnaires and focus groups

14 internal coaches and 2 external coaches participated in this study. Two internal coaches in organisation 1 (belonging to the allied/medical staff), one internal coach in organisation 2 (belonging to the nursing staff), four internal coaches in organisation 3 (two belonging to the nursing staff and two belonging to the allied/medical staff), two in organisation 4 (one belonging to the nursing staff and one to the allied/medical staff), three in organisation 5 (two to the nursing staff and one to the allied/medical staff) and two internal coaches were participating in organisation 6 (belonging to the nursing staff).

Brief reflection on initial theory

The initial theory is presented as hypotheses under the heading’s context, mechanisms and outcomes. Context factors in interprofessional learning and working as mentioned in the initial theory emerged to a greater or lesser extent in this study, except in relation to COVID-19 measures. In the Netherlands, all nursing homes for the elderly were closed to visitors, family and certain allied/medical healthcare professionals who were not involved in the basic care for the elderly. This measure played a major role in interprofessional learning and working because there were fewer physical meetings with the interprofessional teams, and less attention given to interprofessional working and more to the COVID-19 pandemic. 25 The pandemic made it difficult to meet up, but it also improved collaboration and learning around care-related themes such as loneliness or stimulus processing. With respect to the mechanisms, three mechanisms reported in the initial theory were confirmed in this study. In addition, we identified a fourth mechanism that influenced the interprofessional learning and working culture: ‘feeling appreciated for your work’. Described outcomes, such as intended and unintended consequences of the actions, corresponded to the initial theory.

In this study, we were particularly interested in the actions that trigger mechanisms in a specific context and result in the intended outcomes. This study integrated actions in the initial theory and configured the context-mechanism-outcome around the actions.

Themes of actions including context-mechanism-outcome configurations

We identified 21 actions that were clustered into 2 themes of actions: (1) improving person-centred care and (2) getting to know and understand each other’s expertise. For each theme of actions, we presented the actions, the context, the mechanisms they triggered in the context and the outcomes in developing an interprofessional learning and working culture.

Theme 1: improving person-centred care

We distinguished several types of actions to improve person-centred care. Actions focusing on (1) working on care-related themes to solve daily questions in healthcare in a bottom-up way, (2) being aware of the resident’s needs, for example, through a multidisciplinary intake with the resident and all the healthcare professionals and (3) involving family, by using communication tools or motivating residents to use an activity box with their relatives ( table 2 ).

Actions improving person-centred care

In this theme of actions, we saw the following context factors ( figure 2 ) that were also presented in our initial theory: (1) team factors, (2) organisational factors, (3) person-centred factors and (4) research network.

Improving person-centred care.

Individual professional factors

Clear professional roles and tasks helped staff to know what to expect from each other.

Team factors

The presence of students in the units. Students asked critical questions about daily care and working methods. This was helpful to establish a solid cooperation between all healthcare professionals.

A stable, competent, permanent healthcare team contributed to knowing each other’s competences.

‘If you don't have a stable team … yes, you will go under’. (organisation 5 )

The presence of case managers in a team with a nursing background resulted in a context where it was possible to innovate and be involved together.

‘Because we (case managers) have a nursing background and so we also want to be involved in the team in that way. How can we achieve this? By simply joining the medical visits!’ (organisation 6)

Organisational factors

The presence of an existing meeting structure stimulated meeting each other on a regular basis. We saw that this meeting structure was more prevalent in a care innovation unit or in a geriatric rehabilitation unit compared with other units.

‘There is a weekly meeting with the allied/medical team and nursing team together and then a few clients are discussed. I think this meeting allows us to brainstorm and consult with each other in a multidisciplinary way’ (organisation 1 )

The facilitation in space and time to be an internal coach or to learn and work together as an interprofessional team on projects, for example, working on care-related themes or on (small) evidence-based practice projects. The internal coach coached other healthcare professionals or made a project plan to initiate a project.

‘We think this (doing research) is important, so you must be facilitated… If you don’t facilitate, how seriously do you take someone?’ (organisation 1)

In a context where organisations had a clear vision of learning together, performing research and innovating, interprofessional learning was more embedded in daily practices.

Patient-related factors

Working on a rehabilitation unit with short cyclic processes, the nursing home residents were more likely to be involved as partners in care to achieve the rehabilitation goals.

Research network factors

Cooperating with a research network or an academic nursing home network supported the focus on learning together.

These actions in these contexts triggered the mechanisms:

Critical reflective behaviour, through conversations about the best person-centred care. Healthcare professionals were learning from mistakes in daily practice, were making suggestions for a different way of working and were experimenting together. The questionnaire on critical reflective work behaviour showed that only 2 of the 47 statements significantly differed between the start and end of the study ( online supplemental appendix 1 ). The first relates to comparing their own performance with the performance of colleagues, which was more frequent at the end of the study (72.4% pre, 89.4% post, p=0.007). Furthermore, there was a small negative outcome for the statement ‘if I make a mistake, I find it hard to forgive myself’. This statement was more frequent at the end of the study (42.7% pre, 62.1% post, p=0.012).

Supplemental material

Collective ownership of goals, in which a shared vision emerges, and joint responsibility is felt for reaching and achieving shared goals. For example, by engaging in joint discussion, a care plan is immediately drawn up, including a possible discharge date at rehabilitation. Other examples are actions aimed at working together on an electronic patient record because professionals and residents can read, consult and tag each other’s notes. This made them feel involved and jointly responsible.

The actions on person-centred care in the above-described context resulted in an improved interprofessional working and learning culture. It appears that there was more collaboration between professionals and with residents and their families. Professionals were innovating, doing research, sharing information and sharing compliments and successes. They were aware of each other’s expertise, were more motivated to improve daily healthcare and there was more focus on the resident’s well-being. The questionnaire, the Interprofessional Collaboration Measurement Scale, showed that 2 of the 13 statements were significant when comparing the pre and post data, indicating improved interprofessional collaboration ( online supplemental appendices 2 and 3 ). Sharing information about residents between the nursing team and allied/medical professionals was more frequent at the end of the research (81%) compared with the start of the research (53.3%), p=0.031. The item of discussing the resident’s care was more frequent (64.4% pre, 95.2% post) at the end of the study period, p=0.000.

Theme 2: getting to know and understand each other’s expertise

Actions that contribute to knowing and understanding each other’s expertise were seen in the actions (1) getting to know each other and (2) coaching ( table 3 ).

Actions getting to know and understand each other’s expertise

In this theme of actions, we identified the following context factors ( figure 3 ) that were also presented in our initial theory: (1) team factors, (2) organisational factors and (3) social, political and legal factors. We also found a new context factor, the presence of COVID-19 measures. We saw this context factor as a ‘social, political and legal factor’ because the Dutch government implemented the COVID-19 measures for the Netherlands during the pandemic.

Getting to know and understand each other’s expertise.

There were reasonably stable teams in which healthcare professionals had considerably large contracts. This meant there were not too many changes in the team structure and it was easier to get to know each other.

Interprofessional teams that met physically on a regular basis helped to create a safe environment, as a result of more informal contact.

‘And I also think that when you see each other at work … That you know what the other person is doing. Sometimes it’s a bit vague what someone is doing, but if you see it literally then you also know what you have to do with that person…more clarity.’ (organisation 3 )

When management provided support for interprofessional working, such as setting goals for interprofessional working, making time for interprofessional working, discussing interprofessional working and improving interprofessional working, the team felt there was a real opportunity to work together.

Social, political and legal factors

In some teams, COVID-19 measures meant that professionals (also allied and medical professionals) were less physically present in the units, which made it difficult to meet regularly. On the other hand, it also resulted in teams being more focused together on patient loneliness or stimulus processing.

These actions in these contexts triggered the following mechanisms:

Respectful relationships, in which professionals get to know each other better and therefore trust each other more, allowing for greater mutual understanding.

I think that with the peer-group coaching, there was also a bit of, yes… reflection… Okay, so how can this be experienced by another person? (organisation 2)

Collective ownership of goals, in which joint responsibility is triggered among team members for person-centred care.

Feeling appreciated, explained as team members feeling that they are really taken seriously and that their opinions and suggestions are heard. This was expressed, for example, by deliberately asking for everyone’s ideas about the case and using those ideas.

These actions that focus on knowing and understanding each other‘s expertise helped in developing a learning and working culture. This resulted in team members being more aware of each other’s perspectives and expertise, keeping each other informed and learning together. Questioning each other in an approachable way was easier, as was discussing things together. The actions related to informal meetings resulted in easier ways to support each other, give feedback or make suggestions for improvement.

Approaching each other is easier, because you're there. So, you don't have to go searching. (organisation 3) We just need each other, and you have to look for each other. You’re looking for the best and most efficient way to help such a resident as best as possible. (organisation 3)

Furthermore, the peer-group coaching and daily evaluations resulted in sharing compliments and successes more often, more communication with an open attitude, learning together and increased job satisfaction.

We walk in on each other, we use each other’s knowledge, we help each other, also the practitioners, and they help us in the care task as we help them. I feel that very much. There’s also a lot of room for consultation over coffee with each other, but also by sparring and consulting with each other on how we can improve our quality of care … (organisation 5)

This research provided insight into the context and actions that trigger mechanisms for the development of an interprofessional learning and working culture in nursing homes. 21 actions were identified. These are clustered into two themes of actions. The first theme of actions was aimed at improving person-centred care. Actions activated the mechanisms of critical reflective behaviour and collective ownership in a context of, among other things, clear roles and tasks, a stable and competent team, the presence of case managers and facilitating organisational factors such as time for reflection. The second theme of action focused on getting to know and understand each other’s expertise. In this theme of actions, the mechanisms of respectful relationships, collective ownership of goals and feeling appreciated for your work were activated in a context of, among other things, team members who meet regularly and with management supporting interprofessional working.

The development of an interprofessional learning culture has been studied extensively, mainly in hospital settings. 26 A recent study about interprofessional collaboration in hospitals found that building on care relationships and building on constructive feedback were important underlying mechanisms. 19 The same findings were reported in a recent scoping review about facilitators in the development of an interprofessional learning culture in nursing homes, such as having a safe, respectful and transparent environment or having a frontline manager who facilitates and supports change. 27 Unfortunately, information on the operationalisation of such facilitators was limited. The present study identified more specific actions, relevant contextual factors and how these actions contribute to an interprofessional learning and working culture in nursing homes. For example, an interprofessional learning and working culture could be developed through critically reflective behaviour. To achieve this, targeted actions can be implemented, such as developing a safe environment in which professionals feel comfortable giving feedback. Actions to achieve this safe environment are ensuring that professionals meet physically on regular basis, organising daily evaluations to give each other feedback and having peer-to-peer reflection meetings with (external) coaches.

Team and organisational context factors played an important role in developing and selecting actions. For example, actions such as getting to know each other better and aiming at a safe environment are more effective in a context in which careful relationships and a stable team can be built. In addition, this research shows that having a stable, competent and permanent team and facilitating collaboration in time and space act as factors for the development of an interprofessional learning and working culture. This is also a challenge because of the shortage of professionals and time in nursing homes in the Netherlands. 28 Conversely, the presence of an interprofessional learning and working culture works positively on job satisfaction because effective teamwork and shared decision-making are known to be associated with job satisfaction. This is important because job satisfaction contributes to engaging and retaining professionals in a team so that a stable team can be secured. 29 A clear vision of the organisation and management on learning and interprofessional working is also seen as an important factor to create opportunities for individual professionals and the teams to work with a shared vision in daily practice. 30 In addition, units such as a learning unit or a geriatric rehabilitation unit with short stays for residents are a good basis for interprofessional learning and working. A lot of students are participating as interns in such units for several months and work on various professional and interprofessional assignments. 31 This could promote interprofessional learning and working together. The short cycle stays in a geriatric rehabilitation unit, where residents work on rehabilitation goals for an average of 1 month, 32 also means that professionals must work more intensively together with collective ownership of goals. Rehabilitation is a team approach, involving numerous professionals and the resident. 33 This setting would seem more conducive to interprofessional working than a psychogeriatric unit in a nursing home. To promote interprofessional working in a somatic or psychogeriatric unit, it is important to invest in space and time to get to know each other and to meet each other on a regular basis.

This study has given us a better understanding of the mechanisms involved in developing an interprofessional learning and working culture. It turned out that four instead of three mechanisms could be triggered by actions for the development of interprofessional learning and working culture. Actions to get to know each other better triggered respectful relationships in teams and actions to trust and joint responsibility triggered more collective ownership of goals. These are important mechanisms because commitment to goals or respectful relationships creates involvement of all the professionals, the residents and their families and could improve person-centred care and a vision about the best person-centred care in the nursing homes. 19 34 In addition to our presented initial theory, it turned out that feeling appreciated for your work is also important. For example, healthcare professionals are more satisfied when their efforts in daily practices are seen or recognised by team members or the front-line manager. 35 This increases their motivation to improve the quality of care. In interprofessional collaboration, it is, therefore, important to recognise each professional and their expertise. 26 The recognition of a professional’s expertise, ideas or knowledge forms an important part of working in a team. 10

Strengths and limitations

The strength of this study was its realist action design because it was appropriate for the actions to be selected and created by the teams. The internal coaches coached in daily practice by selecting and creating these actions with the teams. It was, therefore, possible to tailor the actions to the specific contexts and needs of the different participating teams. In the present study, an expert on the realist evaluation approach was consulted to discuss the findings and analysis methods to improve this process and provide the best insights to make implications for the daily nursing home practice.

Some limitations were seen in this study. This study focused on the actions to develop an interprofessional learning and working culture. These actions also improved person-centred care in some way. However, the effect of person-centred care was not measured in this study. Further research should be focused to find how the actions affect the person-centred care experienced by the residents in the nursing homes. Due to the COVID-19 measures, it was not always possible to be physically present in the nursing homes for coaching on the job, to discuss and reflect on the actions and to observe the actions. A physical distance was noticed between the internal coaches and professionals in the units and the external coaches. Despite this, the healthcare professionals continued selecting and creating actions to improve the interprofessional learning culture. It seems that the COVID-19 measures provided more insight into how important it is to communicate, work together, be physically present and achieve the highest quality of person-centred care. 36 For example, some care-related themes were selected because of the measures, such as loneliness or well-being of the residents. Due to the limited response to the questionnaires, the power of the questionnaires was probably too low to find significant differences between the start and the end of the study. Professionals may have lacked the time to complete the questionnaires due to the COVID-19 measures. For future research, a shorter questionnaire is recommended and perhaps one instead of two questionnaires to increase the response rate.

Furthermore, the influence of coaches’ (personal) characteristics on the development of interprofessional learning culture was not investigated in this study. It is recommended for further research to investigate the (personal) characteristics of the coaches on interprofessional learning and working so that they can be considered when selecting and training coaches to develop an interprofessional learning and working culture.

This realist action research sheds light on how and in what manner specific actions focused on improving person-centred care and getting to know and understand each other’s expertise contribute to fostering an interprofessional learning and working culture in nursing homes. Depending on the context, the actions triggered four mechanisms: critically reflective behaviour, collective ownership of goals, respectful/caring relationships and feeling appreciated for your work. These mechanisms are the underlying drivers of interprofessional learning and working culture in nursing homes. The findings highlight the significance of prioritising person-centred care and cultivating mutual understanding of diverse expertise. They also highlight the critical influence of contextual factors in cultivating and sustaining such a culture in these healthcare settings. These insights provide valuable guidance for fostering collaborative and effective interprofessional dynamics within nursing homes. It is recommended that interprofessional teams actively invest in promoting an interprofessional learning and working culture by selecting actions appropriate to their context. Further research should focus on the effectiveness and feasibility of the identified actions within specific and different contexts in nursing homes.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by HAN Research Ethics Committee in the Netherlands—registration number EACO 164.12/19. Participants gave informed consent to participate in the study before taking part.

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Contributors FHOV, MHL, ML and AJAHvV were involved in the design of the study. FHOV collected the data. FHOV, ESN and AJAHvV analysed the data. FHOV, ESN and AJAHvV drafted the manuscript for submission to BMJ Open. FHOV, ESN, MHL, CRMGF, GH-dW, ML and AJAHvV were involved in revising the manuscript. FHOV, ESN, MHL, CRMGF, GH-dW, ML and AJAHvV approved the submitted version. AJAHvV accepts full responsibility for the finished work and the conduct of the study, had access to the data, and controlled the decision to publish.

Funding This work was supported by the Netherlands Organisation for Health Research and Development, ZonMw, grant number 516012518.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Int J Prev Med

Qualitative Methods in Health Care Research

Vishnu renjith.

School of Nursing and Midwifery, Royal College of Surgeons Ireland - Bahrain (RCSI Bahrain), Al Sayh Muharraq Governorate, Bahrain

Renjulal Yesodharan

1 Department of Mental Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Judith A. Noronha

2 Department of OBG Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Elissa Ladd

3 School of Nursing, MGH Institute of Health Professions, Boston, USA

Anice George

4 Department of Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Healthcare research is a systematic inquiry intended to generate robust evidence about important issues in the fields of medicine and healthcare. Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and conveyed using a qualitative method. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Introduction

Healthcare research is a systematic inquiry intended to generate trustworthy evidence about issues in the field of medicine and healthcare. The three principal approaches to health research are the quantitative, the qualitative, and the mixed methods approach. The quantitative research method uses data, which are measures of values and counts and are often described using statistical methods which in turn aids the researcher to draw inferences. Qualitative research incorporates the recording, interpreting, and analyzing of non-numeric data with an attempt to uncover the deeper meanings of human experiences and behaviors. Mixed methods research, the third methodological approach, involves collection and analysis of both qualitative and quantitative information with an objective to solve different but related questions, or at times the same questions.[ 1 , 2 ]

In healthcare, qualitative research is widely used to understand patterns of health behaviors, describe lived experiences, develop behavioral theories, explore healthcare needs, and design interventions.[ 1 , 2 , 3 ] Because of its ample applications in healthcare, there has been a tremendous increase in the number of health research studies undertaken using qualitative methodology.[ 4 , 5 ] This article discusses qualitative research methods, their significance, and applicability in the arena of healthcare.

Qualitative Research

Diverse academic and non-academic disciplines utilize qualitative research as a method of inquiry to understand human behavior and experiences.[ 6 , 7 ] According to Munhall, “Qualitative research involves broadly stated questions about human experiences and realities, studied through sustained contact with the individual in their natural environments and producing rich, descriptive data that will help us to understand those individual's experiences.”[ 8 ]

Significance of Qualitative Research

The qualitative method of inquiry examines the 'how' and 'why' of decision making, rather than the 'when,' 'what,' and 'where.'[ 7 ] Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena and make sense of the complex reality. Health interventions, explanatory health models, and medical-social theories could be developed as an outcome of qualitative research.[ 9 ] Understanding the richness and complexity of human behavior is the crux of qualitative research.

Differences between Quantitative and Qualitative Research

The quantitative and qualitative forms of inquiry vary based on their underlying objectives. They are in no way opposed to each other; instead, these two methods are like two sides of a coin. The critical differences between quantitative and qualitative research are summarized in Table 1 .[ 1 , 10 , 11 ]

Differences between quantitative and qualitative research

Areas	Quantitative Research	Qualitative Research
Nature of reality	Assumes there is a single reality.	Assumes existence of dynamic and multiple reality.
Goal	Test and confirm hypotheses.	Explore and understand phenomena.
Data collection methods	Highly structured methods like questionnaires, inventories and scales.	Semi structured like in-depth interviews, observations and focus group discussions.
Design	Predetermined and rigid design.	Flexible and emergent design.
Reasoning	Deductive process to test the hypothesis.	Primarily inductive to develop the theory or hypothesis.
Focus	Concerned with the outcomes and prediction of the causal relationships.	Concerned primarily with process, rather than outcomes or products.
Sampling	Rely largely on random sampling methods.	Based on purposive sampling methods.
Sample size determination	Involves a-priori sample size calculation.	Collect data until data saturation is achieved.
Sample size	Relatively large.	Small sample size but studied in-depth.
Data analysis	Variable based and use of statistical or mathematical methods.	Case based and use non statistical descriptive or interpretive methods.

Qualitative Research Questions and Purpose Statements

Qualitative questions are exploratory and are open-ended. A well-formulated study question forms the basis for developing a protocol, guides the selection of design, and data collection methods. Qualitative research questions generally involve two parts, a central question and related subquestions. The central question is directed towards the primary phenomenon under study, whereas the subquestions explore the subareas of focus. It is advised not to have more than five to seven subquestions. A commonly used framework for designing a qualitative research question is the 'PCO framework' wherein, P stands for the population under study, C stands for the context of exploration, and O stands for the outcome/s of interest.[ 12 ] The PCO framework guides researchers in crafting a focused study question.

Example: In the question, “What are the experiences of mothers on parenting children with Thalassemia?”, the population is “mothers of children with Thalassemia,” the context is “parenting children with Thalassemia,” and the outcome of interest is “experiences.”

The purpose statement specifies the broad focus of the study, identifies the approach, and provides direction for the overall goal of the study. The major components of a purpose statement include the central phenomenon under investigation, the study design and the population of interest. Qualitative research does not require a-priori hypothesis.[ 13 , 14 , 15 ]

Example: Borimnejad et al . undertook a qualitative research on the lived experiences of women suffering from vitiligo. The purpose of this study was, “to explore lived experiences of women suffering from vitiligo using a hermeneutic phenomenological approach.” [ 16 ]

Review of the Literature

In quantitative research, the researchers do an extensive review of scientific literature prior to the commencement of the study. However, in qualitative research, only a minimal literature search is conducted at the beginning of the study. This is to ensure that the researcher is not influenced by the existing understanding of the phenomenon under the study. The minimal literature review will help the researchers to avoid the conceptual pollution of the phenomenon being studied. Nonetheless, an extensive review of the literature is conducted after data collection and analysis.[ 15 ]

Reflexivity

Reflexivity refers to critical self-appraisal about one's own biases, values, preferences, and preconceptions about the phenomenon under investigation. Maintaining a reflexive diary/journal is a widely recognized way to foster reflexivity. According to Creswell, “Reflexivity increases the credibility of the study by enhancing more neutral interpretations.”[ 7 ]

Types of Qualitative Research Designs

The qualitative research approach encompasses a wide array of research designs. The words such as types, traditions, designs, strategies of inquiry, varieties, and methods are used interchangeably. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research.[ 1 , 7 , 10 ]

Narrative research

Narrative research focuses on exploring the life of an individual and is ideally suited to tell the stories of individual experiences.[ 17 ] The purpose of narrative research is to utilize 'story telling' as a method in communicating an individual's experience to a larger audience.[ 18 ] The roots of narrative inquiry extend to humanities including anthropology, literature, psychology, education, history, and sociology. Narrative research encompasses the study of individual experiences and learning the significance of those experiences. The data collection procedures include mainly interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences through “re-storying of stories” and developing themes usually in chronological order of events. Rolls and Payne argued that narrative research is a valuable approach in health care research, to gain deeper insight into patient's experiences.[ 19 ]

Example: Karlsson et al . undertook a narrative inquiry to “explore how people with Alzheimer's disease present their life story.” Data were collected from nine participants. They were asked to describe about their life experiences from childhood to adulthood, then to current life and their views about the future life. [ 20 ]

Phenomenological research

Phenomenology is a philosophical tradition developed by German philosopher Edmond Husserl. His student Martin Heidegger did further developments in this methodology. It defines the 'essence' of individual's experiences regarding a certain phenomenon.[ 1 ] The methodology has its origin from philosophy, psychology, and education. The purpose of qualitative research is to understand the people's everyday life experiences and reduce it into the central meaning or the 'essence of the experience'.[ 21 , 22 ] The unit of analysis of phenomenology is the individuals who have had similar experiences of the phenomenon. Interviews with individuals are mainly considered for the data collection, though, documents and observations are also useful. Data analysis includes identification of significant meaning elements, textural description (what was experienced), structural description (how was it experienced), and description of 'essence' of experience.[ 1 , 7 , 21 ] The phenomenological approach is further divided into descriptive and interpretive phenomenology. Descriptive phenomenology focuses on the understanding of the essence of experiences and is best suited in situations that need to describe the lived phenomenon. Hermeneutic phenomenology or Interpretive phenomenology moves beyond the description to uncover the meanings that are not explicitly evident. The researcher tries to interpret the phenomenon, based on their judgment rather than just describing it.[ 7 , 21 , 22 , 23 , 24 ]

Example: A phenomenological study conducted by Cornelio et al . aimed at describing the lived experiences of mothers in parenting children with leukemia. Data from ten mothers were collected using in-depth semi-structured interviews and were analyzed using Husserl's method of phenomenology. Themes such as “pivotal moment in life”, “the experience of being with a seriously ill child”, “having to keep distance with the relatives”, “overcoming the financial and social commitments”, “responding to challenges”, “experience of faith as being key to survival”, “health concerns of the present and future”, and “optimism” were derived. The researchers reported the essence of the study as “chronic illness such as leukemia in children results in a negative impact on the child and on the mother.” [ 25 ]

Grounded Theory Research

Grounded theory has its base in sociology and propagated by two sociologists, Barney Glaser, and Anselm Strauss.[ 26 ] The primary purpose of grounded theory is to discover or generate theory in the context of the social process being studied. The major difference between grounded theory and other approaches lies in its emphasis on theory generation and development. The name grounded theory comes from its ability to induce a theory grounded in the reality of study participants.[ 7 , 27 ] Data collection in grounded theory research involves recording interviews from many individuals until data saturation. Constant comparative analysis, theoretical sampling, theoretical coding, and theoretical saturation are unique features of grounded theory research.[ 26 , 27 , 28 ] Data analysis includes analyzing data through 'open coding,' 'axial coding,' and 'selective coding.'[ 1 , 7 ] Open coding is the first level of abstraction, and it refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory.[ 1 , 7 ] Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings. Strauss and Corbin highlights that “the value of the grounded theory lies not only in its ability to generate a theory but also to ground that theory in the data.”[ 27 ]

Example: Williams et al . conducted a grounded theory research to explore the nature of relationship between the sense of self and the eating disorders. Data were collected form 11 women with a lifetime history of Anorexia Nervosa and were analyzed using the grounded theory methodology. Analysis led to the development of a theoretical framework on the nature of the relationship between the self and Anorexia Nervosa. [ 29 ]

Ethnographic research

Ethnography has its base in anthropology, where the anthropologists used it for understanding the culture-specific knowledge and behaviors. In health sciences research, ethnography focuses on narrating and interpreting the health behaviors of a culture-sharing group. 'Culture-sharing group' in an ethnography represents any 'group of people who share common meanings, customs or experiences.' In health research, it could be a group of physicians working in rural care, a group of medical students, or it could be a group of patients who receive home-based rehabilitation. To understand the cultural patterns, researchers primarily observe the individuals or group of individuals for a prolonged period of time.[ 1 , 7 , 30 ] The scope of ethnography can be broad or narrow depending on the aim. The study of more general cultural groups is termed as macro-ethnography, whereas micro-ethnography focuses on more narrowly defined cultures. Ethnography is usually conducted in a single setting. Ethnographers collect data using a variety of methods such as observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group with emic and etic perspectives. When the researcher reports the views of the participants it is called emic perspectives and when the researcher reports his or her views about the culture, the term is called etic.[ 7 ]

Example: The aim of the ethnographic study by LeBaron et al . was to explore the barriers to opioid availability and cancer pain management in India. The researchers collected data from fifty-nine participants using in-depth semi-structured interviews, participant observation, and document review. The researchers identified significant barriers by open coding and thematic analysis of the formal interview. [ 31 ]

Historical research

Historical research is the “systematic collection, critical evaluation, and interpretation of historical evidence”.[ 1 ] The purpose of historical research is to gain insights from the past and involves interpreting past events in the light of the present. The data for historical research are usually collected from primary and secondary sources. The primary source mainly includes diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The data gathered from these various sources are synthesized and reported as biographical narratives or developmental perspectives in chronological order. The ideas are interpreted in terms of the historical context and significance. The written report describes 'what happened', 'how it happened', 'why it happened', and its significance and implications to current clinical practice.[ 1 , 10 ]

Example: Lubold (2019) analyzed the breastfeeding trends in three countries (Sweden, Ireland, and the United States) using a historical qualitative method. Through analysis of historical data, the researcher found that strong family policies, adherence to international recommendations and adoption of baby-friendly hospital initiative could greatly enhance the breastfeeding rates. [ 32 ]

Case study research

Case study research focuses on the description and in-depth analysis of the case(s) or issues illustrated by the case(s). The design has its origin from psychology, law, and medicine. Case studies are best suited for the understanding of case(s), thus reducing the unit of analysis into studying an event, a program, an activity or an illness. Observations, one to one interviews, artifacts, and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived. A written case study report includes a detailed description of one or more cases.[ 7 , 10 ]

Example: Perceptions of poststroke sexuality in a woman of childbearing age was explored using a qualitative case study approach by Beal and Millenbrunch. Semi structured interview was conducted with a 36- year mother of two children with a history of Acute ischemic stroke. The data were analyzed using an inductive approach. The authors concluded that “stroke during childbearing years may affect a woman's perception of herself as a sexual being and her ability to carry out gender roles”. [ 33 ]

Sampling in Qualitative Research

Qualitative researchers widely use non-probability sampling techniques such as purposive sampling, convenience sampling, quota sampling, snowball sampling, homogeneous sampling, maximum variation sampling, extreme (deviant) case sampling, typical case sampling, and intensity sampling. The selection of a sampling technique depends on the nature and needs of the study.[ 34 , 35 , 36 , 37 , 38 , 39 , 40 ] The four widely used sampling techniques are convenience sampling, purposive sampling, snowball sampling, and intensity sampling.

Convenience sampling

It is otherwise called accidental sampling, where the researchers collect data from the subjects who are selected based on accessibility, geographical proximity, ease, speed, and or low cost.[ 34 ] Convenience sampling offers a significant benefit of convenience but often accompanies the issues of sample representation.

Purposive sampling

Purposive or purposeful sampling is a widely used sampling technique.[ 35 ] It involves identifying a population based on already established sampling criteria and then selecting subjects who fulfill that criteria to increase the credibility. However, choosing information-rich cases is the key to determine the power and logic of purposive sampling in a qualitative study.[ 1 ]

Snowball sampling

The method is also known as 'chain referral sampling' or 'network sampling.' The sampling starts by having a few initial participants, and the researcher relies on these early participants to identify additional study participants. It is best adopted when the researcher wishes to study the stigmatized group, or in cases, where findings of participants are likely to be difficult by ordinary means. Respondent ridden sampling is an improvised version of snowball sampling used to find out the participant from a hard-to-find or hard-to-study population.[ 37 , 38 ]

Intensity sampling

The process of identifying information-rich cases that manifest the phenomenon of interest is referred to as intensity sampling. It requires prior information, and considerable judgment about the phenomenon of interest and the researcher should do some preliminary investigations to determine the nature of the variation. Intensity sampling will be done once the researcher identifies the variation across the cases (extreme, average and intense) and picks the intense cases from them.[ 40 ]

Deciding the Sample Size

A-priori sample size calculation is not undertaken in the case of qualitative research. Researchers collect the data from as many participants as possible until they reach the point of data saturation. Data saturation or the point of redundancy is the stage where the researcher no longer sees or hears any new information. Data saturation gives the idea that the researcher has captured all possible information about the phenomenon of interest. Since no further information is being uncovered as redundancy is achieved, at this point the data collection can be stopped. The objective here is to get an overall picture of the chronicle of the phenomenon under the study rather than generalization.[ 1 , 7 , 41 ]

Data Collection in Qualitative Research

The various strategies used for data collection in qualitative research includes in-depth interviews (individual or group), focus group discussions (FGDs), participant observation, narrative life history, document analysis, audio materials, videos or video footage, text analysis, and simple observation. Among all these, the three popular methods are the FGDs, one to one in-depth interviews and the participant observation.

FGDs are useful in eliciting data from a group of individuals. They are normally built around a specific topic and are considered as the best approach to gather data on an entire range of responses to a topic.[ 42 Group size in an FGD ranges from 6 to 12. Depending upon the nature of participants, FGDs could be homogeneous or heterogeneous.[ 1 , 14 ] One to one in-depth interviews are best suited to obtain individuals' life histories, lived experiences, perceptions, and views, particularly while exporting topics of sensitive nature. In-depth interviews can be structured, unstructured, or semi-structured. However, semi-structured interviews are widely used in qualitative research. Participant observations are suitable for gathering data regarding naturally occurring behaviors.[ 1 ]

Data Analysis in Qualitative Research

Various strategies are employed by researchers to analyze data in qualitative research. Data analytic strategies differ according to the type of inquiry. A general content analysis approach is described herewith. Data analysis begins by transcription of the interview data. The researcher carefully reads data and gets a sense of the whole. Once the researcher is familiarized with the data, the researcher strives to identify small meaning units called the 'codes.' The codes are then grouped based on their shared concepts to form the primary categories. Based on the relationship between the primary categories, they are then clustered into secondary categories. The next step involves the identification of themes and interpretation to make meaning out of data. In the results section of the manuscript, the researcher describes the key findings/themes that emerged. The themes can be supported by participants' quotes. The analytical framework used should be explained in sufficient detail, and the analytic framework must be well referenced. The study findings are usually represented in a schematic form for better conceptualization.[ 1 , 7 ] Even though the overall analytical process remains the same across different qualitative designs, each design such as phenomenology, ethnography, and grounded theory has design specific analytical procedures, the details of which are out of the scope of this article.

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

Until recently, qualitative analysis was done either manually or with the help of a spreadsheet application. Currently, there are various software programs available which aid researchers to manage qualitative data. CAQDAS is basically data management tools and cannot analyze the qualitative data as it lacks the ability to think, reflect, and conceptualize. Nonetheless, CAQDAS helps researchers to manage, shape, and make sense of unstructured information. Open Code, MAXQDA, NVivo, Atlas.ti, and Hyper Research are some of the widely used qualitative data analysis software.[ 14 , 43 ]

Reporting Guidelines

Consolidated Criteria for Reporting Qualitative Research (COREQ) is the widely used reporting guideline for qualitative research. This 32-item checklist assists researchers in reporting all the major aspects related to the study. The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[ 44 , 45 ]

Critical Appraisal of Qualitative Research

Various scales are available to critical appraisal of qualitative research. The widely used one is the Critical Appraisal Skills Program (CASP) Qualitative Checklist developed by CASP network, UK. This 10-item checklist evaluates the quality of the study under areas such as aims, methodology, research design, ethical considerations, data collection, data analysis, and findings.[ 46 ]

Ethical Issues in Qualitative Research

A qualitative study must be undertaken by grounding it in the principles of bioethics such as beneficence, non-maleficence, autonomy, and justice. Protecting the participants is of utmost importance, and the greatest care has to be taken while collecting data from a vulnerable research population. The researcher must respect individuals, families, and communities and must make sure that the participants are not identifiable by their quotations that the researchers include when publishing the data. Consent for audio/video recordings must be obtained. Approval to be in FGDs must be obtained from the participants. Researchers must ensure the confidentiality and anonymity of the transcripts/audio-video records/photographs/other data collected as a part of the study. The researchers must confirm their role as advocates and proceed in the best interest of all participants.[ 42 , 47 , 48 ]

Rigor in Qualitative Research

The demonstration of rigor or quality in the conduct of the study is essential for every research method. However, the criteria used to evaluate the rigor of quantitative studies are not be appropriate for qualitative methods. Lincoln and Guba (1985) first outlined the criteria for evaluating the qualitative research often referred to as “standards of trustworthiness of qualitative research”.[ 49 ] The four components of the criteria are credibility, transferability, dependability, and confirmability.

Credibility refers to confidence in the 'truth value' of the data and its interpretation. It is used to establish that the findings are true, credible and believable. Credibility is similar to the internal validity in quantitative research.[ 1 , 50 , 51 ] The second criterion to establish the trustworthiness of the qualitative research is transferability, Transferability refers to the degree to which the qualitative results are applicability to other settings, population or contexts. This is analogous to the external validity in quantitative research.[ 1 , 50 , 51 ] Lincoln and Guba recommend authors provide enough details so that the users will be able to evaluate the applicability of data in other contexts.[ 49 ] The criterion of dependability refers to the assumption of repeatability or replicability of the study findings and is similar to that of reliability in quantitative research. The dependability question is 'Whether the study findings be repeated of the study is replicated with the same (similar) cohort of participants, data coders, and context?'[ 1 , 50 , 51 ] Confirmability, the fourth criteria is analogous to the objectivity of the study and refers the degree to which the study findings could be confirmed or corroborated by others. To ensure confirmability the data should directly reflect the participants' experiences and not the bias, motivations, or imaginations of the inquirer.[ 1 , 50 , 51 ] Qualitative researchers should ensure that the study is conducted with enough rigor and should report the measures undertaken to enhance the trustworthiness of the study.

Conclusions

Qualitative research studies are being widely acknowledged and recognized in health care practice. This overview illustrates various qualitative methods and shows how these methods can be used to generate evidence that informs clinical practice. Qualitative research helps to understand the patterns of health behaviors, describe illness experiences, design health interventions, and develop healthcare theories. The ultimate strength of the qualitative research approach lies in the richness of the data and the descriptions and depth of exploration it makes. Hence, qualitative methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

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Conflicts of interest.

There are no conflicts of interest.

Nursing Research for beginners

Post published: 21 September, 2024
Post category: 100% Free Courses / StudyBullet-19
Reading time: 4 mins read

What you will learn

nursing research

Advanced research, research skills, research methods.

Why take this course?

Students integrate knowledge, skills and learning experiences, to demonstrate academic understanding and application, in the development of a final research project, or paper addressing issues in nursing practice, education or administration. Utilizing basic research principles students analyse, interpret, and synthesize information to articulate project questions and goals, devise methods, conduct research and communicate findings.

SPECIFIC OBJECTIVES

Upon successful completion of this course, students should be able to:

Describe the classification, purpose, characteristics, types, and importance of research.
Explain ethical and legal standards in conducting nursing research.
Discuss the roles and responsibilities of the nurse related to evidence-based practice.
Develop research problem statements, objectives, questions and/or hypotheses.
Conduct a literature search on a current issue in nursing practice, education, or administration.
Analyse evidence-based research relevant to nursing practice, education, or administration.
Develop a tool to collect data on an issue in nursing practice, education, or administration.
Utilize specific research designs, methodologies, instruments, and procedures to investigate issues in nursing practice, education, or administration.
Perform basic analysis and interpretation of data on issues in nursing practice, education, or administration.
Communicate a synthesis of research findings addressing issues in nursing practice, education, or administration.

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Open access
Published: 19 September 2024

An organisation working mainly reactively instead of proactively: a qualitative study of how frail users of home care services and their next of kin experience crises

Janne Myhre 1 , 2 , 3 ,
Sverre Bergh 1 , 4 ,
Øyvind Kirkevold 1 , 3 , 5 &
Bjørn Lichtwarck 1

BMC Health Services Research volume 24 , Article number: 1102 ( 2024 ) Cite this article

Metrics details

Frail people receiving home care services face an increased risk of developing crisis, which can result in adverse events, coercive measures, and acute institutionalisation. The prevalence of frailty is expected to increase due to the ageing population in most countries. However, our knowledge of the process leading to crises among frail community-dwelling patients remains limited. The aim of our study was to explore how users of home care services and their next of kin experienced crises and how these crises were approached by home care services.

A qualitative explorative design with 21 interviews was conducted. We explored crises within the last year that had led to an acute institutionalisation (hospital or nursing home) or to an unstable situation with high risk of institutionalisation. Systematic text condensation (STC) was used to analyse the data.

Our findings are summarised into one overarching theme; an organisation working mainly reactively instead of proactively, which is supported by four subthemes: (1) insufficient communication—a determinant of crises, (2) the lack of a holistic approach, (3) a sense of being a burden, and (4) the complexity of crises. The reactive approach is demonstrated in the participant’s experience of insufficient communication and the lack of a holistic approach from the service, but also in the user’s sense of being a burden, which seems to be reinforced by the experienced busyness from the staff in the home care services. This reactive approach to crises seems to have contributed to difficulties in detecting the various stressors involved in the complex process leading to crisis.

Conclusions

Our findings suggest that home care services tend to be characterised by a reactive approach to rising instability and the development of crises for users. This can be interpreted as an emergent property of the organisation and the adaptation towards exceeding demands due to insufficient capacity in health care services. We recommend the use of multicomponent care programmes comprising interdisciplinary case conferences in home care services to implement a cultural change that can shift the service from a reactive, fragmented, and task-oriented approach to a more proactive approach.

Peer Review reports

The risk of developing crises is particularly high in frail community-dwelling people who due to their functional decline are dependent on care from the home care services. These crises can be defined as ‘ a process where the stressors cause an imbalance requiring an immediate decision which leads to a desired outcome and therefore crisis resolution ’ [ 1 ]. Such crises can have a burdensome impact on both users of home care services, their next of kin, and care staff. The stressors that cause this imbalance, thereby triggering and maintaining crises, are heterogeneous and vary among users of home care services. Such stressors may include neuropsychiatric symptoms (NPS), rejection of care, anxiety or depression and social isolation [ 2 ]. For the users, crises often result in adverse events, coercive measures, and acute institutionalisation [ 3 ]. For the users’ next of kin, crises can lead to depression, burn-out, isolation, physical and verbal abuse, and omission of care [ 2 ]. In community-dwelling users of home care services, 1–5% are classified as high-risk patients for the development of crisis, and of these 15–35% have a particularly high risk of acute hospitalisation or acute admittance to long-term care [ 4 ].

Many of the users of home care services have multimorbidity, and they represent a heterogeneous group due to great variation in diseases, functional level and age [ 5 , 6 ]. Because of an aging population in many countries, there will be a rising number and proportion of people with multimorbidity. Multimorbidity will probably double in the next 20 years, and cognitive decline, dementia and depression will affect one-third of these patients [ 6 ]. The risk of frailty increases with increasing age, and for adults 65 years or more the prevalence of frailty is estimated to 11%, increasing to 50% for adults older than 80 years [ 7 ]. A recent report issued by the Norwegian Health Directory noted that 140,648 people aged 75 years and older can be defined as frail, accounting for 31% of the total population within that age group in Norway [ 8 ]. Physiological vulnerability comprising a reduced capacity to adapt to internal and external stressors, is usually described as the core feature of the concept frailty [ 9 ]. However, lately researchers have emphasized a biopsychosocial definition of frailty, which also includes what is labelled psychological frailty and social frailty [ 10 ]. In this way, frailty is understood as a multifaceted concept where biological, psychological, and social stressors interact to cause this state of reduced capacity to adapt and manage stressors.

The literature on crises in home-dwelling people has mainly explored this phenomenon in relation to people with dementia [ 1 , 3 ]. The perceptions of crises experienced by people with dementia, their next of kin and the health care staff have been found to be influenced by the various type of stressors behind the crises and where the users of home care services are living when the crises occur [ 1 ]. This underlines the complexity and diversity of the processes that leads towards crises. This complexity of the process leading towards a crisis may be one of the reasons why it remains a major challenge for the health care system to be able to provide high-quality and safe health care to frail community-dwelling patients [ 11 ]. Frail individuals face high risks of poor outcomes after hospital discharge, with increased 2-year mortality rates, compared to non-frail patients [ 12 ]. Preventing crises from leading to institutionalisation is therefore important, and interventions aimed at reducing preventable hospitalisation are needed. To develop such interventions, research is needed to explore the processes leading to crises with outcomes such as hospitalisation or other types of institutionalisations [ 13 ]. The Norwegian Health Directorate has emphasized the importance of early detecting and responding to changes in the patient’s health condition as a part of a national patient safety programme [ 14 ]. Early detection and response by health care professionals are important patient safety strategies, and have the potential to prevent crises or to alleviate the consequences of such crises when they first have occurred.

Norwegian home care services

Home care services in Norway are part of the public health system and are provided to users free of charge [ 15 , 16 ]. The main tasks for the home care services comprise professional nursing care, providing diverse medical treatment and also assistance with the users’ activities of daily life. Since these tasks are extensive, varied and complex, and since the home care services in their work are dependent on a close collaboration with general practitioners (GPs), hospitals, other primary health care workers, and the social assistance sector etc., the home care services can be considered as complex organisations [ 5 ]. In most Norwegian municipalities, home care services are organised based on a purchaser-provider model that splits such services into care units and administrative units [ 17 ]. The administrative unit makes multiple single decisions regarding the type of health care and assistance that are necessary for the applicant [ 15 , 16 ]. These single decisions define the care tasks the user will receive from the home care services and outline how many minutes the home care services will use for each task. These services are organised based on worklists that describe in detail the users that home care services staff must visit, the tasks that they must perform, and the number of minutes that are allocated to each task [ 17 , 18 ].

Aim of the study

The study aimed to explore (i) how users of home care services and their next of kin experienced crises and (ii) how users of home care services and their next of kin perceived the response of home care services in managing those crises.

We used a qualitative explorative design featuring individual in-depth interviews of users of home care services and their next of kin. Because the questions and topics on which this study focuses are related to vulnerable personal situations resulting from critical situations, individual interviews were perceived as the most appropriate method for this research. Qualitative methods provide “contextual knowledge” concerning people’s experiences of the situations they face and the ways in which they interpret, understand, and link meaning to events [ 19 ]. By collecting information from the perspectives of both users of home care services and their next of kin, the intention of the present study was to develop a deeper understanding of crises from the perspective of the users. This study follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) [ 20 ].

Settings and participants

This study is part of the larger Preventing and approaching crises for frail community-dwelling patients through innovative care study (PRACTIC), which involves 30 municipalities, and their home care services in all health care regions in Norway. The 30 municipalities in the main PRACTIC project were recruited from April until December 2022 (Dalbak E.T, Væringstad A, Lichtwarck B, Myhre J, Holle D, Bergh S, et.al., Preventing and Approching Crisis for Frail community- dweling Patients Through Innovative Care (PRACTIC):study protocol for a process evaluation of a complex intervention in home care service/submitted) [ 21 ]. The sample used in the present study was recruited from nine of the 30 municipalities, including both urban and rural areas. Home care service users and their next of kin were recruited using a stepwise approach from January until July 2023, as we employed a process of theoretical sampling until data saturation was achieved [ 22 ]. This stepwise approach involves a continuous parallel process of analysing interviews and recruitment of informants until no new information emerges. The selection of these nine municipalities was based on factors related to conveniences, such as travel distance and economy; in addition, we did not want to interfere with the randomised controlled trial (RCT) conducted as part of the PRACTIC study (i.e., we did not include users of home care services who were already included in the RCT) (Dalbak ET, Væringstad A, Lichtwarck B, Myhre J, Holle D, Bergh S, et.al., Preventing and Approching Crisis for Frail commuity-dweling patient Through Innovative Care (PRACTIC): study protocol for a process evaluation of a complex intervention in home care service /submitted) [ 21 ].

Within these nine municipalities, purposive sampling was used to ensure that the participants recruited met the following inclusion criteria: (1) in need of home care services and (2) a score ≥ 5 on the Clinical Frailty Scale (CFS) (indicating mild, moderate, or severe frailty) [ 23 ]. In addition, (3) the users were required to have experienced a crisis during the past year, which was defined as (a) having been admitted to acute care in the hospital, (b) having been admitted to acute care in a nursing home, or (c) being perceived by home care service staff as facing an unstable situation featuring a high risk of acute institutionalisation or having exhibited rejection of care. The exclusion criteria for users were as follows: (1) planned hospitalisation or nursing home placement, (2) the presence of a clear single medical cause of institutionalisation (e.g., stroke or hip fracture), or (3) short life expectancy (i.e., < 4 weeks). The inclusion criteria for next of kin were as follows: (1) identity as next of kin of a user of home care services who met the inclusion criteria mentioned above and (2) regular contact with the user in question (i.e., at least once per week).

A total of twenty-one interviews were conducted two months to one year after a crisis had occurred among seventeen users of home care services. The users of home care services and their next of kin decided whether they wanted to be interviewed together or separately. All participants were interviewed only once. The interviews were conducted in the following manner:

Five interviews were conducted with only users as participants; these users did not want to involve their next of kin (5 users interviewed).

Seven interviews were conducted jointly with the user and the next of kin, who functioned as a dyad (7 users and 7 next of kin interviewed).

Six interviews were conducted with three users and three of their next of kin separately (3 users and 3 next of kin interviewed).

One interview was conducted solely with one user’s next of kin. This user was interviewed with another next of kin as a dyad (1 next of kin interviewed).

Two interviews were conducted with only the next of kin as participants; the users were not interviewed due to their deteriorating state of health. Information concerning the users and the crises they faced was obtained (2 next of kin interviewed).

These twenty-one interviews included interviews with thirteen next of kin and fifteen users. The two interviews conducted with the next of kin without the presence of the users involved information concerning the users and the crises they faced; hence, the characteristics of 17 users and 13 next of kin are described in Table 1 .

Data collection

All interviews with the users were performed at the participant’s current location: 12 interviews were conducted at their home, and three interviews were conducted in a nursing home. Six interviews were performed with users’ next of kin via Microsoft Teams. Each interview lasted between 30 min and 90 min depending on the health status of the user and his or her capacity to participate. The mean length of the interviews was 60 min. The first author conducted all the interviews. Before the interviews were conducted, the home care service informed the researcher about the time frame of the crisis, the main causes, whether the crisis involved acute institutionalisation in a nursing home or hospital or whether it was instead an unstable situation featuring a high risk of institutionalisation. The home care services also used the Clinical Frailty Scale (CFS) [ 23 ] and the Clinical Dementia Rating Scale (CDR) [ 24 ] to assess the users who participated in this research. The CFS ranges from 1 to 9, with higher scores indicating more severe frailty (5: mild frailty, 6: moderate frailty, and 7: severe frailty). The CDR focuses on the stages of possible dementia, ranging from 0 to 3 (0: no dementia, 0.5: questionable dementia, 1: mild dementia, 2: moderate dementia, 3: severe dementia). No other information regarding the crisis was conveyed to the researcher before the interviews were conducted.

The experience of the crisis was the main topic of the interviews with all participants. The interview guide was developed for this study and has previously not been published elsewhere (see attachment 1.) The interview guide included questions about participant’s description of the situation, the events that occurred, the participant’s feelings and thoughts, the participant’s beliefs regarding the causes of the situation, ways in which the crisis could ultimately have been prevented, and the manner in which the crisis was approached. These main questions were followed up by open-ended and exploratory questions. The participants were encouraged to speak freely, and when other key themes emerged spontaneously during the interviews, time was allotted to allow participants to elaborate on these themes. The interviews were recorded and transcribed verbatim, and they were cross-checked by listening to the recorded interviews.

Data analysis

The analysis was performed simultaneously by the first and last authors using an inductive, continuous, and iterative process based on systematic text condensation (STC), a method of thematic cross-case analysis that consists of four steps [ 25 ]. After each interview, the first and last authors read the interviews transcripts separately to obtain an overall impression, and they met to discuss any topics that required further exploration during subsequent interviews. When no new topics arose, theoretical saturation in the categories was achieved, and no new participants were recruited for further interviews [ 22 ].

The four steps of the analytical process were as follows. First, the transcripts were read several times to obtain an overall impression and develop preliminary themes, subthemes, and emerging categories that could reflect important meanings across the participants’ experiences. These preliminary themes were also assessed in relation to preliminary topics and situations that had previously been identified during the interview process. Second, meaning units, i.e., short extracts of the text that were viewed as supporting the preliminary themes, were then condensed into summarising codes. Meaning units and codes representing different aspects of the main theme and subthemes were identified. The similarities and differences among the codes were discussed, and the final codes were chosen. Third, the preliminary subthemes were reframed based on the similarities and common semantic aspects exhibited by each code group. Fourth, the condensation pertaining to each of the code groups was summarised to develop a general description and concepts reflecting the experience of crisis with an overarching theme and four final subthemes. Throughout the iterative analysis process, the researchers continually iterated among the abstracted results, i.e., the codes, the subthemes, and the main text.

Ethical considerations

The Regional Committee for Medical and Health Research Ethics in Eastern Norway (REC South-East) approved the study (Project No. 221019). Each participant received oral and written information from the home care service staff regarding the study. Approximately a week later, the users that wanted to participate handed a signed consent form to the home care service. All identifiable characteristics were excluded from the presentation of the data to ensure the anonymity of all participants. Patients who had the capacity to provide consent were asked to provide written consent. Specifically trained staff in the hospitals, nursing homes, or home care services (depending on the patient’s location) assessed the patients’ capacity in this respect. With regard to patients who were believed to lack the capacity to consent, their next of kin were informed about the research and asked to provide consent on the patient’s behalf. Informed consents were obtained from all participants prior to the interview.

The characteristics of the users of home care services and their next of kin, such as their age, gender, degree of frailty, and possible dementia, as well as the relationship between the user and their next of kin, are presented in Table 1 . Among the 17 users of home care services, fifteen were female and fourteen were aged 80 years or older, two had a spouse as their next of kin, and ten had a son or daughter as their next of kin and twelve users were living alone at the time of the crisis. Table 2 presents the characteristics of the 17 cases of crisis experienced by the 17 users of home care services based on the interviews with the 28 participants in our study and on information collected from the staff in the home care services. Among the 17 cases of crisis, two cases resulted in an acute admission to a nursing home, eleven cases resulted in acute admission to a hospital, and four cases involved an unstable situation featuring a high risk of institutionalisation. For the unstable situation, the users and their next of kin perceived a different timeframe and starting point of the crises than the researcher had been informed by the home care services. The participants found it difficult to describe the development of the unstable situations, and determining their starting points was especially difficult.

The analysis revealed one overarching theme, i.e., an organisation working mainly reactively instead of proactively, and four subthemes: (1) insufficient communication—a determinant of crises, (2) the lack of a holistic approach, (3) a sense of being a burden, and (4) the complexity of crises.

An organisation working mainly reactively instead of proactively

The main theme, “an organisation working mainly reactively instead of proactively,” referred to the overall experiences of the users of home care services and their next of kin concerning the reasons underlying crises. The approach that we labelled “reactive” reflects an abstraction of participants’ descriptions of responses to changes in patient health status, which were frequently late, and the difficulties in uncovering the complex process underlying the crisis. The reactive approach taken by the home care service was based mainly on the demands expressed by the patients, and the services failed to develop their own agenda for assessing the patients’ status. This approach often led to actions being taken only once the crisis had already occurred, such as by contacting the hospital for acute admission. On the other hand, a proactive approach based on regular observations and assessments of patients could reduce the likelihood of crisis. The four subthemes expand on this main theme.

Insufficient communication—A determinant of crises

All the next of kin explicitly expressed that insufficient communication was a factor that contributed to the development of crises. The insufficient communication they experienced was connected to the fact that changes in health conditions were not communicated by the home care services to either the user or the next of kin; such communication also did not occur among the staff working for the home care services or between the home care services and the patient’s general practitioner (GP). The home care services involve visits to the same user by several health care staff. This situation was conveyed as one of the main causes for the fact that changes in health conditions were not always uncovered and hence not communicated. In addition, several next of kin also questioned the ways in which these changes, if they were detected, were communicated, followed up, and documented in the electronic health records (EHR).

A stable staff group visiting her will presumably be able to pick up signals about a change in her health status earlier because they know her. But if they are just visiting her occasionally , they may not know what the starting point was. However , you can question the communication within the home care services and what they write in the EHR. Is it such as this: ‘Now there is a change we need to focus on. She is more tired , eating less , has slept a lot.’ That is an interesting question. (Next of kin, 2)

Insufficient communication among the home care services, the user and the next of kin was also conveyed as contributing to unclear responsibilities, especially when the health situation of the user deteriorated. Several next of kin described their uncertainty regarding whether they or the home care services were responsible for contact with the GP. This lack of clear responsibilities led the next of kin to describe themselves as coordinators who focused on communicating the user’s needs.

“Next of kin play a coordinator role to a much greater extent than we should because the home care services do not view it as their task , and I just have to do it for my mother’s sake. So , whether it is booking an appointment or follow-up when my mother feels that she is not getting her point across or being heard , I take charge.” (Next of kin, 12).

The users of home care services, on the other hand, talked about the lack of communication they experienced more implicitly. This was expressed through lack of knowledge of their health status and the fact that they did not know how changes in their health situation were followed up. The communication was often not tailored to the user’s reduced hearing and vision. This factor was also identified as leading to insufficient communication between the home care service staff and the users. In addition, the users also conveyed their concern with not knowing when the home care staff would visit them. They often had trouble contacting the home care service when they wanted to convey a message or request help:

“The time of appointments are challenging. They say that they will arrive then and then , but they don’t. So , something what could have been better is the opportunity to reach them , because sometimes they just don’t answer.” (User, 7).

The lack of a holistic approach

Both the users and their next of kin highlighted the lack of a response to needs other than physical health care needs, such as social and psychological needs. This factor was identified as contributing to unstable situations or acute institutionalisation. Several participants highlighted the use of single decisions as a barrier to a comprehensive approach. The lack of a response to the needs of the user of home care services was perceived as a main factor in the development of the crisis:

“I knew that she was not feeling well psychologically. Therefore , we asked the home care services if they could stay and talk to her for like 10 minutes as a daily routine. However , this was not possible because it is not something you can apply for; it is not something they offer as a single decision , even though that was what she needed.” (Next of kin, 11).

The users of home care services talked about how the different difficulties they encountered in their everyday lives gave rise to concerns, anxiety, and low quality of life, which persisted until a crisis occurred. These concerns included, for example, their inability to clean the house properly, change a light bulb, or empty the trash can themselves or their inability to open the window themselves in the summer heat in addition to their fears of current loneliness, future loneliness, or their failure to receive help when they needed it:

“The loneliness we experience within society now makes us insecure. Because if you are alone and the home care services are the only ones you see , and they are always in a rush , then you are just sitting alone all day long. So , what if the heat is like it is now , and you are unable to open the window and let the heat out , or you are unable to clean the house , or you are out of food , if the house falls into disrepair around you , and you are staying there because you have to?” (User, 15).

Users’ next of kin also expressed their concern for the needs and changes in health care status that were not addressed by the home care services. The next of kin described their concerns regarding fire, low nutritional status, repeated falls, and the lack of practical help; they also indicated that their loved one was alone too frequently, thus leading to loneliness and anxiety. Since not all needs were met by the home care services, all participants relied on neighbours, friend, or next of kin to live safely at home. Some participants also mentioned that they paid someone to be sure that they would receive help when they needed it or to ensure that all their needs were met. Many next of kin also mentioned that they increased their visits when a change in the health care status of their loved ones occurred:

“As she got worse , we had to be there more often to be sure that she got all the help she needed.” (Next of kin, 1).

A sense of being a burden

All users of home care services described their feeling of being a burden because they were dependent on help from others, such as the home care service, their family or their friends, to manage their everyday lives. Being dependent on help from others was expressed as leading to feelings of shame. On the other hand, these feelings led to a desire to remain independent and manage their health care problems and everyday lives themselves without asking for help. This desire for independence was described as a reason why users sometimes rejected care from home care services, which may have contributed to the development of crises:

“The point is that she wants to be independent and manage everything herself , and she says so too: ‘I can do it myself.’ Then , she often says that she manages more than she actually does. So , when the home care service offers her help , she refuses.” (Next of kin, 7).

This sense of being a burden when users needed help from others was partly identified a cultural phenomenon that users learned during their childhood and through their life experiences:

“I had a very good mother , but she was forty-four years old when she had me on top of the other nine children. When she got sick , we looked after her for many years , but she was always saying things about not bothering her or not bothering him. ‘No , I don’t want to bother you.’ So , maybe it is something you learn , that we should not bother each other.” (User, 14).

This culturally learned sense of being a burden and the desire to remain independent were also connected to social views of ageing and the need for help as individuals age.

“I have a feeling that some people look at older people who are in need of help as a nuisance.” (User, 3).

This sense of being a burden was also expressed as being reinforced by perceived signals of busyness from the home care services. All the users and their next of kin emphasised the fact that the home care services featured too few staff members. They had heard about the lack of staff in health care services from the media and from staff themselves who discussed their busy schedules. However, the participants also described busyness in the context of their experiences with home care services, such as situations in which they were not seen as persons and situations in which follow-up regarding changes in the user’s health status was lacking. This situation was also perceived by the users based on the nonverbal signals conveyed by staff when they, e.g., continually looked at their watches or failed to remove their jackets during their visits on when the phones that the staff brought with them were ringing and beeping continually during their visits.

But I see it , and I know that they [the staff working in the home care services] are in a hurry. So , then I think that I can do it myself instead of asking them. (User, 1)

All participants emphasized this sense of being a burden as a reason why the users of home care services hesitated to ask for more help and hence often received less help than they needed.

The complexity of crises

All participants noted that several simultaneously triggers and causes were often responsible for one acute admission to a nursing home or a hospital or to the user’s unstable situation. This highlights the multifaceted character of crises. Figure 1 shows the different determinants mentioned by the participants, abstracted as concepts by the authors. These concepts will be further developed in the discussion section. As shown in this figure, all participants identified biological, psychological, and social factors as determinants of crises. The complexity within the crisis was revealed through their description of how these determinants overlap, influence, and reinforce each other. For example, the side effects of medication were pointed out as leading to repeated falls, which in turn led to pain and anxiety, thereby resulting in poor nutrition and poor health as well as reinforcing users’ unstable gait and exacerbating the risk of falls; in addition, infections often emerged, leading to acute admission.

“After this severe fall , she went to the hospital , where they took away these pills that she was reacting to. In addition , she was very dehydrated , thin , and anxious.” (Next of kin, 10). “ She had been tired for a while , and she didn’t eat much. I think that she was in great pain , and she was very worried and scared. She had several falls , so now she had an armchair that she lived in.” (Next of kin, 13).

The complexity of crisis. Note: The figure summarizes the participants’ experiences of different determinants of crisis, abstracted as concepts by the authors. These determinants represent possible risk factors, triggers, and maintenance factors of a crisis, which often overlap and influence each other, displaying the complexity of crises

However, although both users of home care services and their next of kin described repeated falls or low nutritional status as factors that contributed to crises, all participants were unsure of the degree to which the users were examined and assessed with regard to these conditions. Some participants also related the user’s falls to their advanced age and expressed that they did not expect them to be examined.

“But then , she turns 88 years in July , so in a way , it’s also a bit natural that she has poor balance and then falls .” (Next of kin, 2).

Our findings can be summarised in terms of one overarching theme: an organisation working mainly reactively instead of proactively. This reactive approach is demonstrated not only by the participant’s experience of insufficient communication and the lack of a holistic approach on the part of the service but also by the user’s sense of being a burden, which seems to be reinforced by their experiences of busyness on the part of staff working for the home care services. This reactive approach to a crisis contributed to difficulties with regard to identifying the different stressors involved in the complex process leading to the crisis. Here, we discuss these findings in light of theories drawn from complexity science [ 26 , 27 ] and the concept of “wicked problems” [ 28 ]. We will also discuss how the participants’ sense of being a burden, to a large extent, can be viewed as the consequence of the lack of a holistic approach, the lack of sufficient communication and an internalised discourse of ageism (see Fig. 2 ). The use of theory in qualitative research can serve as an expression of abstraction, thus enhancing our understanding of how related phenomena are connected beyond the level permitted by a mere description of the phenomena in question [ 29 , 30 ].

An organisation working mainly reactively instead of proactively. Note: The figure illustrates the adaption i.e., the self-organization towards a proactive or a reactive approach as a response to the dual complexity in the home care services and the users

Insufficient communication and the lack of a holistic approach to the complexity of crises

The complexity of the crises experienced by frail community-dwelling people and the need for a holistic approach towards such crises were evident in our findings. As shown in Fig. 1 , biological, psychological, and social factors were identified by the participants as determinants of such crises. The participants experienced a lack of response from the home care services when it came to needs beyond physical health care. A longitudinal study conducted by Teo et al. to examine the dimension of frailty among community-dwelling people exhibited empirical clinical relevance when physical, mental, and social dimensions were included in the description of frailty [ 10 ]. Frailty among the users of home care services and the development of crises can be viewed as the results of complex interactions between biological, psychological, and social determinants [ 27 , 31 ]. According to complexity theory, this implies that these interactions are often non-linear with a certain unpredictability in the development of crises [ 32 ]. These determinants can interchangeably be risk factors, triggers, and maintenance factors of a crisis. For example, frailty increases the risk of physical illness, which in turn is a risk factor for mental illness, reinforced by loneliness and poor living conditions; and vice versa, mental illness increases the risk for physical illness, and both factors can lead to crises.

In our context, the complex needs of frail users of home care services cause these individuals to be prone to instability [ 10 , 27 ], and when such instability emerges, it ultimately culminates in a crisis. The unpredictable interactions between these factors were displayed by the participants’ difficulties to establish a starting point for the crisis and describing how the crisis developed. In this way, a crisis can be viewed as an example of a “wicked problem,” as described by Rittel and Webber [ 28 ]. These problems are interwoven with each other; they exhibit complex and overlapping causes and are difficult to delineate or define. Wicked problems are characterised by the fact that they have no natural starting or stopping point; i.e., they are not solved once and for all, are instable and require constant effort to manage [ 28 ]. Therefore, such a crisis cannot easily be defined with the aim of providing a “true” definition because each process leads to a specific crisis, and each user is different and unique [ 10 ].

In addition to the complexity of the phenomenon crisis, a dual complexity emerges, as home care services can be described as complex systems [ 33 , 34 , 35 ]. The complexity of the user’s needs and the complexity comprising different stakeholders around each user, such as professionals, next of kin, managers, policymakers and technologies, all of which interact with each other, account for this dual complexity. These adaptive systems rely on trade-offs and adjustments to succeed in everyday clinical work [ 26 ]. The participants highlighted insufficient communication and the lack of a holistic approach on the part of the home care services as factors that could explain why changes in the user’s health condition were not always uncovered. The fact that several health care staff members visited the same user was perceived as a primary barrier to uncover and communicate changes. If changes were not uncovered, they could not be communicated. Complexity theory describes a complex system as a system that adapts to internal and external demands, and that this behaviour is dynamic and nonlinear, exhibiting a varying degree of instability [ 32 , 35 ]. Studies on patient safety have documented how adaptive actions can solve problems and prevent harm [ 36 , 37 ]; however, they have also indicated that adaptability can have negative consequences if the system does not balance demands with capacity in the context of a constant effort to provide sound and safe patient care [ 38 , 39 , 40 ]. This adaptation is known as self-organisation in a complex system [ 32 ]. Members of an organisation, such as home care services, develop social knowledge related to routines, norms and rules related to daily life, which involves adaptation to demands and capacity, such as the acceptance of different staff members visiting the same user, the ways in which they communicate and the lack of a holistic approach [ 32 , 38 , 40 ]. Furthermore, the participants noted that the organisation of health care within the home care service was based on single decisions regarding physical needs, which was perceived as a barrier to meeting the actual needs of the users. In the light of complexity theory, single decisions can be viewed as a linear and simple approach to complex problems due to their task-oriented and fragmented character [ 41 ]. As previously described, frailty and the process leading to crises constitute complex or wicked problems, which consist of many determinants that are biological, psychological, or social and that interact with each other; furthermore, in this context, new challenges emerge continually over the course of the day, week, or month [ 26 , 28 ]. This implies that regular professional judgements and comprehensive assessments are necessary to uncover changes in each user’s health situations [ 35 ]. Several users experienced a fall during the process of a crisis, but none had experienced an examination aimed at detecting the possible reasons underlying their falls.

Self-organisation, i.e., adaptation to internal and external demands, also occurs among users and their next of kin because these actors are in a constant dynamic relationship with each other and the home care service. When they encountered insufficient communication from the service, users’ next of kin adapted and emerged as a coordinator for communication. The lack of a holistic approach on the part of the service caused all participants to rely on neighbours, friends or next of kin to be able to live safely at home. Many next of kin increased their visits when a change in the health care status of their loved one occurred. According to complexity theory, these visits from the next of kin can be regarded as attractors to the complexity of the frailty users [ 26 ]. Attractors are factors in complex systems that contribute to increased stability and order [ 32 ]. In our study, these attractors could have caused the users to be able to remain safely at home for longer periods.

The participants also conveyed how the users’ sense of being a burden contributed to the development of the crisis. The burden of care for informal and formal caregivers has been acknowledged as a concept for decades [ 42 , 43 ]. Although care is provided in the context of a dynamic relationship, less attention has been given to care recipients’ sense of being a burden to others. A systematic review of the end-of-life experiences of dependent patients revealed an overall increase in their feelings of being a burden to others [ 44 ]. These feelings involved frustration and guilt due to the hardships they imposed on their caregivers. In a study of suicide among older people, living as a burden was identified as a factor that can explain why older people commit suicide [ 45 ]. Living with such a sense of being a burden was found to be connected to functional decline and illness among older persons [ 44 , 45 ].

The participants in our study identified the sense of being a burden they experienced and their desire to remain independent as social phenomena they had learned through their life experiences. The tendency to strive for independency even in need of help can be interpreted as a learned coping strategy and as a part of the user’s personality [ 46 ]. In addition, society’s negative views of ageing and being a person who is dependent on care, which were reinforced through the signals of busyness from the home care service, enhanced this sense of being a burden. With regard to ageism [ 47 ], such a sense of being a burden can be viewed in connection to the ways in which society perceives and treats older people. Ageism refers to how we think (stereotypes), how we feel (prejudices), and how we act (discrimination) towards people as a result of their age [ 47 ]. In contemporary society, values such as independence, youthfulness, productivity, effectiveness, and coping are located at the top of the value hierarchy [ 45 , 47 ]. This society identifies positive values with independence and people’s ability to cope with challenges on their own, thus implying that dependency and vulnerability can be viewed as negative factors. The most appreciated values within a society affect (often in an implicit manner) how we think, feel, and act towards older people, i.e., the discourse on old age that characterizes the society in question [ 47 , 48 ]. This discourse can be insidiously internalised by older people and affect how older people think and feel regarding themselves [ 45 , 47 , 48 ].

The signals of busyness from staff seem to have reinforced users’ sense of being a burden and were a factor that participants highlighted to explain why the users did not receive the help they needed. This finding implies that the actions of staff members express their adaptation in the home care services, which among other factors, may be influenced by their competence, attitudes as well as low staffing, and the culture of which they are a part. This adaption is also influenced by societal attitudes towards ageing and dependency [ 33 , 35 , 46 ]. Furthermore, it implies that the actions taken by users, such as avoiding asking for help, are ways of adapting to the users’ experiences of busyness on the part of staff working for the home care services as well as society’s attitudes towards dependency and vulnerability.

An organisation working mainly reactively instead of proactively - Implications for practice

All the participants in our study expressed a need for what we have termed a proactive approach from these services. A proactive approach stands in contrast to an approach based on a system of single decisions that is entailed by the purchaser-provider model in many municipalities. Fragmented single decisions can be perceived as both a consequence of a reactive approach and an important factor maintaining such a reactive task-oriented approach.

For home care services to display a proactive approach to crises, the organisation must have the ability to discover changes in the user’s health during their everyday work [ 38 , 40 ]. The implication for practice for the home care services is to develop routines with a focus on daily professional judgements based on regular systematic comprehensive assessments, joint reflection, and effective communication routines.

This self-organisation observed in complex organisations such as home care services, which was here shown to result in a mainly reactive approach towards users, cannot be controlled; rather, it can only be influenced [ 32 , 38 ]. According to Stacy [ 49 ], three conditions influence such self-organisation in complex organisations: (1) increasing information flow, (2) facilitating more contact points between the participants in the organisation, and (3) promoting the development of greater variety in terms of cognitive schemas (interpretation and understanding). One suggestion for implementing a shift from a mainly reactive to a more proactive approach is the use of systematic multicomponent care programmes based on regular assessments and interdisciplinary reflection involving case conferences [ 35 , 50 ]. These case conferences have the potential to influence self-organisation in terms of all three of these aspects [ 35 , 46 ]. The use of multicomponent care programmes in home care services may therefore contribute to a cultural shift from a reactive and fragmented, task-oriented service to a more proactive, holistic approach. As part of our research project, i.e., the PRACTIC study, we are now testing the effectiveness of a multicomponent model called TIME through an RCT conducted in the context of home care services (Dalbak ET, Væringstad A, Lichtwarck B, Myhre J, Holle D, Bergh S, et.al., Preventing and Approching Crisis for Frail community -dweling Patient Through Innovative Care (PRACTIC): study protocol for a process evaluation of a complex intervention in home care service / submitted) [ 21 ]. TIME is a manual based programme that includes a rigorous assessment of the crisis, one or more interdisciplinary case conferences and the testing and evaluation of customised treatment measures [ 50 , 51 ].

Strengths and limitations of the study

This study involved 21 interviews with users of home care services and their next of kin, from nine different municipalities in Norway. This approach increases the transferability of our findings. By collecting information from the perspectives of both users of home care services and their next of kin, the aim of the present study was to develop a deeper understanding of the crisis from the users’ perspectives. This approach strengthens the credibility and trustworthiness of the study. The research team has used a biopsychosocial approach to frailty to get a broader and more comprehensive understanding of this concept. This approach could have contributed to a richer description of different determinant of crisis. However, it may also have increased the transferability of our findings to the heterogeneous population of frail users of home care services. All interviews were conducted two months to one year after a crisis had occurred. A limitation of this research is that it can be difficult to remember events that occurred a year ago. However, all the crises reported in this research, with two exceptions, represented situations that had occurred during the past six months. The experienced crises seemed to be situations associated with strong emotional impacts on the participants, which may have strengthened their memories of the events. Since both users and their next of kin were included in most of the interviews, they also helped each other recall the crises.

The first author of this study, JM, is a nurse as well as a researcher and has previously worked in home care services; however, none of those home care services were involved in this study. Because of this background knowledge, it was possible to pose in-depth questions to explore a broad range of issues. However, background knowledge could also affect the type of follow-up questions that were asked during the interviews. To counterbalance this potential bias, two researchers, JM and BL (a physician with particular competence in old age and nursing home medicine), analysed the data continuously beginning with the first interview using the STC analytical method, which made it possible to develop and deepen the questions asked during the interviews further. The STC analytical method is clearly described and can easily be replicated by others, thus contributing to the transparency of our study.

Our findings indicate that homecare services are characterised by a mainly reactive approach towards instability and crises on the part of users. This can be interpreted as an emergent property of health care service self-organisation, i.e., the adaptation of these services to internal and external demands. The reactive approach to a crisis contributes to difficulties in identifying the different stressors involved in the complex process leading to the crisis. A proactive approach, on the other hand, involves professional judgement on a daily basis, regular systematic comprehensive assessments and effective communication concerning changes in a user’s health condition. We recommend the use of multicomponent care programmes including interdisciplinary case conferences in home care services to contribute to a cultural shift from a reactive, fragmented, task-oriented approach to service to a more proactive approach.

Availability of data and materials

The datasets generated and analysed as part of the current study are not publicly available due to the fact that the format of the data does not allow for complete anonymisation. However, the data are available from the corresponding author upon reasonable request.

Abbreviations

Clinical Dementia Rating Scale

Clinical Frailty Scale

Electronic health records

General practitioner

Preventing and Approaching Crises for Frail Community-dwelling Patients Through Innovative Care

Randomised controlled trial

Systematic Text Condensation

Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms

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Acknowledgements

We would like to express our gratitude to the participants in this research for sharing their experiences with and thoughts concerning the topic of crisis among frail community-dwelling people receiving home care services. We also thank the staff working at the home care service who helped us recruit participants for this study.

Open access funding provided by Inland Norway University Of Applied Sciences. The study is funded by the South-Eastern Norway Regional Health Authority [Helse Sør-Øst], Norway, project number: 2023007.

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Janne Myhre

Norwegian Centre for Violence and Traumatic stress Studies, (NKVTS), Oslo, Norway

Janne Myhre & Øyvind Kirkevold

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Contributions

JM, SB, ØK and BL developed the study design. JM conducted the interviews, and JM and BL performed the analyses of the interviews. JM wrote the manuscript, and BL was the principal investigator (PI) and supervised the study. All the authors contributed to the critical revision of the manuscript for important intellectual content, and all the authors read and approved the final manuscript.

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Correspondence to Janne Myhre .

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The Regional Committee for Medical and Health Research Ethics in Eastern Norway (REC South‒East) granted ethical approval for this study, registration No. 221019. All participants were provided with written information concerning the study, and all participants provided written informed consent for their participation in the interviews and for our use of the data obtained through the interviews.

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Myhre, J., Bergh, S., Kirkevold, Ø. et al. An organisation working mainly reactively instead of proactively: a qualitative study of how frail users of home care services and their next of kin experience crises. BMC Health Serv Res 24 , 1102 (2024). https://doi.org/10.1186/s12913-024-11544-5

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