critical in qualitative research

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How to use and assess qualitative research methods

Loraine busetto.

1 Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany

Wolfgang Wick

2 Clinical Cooperation Unit Neuro-Oncology, German Cancer Research Center, Heidelberg, Germany

Christoph Gumbinger

Associated data.

Not applicable.

This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.

What is qualitative research?

Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].

Why conduct qualitative research?

Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.

While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 – 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 – 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig.  1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.

Iterative research process

While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].

Data collection

The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].

Document study

Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.

Observations

Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].

Semi-structured interviews

Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].

Focus groups

Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.

Choosing the “right” method

As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.

Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig.  2 .

Possible combination of data collection methods

Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project

The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].

Data analysis

To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig.  3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].

From data collection to data analysis

Attributions for icons: see Fig. ​ Fig.2, 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project

How to report qualitative research?

Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 – 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.

How to assess qualitative research?

A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.

Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].

Reflexivity

While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].

Sampling and saturation

The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].

This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).

Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].

Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.

Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.

Member checking

Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].

Stakeholder involvement

In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 – 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.

How not to assess qualitative research

The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.

Protocol adherence

Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 – 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.

Interrater reliability, variability and other “objectivity checks”

The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].

Not being quantitative research

Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.

The main take-away points of this paper are summarised in Table ​ Table1. 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

Take-away-points

Acknowledgements

Abbreviations, authors’ contributions.

LB drafted the manuscript; WW and CG revised the manuscript; all authors approved the final versions.

no external funding.

Availability of data and materials

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare no competing interests.

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9 Critical Approaches to Qualitative Research

Kum-Kum Bhavnani, Department of Sociology, University of California at Santa Barbara

Peter Chua, Department of Sociology, San José State University

Dana Collins, Department of Sociology, California State University, Fullerton

• Published: 04 August 2014
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This chapter reflects on critical strategies in qualitative research. It examines the meanings and debates associated with the term “critical,” in particular, contrasting liberal and dialectical notions and practices in relation to social analysis and qualitative research. The chapter also explores how critical social research may be synonymous with critical ethnography in relation to issues of power, positionality, representation, and the production of situated knowledges. It uses Bhavnani’s framework to draw on Dana Collins’ research as a specific case to suggest how the notion of the “critical” relates to ethnographic research practices: ensuring feminist and queer accountability, resisting reinscription, and integrating lived experience.

Qualitative research is now ubiquitous and fairly well-respected throughout the human sciences. That Oxford University Press is producing this much-needed volume is further testament to that notion, and one which we applaud. However, although there are different approaches to conducting qualitative research, what is often not addressed are the philosophical notions underlying such research. And that is where the “critical” enters. Indeed, “critical,” used as an adjective and applied, within the academy, to methods of research is also a familiar phrase. The question is, therefore: what does “critical” mean, and how might it be translated such that present and future researchers could draw on some of its fundamentals as they plan their research studies in relation to progressive political activism?

The popularity of critical research is not predictable. Although the 1960s and early 1970s did offer a number of publications that engaged with critical research traditions (e.g., Gouldner, 1970 ), and the 1990s also led to a resurgence of interest in this area (e.g., Harvey, 1990 ; Thomas, 1993 ), it is now two decades since explicit discussions of critical research have been widely discussed within the social sciences (see Smith, 1999 ; Madison, 2012 , as exceptions).

In this chapter, we first outline meanings associated with “critical.” We then suggest that the narratives of critical ethnography are best suited for an overview chapter such as this. We consider critical ethnography to be virtually synonymous with critical social research as we discuss it in this chapter. In the final section of our chapter, we discuss Dana Collins’ specific research studies to suggest how her approach embraces the notion of “critical” ( Collins, 2005 ; 2007 ; 2009 ).

The “Critical” in Critical Approaches

“Critical” is used in many ways. In everyday use, the term can refer, among other definitions, to an assessment that points out flaws and mistakes (“a critical approach to the design”), or to being close to a crisis (“a critical illness”). On the positive side, it can refer to a close reading (“a critical assessment of Rosa Luxembourg’s writings”) or as being essential (“critical for effective educational strategies”). A final definition is that the word can be used to either denote considerable praise (“the playwright’s work was critically acclaimed”) or to indicate a particular turning point (“this is a critical time to vote”). It is this last definition that is closest to our approach as we reflect on “critical” in the context of qualitative research. That is, drawing from the writings of Marx, the Frankfurt School, and others (see Delanty, 2005 ; Marx, 1845/1976 ; Strydom, 2011 ), we suggest that critical approaches to qualitative methods do not signify only a particular way of thinking about the methods we use in our research studies, but that “critical approaches” also signify a turning point in how we think about the conduct of research across the human sciences, including its dialectical relations to the progressive and systematic transformation of social relations and social institutions.

The most straightforward notion of “critical” in this context is that it refers to (at the least) or insists (at its strongest) that research—and all ways by which knowledge is created—is firmly grounded within an understanding of social structures (social inequalities), power relationships (power inequalities), and the agency of human beings (an engagement with the fact that human beings actively think about their worlds). Critical approaches are most frequently associated with Marxist, feminist, and antiracist, indigenous, and Third World perspectives. At its most succinct, therefore, we argue that “critical” in this context refers to issues of epistemology, power, micropolitics, and resistance.

What does this mean, both theoretically and for how we conduct our research? Most would agree that whereas qualitative research does not, by definition, insist on a nonpositivist way of examining the social world, for critical approaches to be truly critical, an antipositivist approach is the sine qua non of critical research. Furthermore, it is evident as we survey critical empirical research that issues of reflexive and subjective techniques in data collection and the researcher’s relationship with research subjects also frame both the practices and the theories associated with research.

The following section begins by drawing attention to developments and debates involving the more restricted use the term critical as related to Marxism and then explores the ramifications for varying attempts to conduct critical qualitative research.

The Critical Debates

Karl Marx, Friedrich Engels, and their contemporaries (see Engels, 1877/1969 ; Harvey, 1996 ; Lenin, 1915/1977 ; Mao, 1990 ; Ollman, 2003 ) developed dialectical materialist notions of critique and “critical” that were substantively different from prior notions. They incorporated these dialectical materialist notions to develop Marxist theories and politics.

Dialectical materialism refers to an outlook on reality that emphasizes the importance of process and change that are inherent to things (such as objects, phenomena, and situations), as well as of the importance of human practices in making change. Significantly, human struggle over existing conditions and contradictions in things creates not only new conditions, but also new contradictions. This outlook serves as an analytical tool over idealist and old-fashioned materialist worldviews and as a source of strength for exploited peoples in their struggle against ruling elites and classes. It emphasizes that correct ideas, knowledge, and theoretical abstractions are established initially, and perhaps inevitably, through practice.

Dialectical materialism may be used to examine two aspects of the research process and the production of academic knowledge. The first aspect involves the writing process as it is carried out among multiple authors. At the drafting phase, the authors craft their distinct ideas into textual form. Contradictions in ideas are bound to exist in the draft. In doing revisions, some contradictions may become intensified and remain unresolved, yet, most frequently (and hopefully!), many are addressed in the form of clearer, more solid, and coherent arguments, thus resolving the earlier contradictions in the text. Yet, new struggles and contradictions emerge. The synthesis of ideas and argument in the final manuscript may again, however, engage in new struggles with the prevailing arguments being discussed.

The second aspect involves the relationship and interaction between the researcher and the interviewee. As their relationship begins, contradictions and differences usually exist between them, for instance, in terms of their prior experiences and knowledge, their material interests in the research project, and their communication skills in being persuasive and forging consent. The struggle of these initial contradictions could result in new conditions and contradictions. For example, this could lead to

the establishment of quality rapport between them, allowing the interview to be completed while the researcher maintains control over the situation;

the abrupt end of the interview due to the interviewee refusing and asserting her or his right to comply with the interview process; or

an explicit set of negotiations that address the unevenness in power relations between them, along with an invitation for both to be part of the research team and to collaborate in the collection and analysis of data and in the forging of new theories and knowledges.

In the first possibility, the prevailing power relations in interviews remain but shift to beneath the surface of the relationship, under the guise of “rapport.” In the second possibility, power relations in the interview process and initial contradictions are heightened, resulting in new conditions and contradictions that the researcher and research participant have to address, jointly and singly. In the third possibility, the research subject is transformed into a researcher as well, and the relationship between the two is transformed into a more active co-learning and co-teaching relationship. Still, new conflicts and contradictions may emerge as the research process continues to unfold. 1 In short, dialectical materialism stresses the analysis of change in the essence (1), practice (2), and struggle (3). Such analyses are at the root of how change may be imagined within the practices of social research.

Dialectical materialism, which forms the basis of the concept of “critical,” emphasizes the need to engage with power, inequality, and social relations in the arenas of the social, political, economic, cultural, and ideological. Based on this status, it is argued that an analysis of societies and ways of life demands a more comprehensive approach, one that does not view society and social institutions merely as a singular unit of analysis but rather as ones that are replete with history. Dialectical materialism directs its criticism against prevailing views or hegemonies, and, within the context of academic endeavors, engages in debates against positivism and neo-Kantian forms of social inquiry. It is this basis of “critical” that defines it in the context of research as a deep questioning of science, objectivity, and rationality. Thus, the meaning of the term “critical,” based on the idea of “critique,” emerges from the practice and application of dialectical materialism.

Historical materialism emerges from and is based on dialectical materialism. That is, any application of the dialectic to material realities is historical materialism. For example, any study of human society, its history, its development, and its process of change demands a dialectical approach rooted in historical materialism. This involves delving deeper into past and present social phenomena to thereby determine how people change the essence of social phenomena, and, simultaneously, transform their contradictions.

Dialectical materialism regards positivism as a crude and naïve endeavor to seek knowledge and explain phenomena and as one that assumes it is the task of social researchers to determine the laws of social relationships by relying solely on observations (i.e., by assuming there is a primacy of external conditions and actions). In addition, positivism separates the subject (the seemingly unbiased, detached observer) and object (the phenomenon/a under consideration) of study. Dialectical materialism overcomes the shortcomings of positivism by offering a holistic understanding of (a) the essence of phenomena; (b) the processes of internal changes, the handling of contradictions, and the development of knowledge; (c) the unity of the subject and object in the making of correct ideas; and (d) the role of practice and politics in knowledge creation.

Dialectical materialism directs its criticism against dominant standpoints. These standpoints can offer a simplistic form of idealism and philosophical materialism. Within the context of academic endeavors, the methods of dialectical materialism engage in debates against positivism and neo-Kantian forms of social inquiry. This approach challenges assertions that science, objectivity, and rationality are the sine qua non of research and that skepticism and liberalism are the only appropriate analytical positionings by which a research project can be defined as “critical.”

For instance, Auguste Comte and Emile Durkheim, in developing sociological positivism, argued for a new science to study society, one that adopted the methods of the natural sciences, such as skeptical empiricism and the practices of induction. In adopting these methods, approaches relying on early positivism sought to craft knowledge based on seemingly affirmative verification rather than being based on judgmental evaluation and transformative distinctions.

Positivism and dialectical materialism were both developed in response to Kantian and idealist philosophy. In the context of the European Enlightenment, in the late 1700s, Immanuel Kant inaugurated the philosophy of critique. Positivism challenged Kant’s philosophy of critique as the basis for the theory of knowledge.

Kant developed his notion of critique to highlight the workings of human reason and judgment, to illuminate its limitations, and to consolidate its application in order to secure a stable foundation for morality, religion, and metaphysical concerns. Politically, Kantian philosophy provided justification for both a traditionalism derived from earlier periods and a liberalism developed during the ascendance of the Enlightenment.

Kant sought to settle philosophical disputes between a narrow notion of empiricism (that relies on pure observation, perception, and experience as the basis for knowledge) and a narrow notion of rationalism (that relies on pure reason and concepts as the basis for knowledge). He argued that the essence (termed “thing-in-itself”) is unknowable, countering David Hume’s skeptical empiricism, and he was convinced that there is no knowledge outside of innate conceptual categories. For Kant, “concepts without perceptions are empty; perceptions without concepts are blind” (1781/1965, pp. A 51/B 75).

The method of dialectical materialism challenges Kant’s idealism for (what is claimed to be) its faulty assertion that correct ideas and knowing about the “thing-in-itself” can only emerge from innate conceptual categories, ones that are universal and transcendental. In Kantian philosophy, there is no reality (out there) to be known. Rather, it is the experience of reality itself that provides for human reason and consciousness.

Dialectical materialism overcomes Kant’s idealism with its recognition of the existence of concrete phenomena, outside and independent of human reason. Dialectical materialism stresses that social reality and concrete phenomena reflect on and determine the content of human consciousness (and also, we would argue, vice versa). Dialectical materialism also emphasizes the role of practice and politics in knowledge development, instead of merely centering the primacy of ideas and the meanings of objects.

In sum, the core debate against positivism centers on the practices of science. Dialectical materialism regards positivist approaches as crude and naïve endeavors that seek to determine unchangeable laws of nature, rely solely on observations and “sense experience” of phenomena as the basis for knowledge, highlight the primacy of external conditions and actions to explain phenomena, and separate the subject from the object of study. That is, dialectical materialism views positivism as a form of mechanical, as distinct from historical, materialism.

This abridged account of dialectical materialism and the critiques it offers of Kantian idealism and sociological positivism can allow for the formation of a preliminary set of criteria for what may constitute the “critical.” We argue that qualitative research may be critical if it makes clear conceptually and analytically:

The essence and root cause of any social phenomena (e.g., youth and politics);

The relationship between the essence of the social phenomena under consideration to the general social totality (such as how youth and their views of politics are related to wider systems within society, such as education, age, exploitation);

The contradictions within this social phenomenon (such as how young people are expressing their discontent),

and, therefore,

How to conduct more reflexive practices that interrelate data generation, data analysis, and political engagement that challenge existing relations of power.

Contemporary debates between neo-Kantian idealists and dialectical materialists have often been friendly regarding the direction for carving out what is meant by a critical project in qualitative social research. These debates bring to the fore issues of politics, ethics, research design, and the collection and analysis of data. They have also prompted a variety of ways in which “critical” may be used in relation to qualitative research. For the purposes of this chapter, we suggest four substantial ways in which “critical” is used in the context of qualitative research: (a) critical as a form of liberalism, (b) critical as a counterdisciplinary perspective, (c) critical as an expansion of politics, and (d) critical as a professionalized research endeavor and perspective.

Critical as a form of Kantian liberalism is one of the more conventional uses of the term in qualitative research. This use of critical is generally contrasted against the dogmatism of positivist approaches within social scientific research. Yet, to use critical in this way means that we embrace a liberalism that ends up promoting idealism in outlook and pluralism in practice. That is, Kantian liberalism presents itself as a “critical” and novel analysis by combining eclectic ideas and theories while not making known its political stand and its material interests. As a result, it supports prevailing modes of thinking that emphasize abstraction over concrete reality, and it succumbs to relativistist and pragmatist practices in research, such as “anything goes” in collecting data. In terms of methods, this use of “critical” promotes looseness and leniency in ethics and data collection and analysis, often without a structured accountability to the many constituencies that underlie all social research. Furthermore, the use of, for example, phrases such as “critical spaces,” when applied to social research, may be better understood as a celebration of method above theory and meta-theory and an engagement with some (of the often rather) excessive approaches to reflexivity and meta-reflexivity. In sum, this understanding of “critical” lacks appropriate structures of ethics and accountability and often tends to reject dialectic materialism.

The second use of “critical” in regards to qualitative research proposes a more analytical disagreement with conventional scholarly disciplines and, in so doing, seeks to take up counterdisciplinary positions ( Burawoy, 1998 ; 2003 ; Carroll, 2004 ; Smith, 2007 ). There are two main strands in this use of “critical.” One strand argues that “critical” is a means of exposing the weaknesses of conventional academic disciplines such as anthropology, political science, psychology, and sociology. At the same time, this strand maintains the viability of these core social science disciplines. For instance, academic feminists have continually highlighted the masculinist and heterosexist bias in what is considered top-tier scholarship and the need for these disciplines to be more inclusive in terms of perspectives and methodological techniques (e.g., Fonow & Cook, 1991 ; Harding, 1991 ; Ray, 2006 ). Yet such an approach may not inevitably focus on the fundamental problems, such as a neglect of the study of power inequalities (e.g., Boserup 1970 ; and see examples in Reinharz & Davidman, 1992 ). This second strand seeks to carve out interdisciplinary and multidisciplinary fields such as women studies, cultural studies, and area studies to overcome the paradigmatic and fundamental crises within core disciplines ( Bhavnani, Foran, & Kurian, 2003 ; March, 1995 ; Mohanty, 2003 ). Many of these interdisciplinary and multidisciplinary fields have often been more historical and qualitative in their approaches, seeking to go beyond positivist limitations and present a more nuanced and thorough analysis. However, even these multi-, inter-, and antidisciplinary fields have an uneven impact on dominant and conventional knowledge.

Moreover, both strands have not been able to overcome the increasing corporatization and neoliberalization of academic institutions. This issue addresses the increasing restructuring of public education into a private domain, one that relies on privatized practices and funding of both teaching and research. The neoliberalization of the academy is found in the ties of academic research to corporate grants, individualized career advancement, excessive publishing demands and citation indices, and the use of outsourcing for transcription, interviewing, online education, and private research spaces that are “rented” by public institutions, to name a few. These neoliberal conditions of research usually push out those critical researchers who attempt to avoid such exploitative avenues for research, writing, and collaboration. This use of “critical,” however, does expose that critical research is taking shape within contemporary processes of neoliberalism and the increasing privatization of the academy ( Giroux, 2009 ; Greenwood, 2012 ; Pavlidis, 2012 ).

The third and less familiar approach is to view “critical” as invigorating politics through the practices of feminist, antiracist, and participatory action research. This approach, for example, highlights the importance of analyzing power in research, as in terms of the conduct of inquiry, in political usefulness, and in affecting relations of power and material relations. Yet this view of “critical” is dogmatic because this approach demands that every research study meet all criteria of criticality comprehensively and perfectly.

A final use of “critical” emerges from the many scholarly and professionalized approaches that engage with the politics of academic knowledge construction while making visible the limits of positivism. “Critical” is used here as a means to focus primarily on revitalizing scholarship and research endeavors. However, we argue that even this use of “critical” ossifies the separation of the making of specialized knowledge from an active engagement to transform social life. Such a separation is antithetical to dialectical materialism. Often, this fourth form of the term “critical” is based on the logics of the Frankfurt School of critical theory (such as that of Adorno [1973] , Habermas [1985] , and Marcuse [1968] ) and other Western neo-Marxisms (from Lukacs [1971] and Gramsci [1971] to Negri [1999] ). Critical ethnographers and other critical social researchers, drawing from this tradition, often develop public intellectual persona by writing and talking about politics through scholarly and popular forms of publishing and speaking presentations and are even seen to take part in political mobilizations. Yet they can also shy away from infusing their research with a deep engagement in political processes outside the academy.

Later in this chapter, we discuss how to avoid some of the pitfalls of these four types of “critical,” but suffice it to say, in short, that it is the politics and the explicit situatedness of research projects that can permit research to remain “critical.”

Is Critical Ethnography the Same as Critical Research?

George Marcus (1998) argues that the ethnographer is a midwife who, through words, gives birth to what is happening in the lives of the oppressed. Beverley Skeggs (1994) has proposed that ethnography is, in itself, “a theory of the research process,” and Asad (1973) offered the now-classic critique of anthropology as the colonial encounter. However, although many approaches to and definitions of ethnography abound, it is the case that they all agree on one aspect: namely, that ethnographies offer an “insider’s” perspective on the social phenomena under consideration. It is often suggested that the best ethnographies, whether defined as critical or not, offer detailed descriptions of how people see, and inhabit, their social worlds and cultures (e.g., Behar, 1993 ; Ho, 2009 ; Kondo, 1990 ; Zinn, 1979 ).

It is evident from our argument so far that we do not think of ethnographic approaches to knowledge construction as being, in and of themselves, critical. This is because an ethnographic study, although not in opposition to critical ethnography or to critical research in general, has practices rooted in social anthropology. Therefore, its assumptions are often in line with anthropological assumptions (see Harvey [1990] for a recounting of some of these assumptions). Concepts such as “insider” versus “outsider,” “going native,” “gaining access,” and even conceptualizations of a homogenized and/or exoticized “field” that is out there ready to be examined by research remain as significant lenses of methodological conceptualization in much ethnographic research.

Despite, or perhaps because of, the move to reflexivity in ethnographic research, there remain enduring assumptions about best practices. As a result, a certain fetishization of research methods transpires, one that is often epitomized as reflexivity. In this instance, ethnographic and qualitative research become an ideal set of practices for extracting information. In sum, “best research practices,” as ways to extract information, reproduce core power dynamics of racism, gender, class, imperialism, and heteronormativity, which, in turn, reproduce the oppressive dynamics of noncritical qualitative research.

Furthermore, when presenting research merely as reflexive research, it is the case that the researcher can lose sight of the broader social structural and historical materialist context. In addition, a static notion of reflexivity can lead to the researcher not looking outward to assess the wider interconnections among the micropolitics of the research. That is, reflexivity is a dialectic among the researcher, the research process, and the analysis ( Jordan & Yeomans, 1995 ), but it is often presented simply as a series of apparently unchangeable/essential facets of the researcher. Our final point is that for theory to be critical in the development of research paradigms, it has to explicitly engage with lived experiences and cultures for, without that engagement, it remains as formalism (see, e.g., the work of Guenther [2009] and Kang [2010] as examples of critical qualitative research). We are very much in tune with Hesse-Biber and Leavy, who have suggested that (grounded) theory building is a “dynamic dance routine” in which “there is no one right dance, no set routine to follow. One must be open to discovery” (2006, p. 76).

An example of the limitation of conventionally reflexive research is in the area of lesbian and gay research methods that focus on the experiences of gay men and lesbians conducting qualitative research. It also offers a commentary on the role that non-normative sexuality plays in social research. By looking inward (see the earlier comment on “reflexivity”), these methodological frameworks focus on the researcher’s and participants’ lesbian/gay identifications. In so doing, this can fabricate a shared social structural positionality with research participants who have been labeled “gay” or “lesbian.” Such an approach to reflexivity overlooks the fabricated nature of positionalities and ignores the sometimes more significant divisions between researchers and participants that are expressed along the lines of race, class, gender, and nationality. Reflexivity is used only as a way to forge a connection for the exchange of information. A grave mistake is made in this rush to force similarity along the lines of how people practice non-normative sexualities ( Lewin & Leap, 1996 ; for a more successful engagement with queer intersectionality in research, see Browne & Nash, 2010 ).

The point to be made is that critical researchers should not merely ask “how does this knowledge engage with social structure?” Critical researchers, when contemplating the question “What is this?” as they set up and analyze their research, could also ask, “What could this be?” ( Carspecken, 1996 ; Degiuli, 2007 ; Denzin, 2001 ; Noblit, Flores, & Murillo, 2004 , all cited in Degiuli, 2007 ). Perhaps, borrowing from Karen O’Reilly’s thoughts on critical ethnography, one may think of critical research as “an approach that is overtly political and critical, exposing inequalities in an effort to effect change” ( Reilly, 2009 , p. 51). That is, in order for qualitative research to be critical, it must be grounded in the material relationships of history, as may be seen in the work of Carruyo (2011) , Chua (2001 ; 2006 ; 2007 ; 2012 ), Collins (2005 ; 2007 ; 2009 ), Lodhia (2010) , and Talcott (2010) .

Quantz (1992) , in his discussion of critical ethnography, suggests that five aspects are central to the discussion of critical research/ethnography: knowledge, values, society, history, and culture. So far in this chapter, we have discussed knowledge and its production, values/reflexivity and qualitative research/ethnography, society and unequal social relationships, and history as a method of historical and dialectical materialism in order to better understand social and institutional structures. What we have not discussed, however, is the notion of culture, nor, indeed, the predicament of culture ( Clifford, 1998 ): “Culture is an ongoing political struggle around the meaning given to actions of people located within unbounded asymmetrical power relations” ( Quantz, 1992 , p. 483).

Quantz elaborates by stating that culture develops as people struggle together to name their experiences (see Comaroff & Comaroff, 2012 , for a sophisticated and elegant discussion of this thinking). For example, one key task of critical research is to tease out how disempowerment is achieved, undermined, or resisted. That is, the job of the researcher is to see how the disempowerment—economic, political, cultural—of subordinated groups manifests itself within culture, and, indeed, whether the subordinated groups even recognize their disempowerment. For example, “the hand that rocks the cradle rules the world” is one example of how the material disempowerment of many groups of women is presented, in fact, as a strength of women, and yet it takes the gaze away from seeing the subordination of women by ostensibly emphasizing women’s hidden social power.

It is critical qualitative research that has to simultaneously analyze how our research can identify processes and expressions of disempowerment and can then lead to a restructuring of these relationships of disempowerment. At times, critical social researchers engage in long-term projects that involve policy advocacy and community solidarity to link community-driven research with social empowerment and community change (see Bonacich, 1998 ; Bonacich & Wilson, 2008 ; Hondagneu-Sotelo, 2007 ; Stoecker, 2012 ).

The key point is that critical qualitative research parts company with positivistic approaches because it is argued that positivism is only able to offer a superficial set of findings. Critical qualitative research hones research concepts, practices, and analyses into finer points of reference so that societal relationships may be not only understood, but also so that social power inequalities can be undermined. In short, critical social research has a Foucauldian notion of power at its very core and may thus be thought of as offering insights into people’s lived experiences ( Williams, 1976 ) as they negotiate asymmetrical societal power relations (see e.g., Novelli, 2006 ).

The Practices of Critical Qualitative Research

Within our current era of enduring global inequalities, what could constitute a truly critical approach to qualitative research? More than twenty years ago, in “Tracing the Contours” ( Bhavnani, 1993 ), it was argued that if all knowledge is historically contingent and, therefore, that the processes of knowledge production are situated, then this must apply to all research practices as well. 2 This argument was based on Haraway’s (1988) idea that the particularities of knowledge production do not lie in the characteristics of individuals. Rather, knowledge production is “about communities, not about isolated individuals” (p. 590). Building on this, Haraway discussed the significance of partiality and its relationship to objectivity. She suggested that it is the researcher’s knowledge of her own “limited location” that creates objectivity. In other words, knowing the limitations of one’s structural position as a researcher contributes to objective research because there is no objectivity that is omniscient, one from which all can be revealed (Haraway discusses this as the “god trick,” which is like “seeing everything from nowhere,” p. 582).

It is from Haraway’s insights that we develop our argument that situated knowledges are not synonymous with the static reflexivity we describe earlier. This is because, in this latter scenario, the researcher implies that all research knowledge is based on and derives from an individual’s personal historical and biographical perspectives. That is, researchers note their racial/ethnic identity, sex/gender, sexuality, age, class, and ability (i.e., biographical aspects of themselves), which are presented as essential and unchanging factors and that determine the knowledge created by the research. This has also been called “absolute relativism” ( Bhavnani, 1993 ) or “extreme relativism” ( Alcoff & Potter, 1993 ).

We suggest that the three elements central to research being “critical” are partiality, positionality, and accountability. Partiality leads to critical research interrogating prevailing representations as the research is conducted, and this builds on difference. Positionality is not about being reflexive, but about understanding the sociohistorical/political context from which research is created and thus engages with the micropolitics of a research endeavor. Accountability makes it evident that there are many constituencies to which all academic researchers are accountable—for example, their discipline, intellectual integrity, their institution and academic colleagues, the idea of rigorous scientific research, and academic freedom in research—as well as being accountable to the people with whom the research is being conducted. It is accountability that leads to a critical research project interrogating how the lived experiences and cultures of the research participants are inscribed within the research (see Stoecker, 2012 ).

What might the necessary elements be for ensuring that our research practices retain the criticality we have discussed earlier? We offer four possibilities that could form a filter through which one could decide if research is critical, using our definition of the term. First, all critical qualitative researchers should interrogate the history of ethnographic research that has led to the systematic domination of the poor; working classes; ethnic, racialized, sexual Others; women; and colonized peoples. That is, critical qualitative researchers must begin research with an understanding of how previous research, including their own, may continue to play a part in the subordination of peoples around the world, for example, by reinscribing them into predictable and stereotypical roles. Second, critical qualitative researchers should work to develop a consciousness of what might constitute critical research practices—without fetishizing methods—that challenge the system of domination often present in social research. Third, researchers who embrace critical qualitative approaches must develop comfort with the notion that they are conducting research with a purpose; that is, researchers grapple with and comprehend that critical research demands that they engage with the idea that they conduct research into research inequalities in order to undo these inequalities. Finally, critical qualitative researchers comprehend that their level of comfort can extend into the idea that research does not simply capture social realities; rather, the critical research approach is generative of narratives and knowledges. Once this last idea is accepted—namely, that knowledge is created in a research project and not merely captured—it is then a comparatively straightforward task to see the need for a researcher’s accountability for the narratives and knowledges he or she ultimately produces. In so doing, it is possible to recognize that all representations have a life of their own outside of any intentions and that representations can contribute to histories of oppression and subordination.

We propose that it is the actual practice of research, and, perhaps, even the idea of researcher as witness ( Fernandes, 2003 ), and not a notion of “best practices,” that keeps the politics of research at the center of the work we do. This includes insights into the redistribution of power, representation, and knowledge production. We suggest that critical research is work that shifts research away from the production of knowledge for knowledge’s sake and edges or nudges it toward a more transformative vision of social justice (see Burawoy, 1998 ; Choudry, 2011 ; D’Souza, 2009 ; Hussey, 2012 ; Hunter, Emerald, & Martin, 2013 ).

Thoughts from the Field

Here, based on Collins’s fieldwork, we highlight a set of critical methodological lessons that became prominent while she was conducting her field research in Malate, in the city of Manila, the Philippines, currently a tourist destination but once famous as a sex district. We define her work as a critical research practice.

Since 1999, Dana Collins has conducted urban ethnographic work in Malate, exploring gay men’s production of urban sexual place. She has been interested in the role of “desire” in urban renewal, and, in particular, how informal sexual laborers (whom she terms “gay hospitality workers,” a nomenclature drawn from their own understandings of their labor and lives) use “desire” to forge their place in a gentrifying district that is also displacing them. This displacement has involved analyzing urban tourism development, city-directed urban renewal, and gay-led gentrification, as well as informal sexual labor.

The research has involved her precarious immersion in an urban sexual field. She undertook participant observation of gay night life in the streets, as well as in private business establishments, and conducted in-depth and in-field interviews with gay business owners, city officials, conservationists, gay tourists, and gay-identified sexual laborers. In addition, she drew on insights from visual sociology and also completed extensive archival work and oral history interviewing. In all of this, she explored the collective memories of Malate as a freeing urban sexual space.

There exist multiple and shifting positionalities of power, knowledge, exchange, and resistance in her research. For one, she points out that she occupies multiple social locations as a white, lesbian-identified feminist ethnographer from a US university, one who forges complicated relationships with urban sexual space, sex workers, and both gay Filipino men and gay tourists.

A critical research practice at heart involves the shifting of epistemological foundations of social science research by addressing core questions of how we know what we know, how power shapes the practices of research, how we can better integrate research participants and communities as central producers of knowledge in our research, and how we can better conceptualize the relationship between the research we do and the social justice we are working toward in this world. 3 Such questions function as a call to action for critical researchers not only to examine the power relations present in research, but to generate new ways of researching that can confront the realities of racism, gender and class oppression, imperialism, and homophobia. This is about not only becoming better researchers, but also about seeking ways to shift the very paradigm of qualitative research and ensuring its service to social change. We have learned to use these questions as a central and ongoing part of the research we do.

Feminist and Queer Accountability to the Micropolitics of the Field

One of the primary tenets of critical qualitative research is that researchers must work with a wider understanding and application of the politics of research. For Kum-Kum Bhavnani (1993) , this means that one needs to be accountable to the micropolitics of research because such accountability destabilizes the tendency to conduct and present research from a transcendent position—the “all knowing” ethnographer, the “outsider” going in to understand the point of view of “insiders,” the attempt to (avoid) “go(ing) native,” and the researcher who aims to “gain access” at all costs and in the interests of furthering research. Micropolitics is not only the axis of inequality that shapes contemporary field relations; it is also the historical materialist relationship that constitutes the field and informs the basis of critical qualitative research. Micropolitics therefore is a critical framework that questions the essentializing and power-laden perceptions of research spaces and people because it encourages both a reflexive inquiry into the limited locations of research, and it involves the more critical practice of the researcher turning outward, to comprehend what Bhavnani calls the “interconnections” among researcher, research participants, and the social structural spaces of “the field.”

Micropolitics illuminates how all research is conducted from the limited locations of gender, race, class, sexual identification, and nationality, as well as illuminating the interconnections among all of these locations. This is not a simplistic reflexive practice of taking a moment in research to account for one’s positionality and then moving on to conduct normative field work; Bhavnani has been critical of such moments of inward inspection that lack substantial accountability to the wider micropolitics of the field. Rather, this move requires an ongoing interrogation of the limited locations of research that show how knowledge is not transcendent. Furthermore, when used reflexively, limited locations offer a more critical framework from which to practice research.

Micropolitics encouraged Collins’ attention to the limited location of a global feminist ethnographer doing research on gay male urban sexual space in Manila. For one, she moved among different positionalities throughout her research—of woman, queer-identified, white, US academic, tourist, ate (Tagalog term for older sister)—and none of these positions was either a transcendent or more authentic standpoint from which to conduct ethnographic work. So, for instance, as a white tourist, she moved easily among the gentrifying gay spaces because these spaces were increasingly designed to encourage her movement around Malate. This limited location showed the increasing establishment of white consumer space, which encouraged the movement of consumers like herself yet dissuaded the movement of the informal sexual laborers with whom she was also spending time—the gay hosts. Her limited location as a white woman researcher from a major US university meant that gay hosts sometimes shared their spaces and meanings of urban gay life with her, yet many times those particular spaces and dialogues were closed—she was not allowed into the many public sexual spaces (parks and avenues for cruising and sex late at night), yet gay hosts treated her as an audience for their many romantic stories about the boyfriends they met in the neighborhood.

Hosts emphasized that they gained much from hosting foreigners in terms of friendship, love, desire, and cultural capital. Yet they monitored the information they shared because she remained to them a US researcher who wielded the power of representation over their lives, despite her closeness with a group of five gay hosts. Hence, gay hosts often chose to remain silent about their difficult memories of sex work or any information that could frame them as one-dimensional “money boys,” as distinct from the “gay”-identified Filipino men who migrated to Malate to take part in a gay urban community.

Micropolitics challenges the authenticity of any one positionality over another; it was Collins’ movement among all of them, as well as her ongoing consideration of their social structural places, that provided her with a more critical orientation to the research. She suggests that she was not essentially a better “positioned” researcher to study “gay” life in Manila because she too is gay. Rather she found that differences of race, class, gender, and nationality tended to serve as more enduring, limited locations that influenced relationships within this research and that required ongoing critical reflexive engagement.

We want to add that a queer micropolitics of the field also offers critical insight into how identities are not stagnant but rather can be fabricated and performative during the research process. This moves researchers away from an essentialist take on their standpoint because an essentialist mind-set can lead to a search for the authentic insider and outsider. It can also lead to an essentialist social positionality that is more conducive for researching. Queer micropolitics show that research is made up of a collection of productive relations and identities. So, for example, her lesbian identification did not create a more authentic connection with gay hosts in Manila; rather, she often fabricated a shared “gay” positionality. This was a performance that served as a point of departure for her many conversations, from which she could proceed to share meanings of what it meant to be “gay” in the Manila and the United States.

Some of the productive relations that arise in research are the continuum of intimacies that develop while doing research. So, like feminists before her, she chose to develop close friendships with hosts where they genuinely loved (in a familial way) as they spoke of love. While learning about gay life in Malate, she stroked egos, offered advice, cried over broken hearts and life struggles, and built and maintained familial relations. Queer micropolitics shows, however, the limitations of such intimacies because intimacy does not equal similarity—the differing social locations of class, race, gender, and nationality meant that the experiences of urban gay life varied immensely. Thus, building such intimacies across these differences requires both the recognition and respect for boundaries that hosts constructed. She had to learn to see and know that when hosts became quiet and pulled away these were acts of self-preservation as well as acts of defiance against the many misrepresentations of their lives that had taken shape in academic research and journalistic renderings of their place in “exotic” sex districts.

A queer micropolitics also shows how research is an embodied practice: researchers are gendered, racialized, classed, and sexualized in the field. This became most apparent as she walked alone at night in the “field” and developed a keen awareness of the deeply gendered aspects of Malate’s urban spaces. For one, her embodiment was a peculiar presence because women in Manila do not walk alone at night. This includes women sex workers who publicly congregate in groups or with clients and escorts; otherwise, they are subject to police harassment. Hence, her very movement in the field as a sole woman felt like a transgression into masculine urban space because her feminine body was treated as “out-of-place” in the public spaces of the streets at night—she was flirted with, name called, followed, and sexually handled as she walked to gay bars for her research. As much as her queer location afforded her an understanding of how gender is a discursive production on the body, replete with the possibility of her being able to transcend and destabilize the gendered body as a biological “reality,” she confronted the discomfort of being read as a real woman in what became predominantly men’s spaces at night.

Yet this gendered embodiment, in part, shaped her knowledge of the district as she developed quick and knowledgeable movement through the streets, a queer micropolitical reading of urban space that arose out of this limited gender location. She was aware of the spacing of blocks, the alleys, the street lighting, and the time of night when crowds spilled out from the bars and onto the streets, allowing her to realize that a socially vibrant street life actually facilitated her movement. This queer micropolitical reading of urban space showed how both researchers and research participants do not simply exist in a neutral way in city space; rather, gender leads to our use and misuse of urban space. She has juxtaposed her experience with those of research participants in her study. The latter spoke at length about their exploratory and liberatory experiences of urban space, replete with their access to masculine sexual spaces—parks for cruising and sex, city blocks for meeting clients or picking up male sex workers, and alleys, movie theaters, and mall bathrooms for anonymous sex.

This queer micropolitical read of Malate’s gentrified space showed how very different was her access to the newly opening bars, restaurants, cafés, and lifestyle stores. Her whiteness signaled assumptions of her class location and positioned her as part of the international presence that this gentrifying space was targeting and whose movement among establishments was encouraged. She received free entry, free drinks, exceptional hospitality, and invitations to private parties, and her movements were closely monitored as she entered and exited establishments for the sake of “protecting a foreign tourist from street harassment” (interview with bar owner).

Overall, she experienced whiteness and class as equally embodied because these locations signaled her power as a “legitimate” consumer, allowing access to urban consumer sites and a privileged movement among gentrified spaces. This embodied experience of gentrified space differed from that of her gay hosts, who were often denied access to these establishments for being Filipino, young, working class, gay, and interested in foreigners. Contrarily, their bodies were constructed as a “threat” to urban renewal in the district.

Resisting Reinscription

Critical qualitative research is also concerned with the politics of representation in research. This requires a hard look at the implicit imperialisms of ethnographic work, including the tendency to go in and get out with abundant factual information, as well as the lasting impact of objectificatory research practices on fields of study. Such practices are evident in the now global rhetoric about the so-called Third World prostitute, who in both academic and journalistic renderings tends to be sensationalized and sexually Othered. This rendering is part of a long history of exoticization that has denied subjectivity and rendered invisible the lived experiences of sexual laborers around the world.

Such failed representations are part of what Kum-Kum Bhavnani (1993) has called “reinscription”—the tendency in research to freeze research participants and sites in time and space, thus rendering them both exotic and silenced. Reinscription denies agency to research participants and renders invisible the dynamic lived experiences of those same research participants. Doing research in both postcolonial and sexual spaces means that researchers must grapple with how our research participates in histories of reinscription—we both enter into and potentially contribute to a field that has been already “examined,” overstudied, and often exoticized. Thus, a critical qualitative approach is one that begins with a thorough understanding of these histories of representation so that we are not entering fields naïvely, as spaces only of exploration. Rather, we enter with knowledge of how the field has already been constituted for us through reinscription. A critical orientation has a core objective of understanding how our representations of research at all levels of the research process could contribute to exoticization by reinscribing participants and sites.

The issue of reinscription became particularly apparent when Dana Collins interviewed gay hosts and grappled with what appeared to be their elaboration of a contradictory picture of their sexual labor, as well as of their lives. In short, hosts tended to “lie,” remain silent, embellish “truths,” and articulate contradictory allusions to their life and labor in Malate. When Collins began her interviewing, she held the implicit objective of obtaining the “truth” about hosts’ lives, which she believed resided in “what they do” in the tourism industry. She was concerned with the “facts” about their lives, even though gay hosts were more likely to express their desire—desire for relations with foreigners, desire to migrate to a “gay” urban district, desire for rewarding work, and desire for community and social change. She struggled with many uncertainties about the discussions: how could they hold a range of “jobs” and attend school, yet spend most of their days and nights in Malate? How could they understand gay tourists as both boyfriends and clients? Why resist the label “sex worker” yet refer to themselves as “working boys” and claim to have “clients?” She struggled to make sense of the meanings that hosts offered even as she simultaneously felt misled concerning the “real” relations of hospitality.

Interviewing hosts about sexualized labor—as a way to produce a representation of sex work—did not facilitate the flow of candid information; hosts later expressed their view that sex work and their lives were already “overstudied.” Many researchers had previously descended on Malate to study sex work, and the district was a prime location for the outreach of HIV/AIDS organizations, some of which had breached the confidence of the gay host community. In short, Dana mistakenly started her research without the knowledge of Malate as a hyperrepresented field, and her research risked reinscribing gay hosts’ lives within that field as static and unchanging.

Importantly, those gay hosts who resisted becoming the “good research subjects” who give accurate and bountiful information, prompted a radical shift in her research framework. They told her stories about their imagined social lives, which encouraged her to rethink her commitment to researching sex work because the transformation of the discourses offered another view of the district, their work, and lives, one that offered a more visionary perspective. She began to focus less on “misinformation” and instead followed how hosts framed their lives. She treated these framings as social imaginings in which Malate features prominently in their understandings of gay identity, community, belonging, and change. In short, their social imaginings functioned as counternarratives to reinscription and offered their lived experience of urban gay place. Such imaginations expressed hope, fear, critique, and desire—in short, they present a utopic vision of identity, community, and urban change.

Integrating Lived Experience

Finally, critical qualitative research is a call to study lived experience, which is a messy, contradictory realm, but a deeply important one if we as critical researchers are truly interested in working against a history of research that has silenced those “under study” (see Weis & Fine, 2012 ). Paying attention to lived experience allows us to better engage with the contradictions mentioned earlier because lived experience is about understanding the meanings that research participants choose to share with researchers, and it is also about respecting their silences. As Kum-Kum Bhavnani (1993) has argued, silences can be as eloquent as words. Finally, integrating lived experience can take a critical qualitative project further because lived experience allows researchers to explore the epistemological relationship of the meanings and imaginings offered by research participants and to be explicit about the project of knowledge production. In other words, a central guiding question of critical qualitative research is how can research participants speak and shape epistemology, rather than solely being spoken about or being the subjects of epistemology?

Collins used hosts’ social imaginings as an epistemological contribution because their imaginings showed how hosts draw from experiences of urban gay community to articulate their desires for change, despite their simultaneous experiences of inequality and exclusion. We read social imaginings as a subjective rendering of urban place—the hosts’ social imaginings expressed their history, identity, subversive uses of urban space, and, ultimately, the symbolic reconstitution of that urban space. In this way, hosts were refiguring transnational urban space by writing themselves and their labor back into the district’s meaning, even as the global forces of tourism and urban renewal threatened to displace them.

In conclusion, we seek to highlight how critical research insists on the interplay of reflexivity, process, and practice. In particular, we encourage critical researchers to be mindful of the multiple meanings and usages of the term “critical” so that we can make more explicit our political interests and stand within our disciplines, the academy, our community, and the world. We offer dialectical materialism as a distinct mode of critical analysis that emphasizes an analysis of change in essence, practice, and struggle. We also suggest that, for researchers to be critical in their research, they should strive to take up research questions and projects that study change, contradictions, struggle, and practice in order to counter dominant interests and advance the well-being of the world’s majority. We should strive to build new research relationships—such as overcoming the faulty divides between researchers and research participants and by promoting systems of community accountability—that dialectically fuse research, political activism, and progressive social change.

Furthermore, we suggest that critical research can agitate against the homogeneity of ethnographic representation, allowing for the realities of people’s lives to come into view. Critical researchers recognize the contested fields of research; yet this requires our critical engagement with the research process, as a reflexive, empathetic, collective, self-altering, socially transformative, and embedded exercise in knowledge production. Therefore, critical research can resist imperialist research practices that are disembodied and that assume a singular social positioning. We use an imperative here to say that we must conduct research as embodied subjects who shift between multiple and limited locations. We also have to find more ways to remain accountable to our communities of research as a way to undo implicit imperialisms in social research. Critical research can work against the remnants of an objectivist and truth-seeking method that supports prevailing interests, classes, and groups while embracing research from social locations that offer situated knowledges and the possibility for greater shared understandings. Finally, critical research can engage the micropolitics of research and foreground the need for the accountability of researchers to resist reproducing epistemic violence.

This last is an idealist imagining of what should happen. However, a number of research projects have approximated closely to these goals.

Parts of our argument have appeared in some of our earlier work (e.g., Bhavnani & Talcott, 2011 ; Collins, 2009 ; 2002 ; Chua, 2001 ).

Although we, as the chapter’s three authors, do not usually use “we” in our writing as a general pronoun, it is the most direct way to offer our insights in this section.

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Critically appraising qualitative research

• Related content
• Peer review
• Ayelet Kuper , assistant professor 1 ,
• Lorelei Lingard , associate professor 2 ,
• Wendy Levinson , Sir John and Lady Eaton professor and chair 3
• 1 Department of Medicine, Sunnybrook Health Sciences Centre, and Wilson Centre for Research in Education, University of Toronto, 2075 Bayview Avenue, Room HG 08, Toronto, ON, Canada M4N 3M5
• 2 Department of Paediatrics and Wilson Centre for Research in Education, University of Toronto and SickKids Learning Institute; BMO Financial Group Professor in Health Professions Education Research, University Health Network, 200 Elizabeth Street, Eaton South 1-565, Toronto
• 3 Department of Medicine, Sunnybrook Health Sciences Centre
• Correspondence to: A Kuper ayelet94{at}post.harvard.edu

Six key questions will help readers to assess qualitative research

Summary points

Appraising qualitative research is different from appraising quantitative research

Qualitative research papers should show appropriate sampling, data collection, and data analysis

Transferability of qualitative research depends on context and may be enhanced by using theory

Ethics in qualitative research goes beyond review boards’ requirements to involve complex issues of confidentiality, reflexivity, and power

Over the past decade, readers of medical journals have gained skills in critically appraising studies to determine whether the results can be trusted and applied to their own practice settings. Criteria have been designed to assess studies that use quantitative methods, and these are now in common use.

In this article we offer guidance for readers on how to assess a study that uses qualitative research methods by providing six key questions to ask when reading qualitative research (box 1). However, the thorough assessment of qualitative research is an interpretive act and requires informed reflective thought rather than the simple application of a scoring system.

Box 1 Key questions to ask when reading qualitative research studies

Was the sample used in the study appropriate to its research question, were the data collected appropriately, were the data analysed appropriately, can i transfer the results of this study to my own setting, does the study adequately address potential ethical issues, including reflexivity.

Overall: is what the researchers did clear?

One of the critical decisions in a qualitative study is whom or what to include in the sample—whom to interview, whom to observe, what texts to analyse. An understanding that qualitative research is based in experience and in the construction of meaning, combined with the specific research question, should guide the sampling process. For example, a study of the experience of survivors of domestic violence that examined their reasons for not seeking help from healthcare providers might focus on interviewing a sample of such survivors (rather than, for example, healthcare providers, social services workers, or academics in the field). The sample should be broad enough to capture the many facets of a phenomenon, and limitations to the sample should be clearly justified. Since the answers to questions of experience and meaning also relate to people’s social affiliations (culture, religion, socioeconomic group, profession, etc), it is also important that the researcher acknowledges these contexts in the selection of a study sample.

In contrast with quantitative approaches, qualitative studies do not usually have predetermined sample sizes. Sampling stops when a thorough understanding of the phenomenon under study has been reached, an end point that is often called saturation. Researchers consider samples to be saturated when encounters (interviews, observations, etc) with new participants no longer elicit trends or themes not already raised by previous participants. Thus, to sample to saturation, data analysis has to happen while new data are still being collected. Multiple sampling methods may be used to broaden the understanding achieved in a study (box 2). These sampling issues should be clearly articulated in the methods section.

Box 2 Qualitative sampling methods for interviews and focus groups 9

Examples are for a hypothetical study of financial concerns among adult patients with chronic renal failure receiving ongoing haemodialysis in a single hospital outpatient unit.

Typical case sampling —sampling the most ordinary, usual cases of a phenomenon

The sample would include patients likely to have had typical experiences for that haemodialysis unit and patients who fit the profile of patients in the unit for factors found on literature review. Other typical cases could be found via snowball sampling (see below)

Deviant case sampling —sampling the most extreme cases of a phenomenon

The sample would include patients likely to have had different experiences of relevant aspects of haemodialysis. For example, if most patients in the unit are 60-70 years old and recently began haemodialysis for diabetic nephropathy, researchers might sample the unmarried university student in his 20s on haemodialysis since childhood, the 32 year old woman with lupus who is now trying to get pregnant, and the 90 year old who newly started haemodialysis due to an adverse reaction to radio-opaque contrast dye. Other deviant cases could be found via theoretical and/or snowball sampling (see below)

Critical case sampling —sampling cases that are predicted (based on theoretical models or previous research) to be especially information-rich and thus particularly illuminating

The nature of this sample depends on previous research. For example, if research showed that marital status was a major determinant of financial concerns for haemodialysis patients, then critical cases might include patients whose marital status changed while on haemodialysis

Maximum-variation sampling —sampling as wide a range of perspectives as possible to capture the broadest set of information and experiences)

The sample would include typical, deviant, and critical cases (as above), plus any other perspectives identified

Confirming-disconfirming sampling —Sampling both individuals or texts whose perspectives are likely to confirm the researcher’s developing understanding of the phenomenon under study and those whose perspectives are likely to challenge that understanding

The sample would include patients whose experiences would likely either confirm or disconfirm what the researchers had already learnt (from other patients) about financial concerns among patients in the haemodialysis unit. This could be accomplished via theoretical and/or snowball sampling (see below)

Snowball sampling —sampling participants found by asking current participants in a study to recommend others whose experiences would be relevant to the study

Current participants could be asked to provide the names of others in the unit who they thought, when asked about financial concerns, would either share their views (confirming), disagree with their views (disconfirming), have views typical of patients on their unit (typical cases), or have views different from most other patients on their unit (deviant cases)

Theoretical sampling —sampling individuals or texts whom the researchers predict (based on theoretical models or previous research) would add new perspectives to those already represented in the sample

Researchers could use their understanding of known issues for haemodialysis patients that would, in theory, relate to financial concerns to ensure that the relevant perspectives were represented in the study. For example, if, as the research progressed, it turned out that none of the patients in the sample had had to change or leave a job in order to accommodate haemodialysis scheduling, the researchers might (based on previous research) choose to intentionally sample patients who had left their jobs because of the time commitment of haemodialysis (but who could not do peritoneal dialysis) and others who had switched to jobs with more flexible scheduling because of their need for haemodialysis

It is important that a qualitative study carefully describes the methods used in collecting data. The appropriateness of the method(s) selected to use for the specific research question should be justified, ideally with reference to the research literature. It should be clear that methods were used systematically and in an organised manner. Attention should be paid to specific methodological challenges such as the Hawthorne effect, 1 whereby the presence of an observer may influence participants’ behaviours. By using a technique called thick description, qualitative studies often aim to include enough contextual information to provide readers with a sense of what it was like to have been in the research setting.

Another technique that is often used is triangulation, with which a researcher uses multiple methods or perspectives to help produce a more comprehensive set of findings. A study can triangulate data, using different sources of data to examine a phenomenon in different contexts (for example, interviewing palliative patients who are at home, those who are in acute care hospitals, and those who are in specialist palliative care units); it can also triangulate methods, collecting different types of data (for example, interviews, focus groups, observations) to increase insight into a phenomenon.

Another common technique is the use of an iterative process, whereby concurrent data analysis is used to inform data collection. For example, concurrent analysis of an interview study about lack of adherence to medications among a particular social group might show that early participants seem to be dismissive of the efforts of their local pharmacists; the interview script might then be changed to include an exploration of this phenomenon. The iterative process constitutes a distinctive qualitative tradition, in contrast to the tradition of stable processes and measures in quantitative studies. Iterations should be explicit and justified with reference to the research question and sampling techniques so that the reader understands how data collection shaped the resulting insights.

Qualitative studies should include a clear description of a systematic form of data analysis. Many legitimate analytical approaches exist; regardless of which is used, the study should report what was done, how, and by whom. If an iterative process was used, it should be clearly delineated. If more than one researcher analysed the data (which depends on the methodology used) it should be clear how differences between analyses were negotiated. Many studies make reference to a technique called member checking, wherein the researcher shows all or part of the study’s findings to participants to determine if they are in accord with their experiences. 2 Studies may also describe an audit trail, which might include researchers’ analysis notes, minutes of researchers’ meetings, and other materials that could be used to follow the research process.

The contextual nature of qualitative research means that careful thought must be given to the potential transferability of its results to other sociocultural settings. Though the study should discuss the extent of the findings’ resonance with the published literature, 3 much of the onus of assessing transferability is left to readers, who must decide if the setting of the study is sufficiently similar for its results to be transferable to their own context. In doing so, the reader looks for resonance—the extent that research findings have meaning for the reader.

Transferability may be helped by the study’s discussion of how its results advance theoretical understandings that are relevant to multiple situations. For example, a study of patients’ preferences in palliative care may contribute to theories of ethics and humanity in medicine, thus suggesting relevance to other clinical situations such as the informed consent exchange before treatment. We have explained elsewhere in this series the importance of theory in qualitative research, and there are many who believe that a key indicator of quality in qualitative research is its contribution to advancing theoretical understanding as well as useful knowledge. This debate continues in the literature, 4 but from a pragmatic perspective most qualitative studies in health professions journals emphasise results that relate to practice; theoretical discussions tend to be published elsewhere.

Reflexivity is particularly important within the qualitative paradigm. Reflexivity refers to recognition of the influence a researcher brings to the research process. It highlights potential power relationships between the researcher and research participants that might shape the data being collected, particularly when the researcher is a healthcare professional or educator and the participant is a patient, client, or student. 5 It also acknowledges how a researcher’s gender, ethnic background, profession, and social status influence the choices made within the study, such as the research question itself and the methods of data collection. 6 7

Research articles written in the qualitative paradigm should show evidence both of reflexive practice and of consideration of other relevant ethical issues. Ethics in qualitative research should extend beyond prescriptive guidelines and research ethics boards into a thorough exploration of the ethical consequences of collecting personal experiences and opening those experiences to public scrutiny (a detailed discussion of this problem within a research report may, however, be limited by the practicalities of word count limitations). 8 Issues of confidentiality and anonymity can become quite complex when data constitute personal reports of experience or perception; the need to minimise harm may involve not only protection from external scrutiny but also mechanisms to mitigate potential distress to participants from sharing their personal stories.

In conclusion: is what the researchers did clear?

The qualitative paradigm includes a wide range of theoretical and methodological options, and qualitative studies must include clear descriptions of how they were conducted, including the selection of the study sample, the data collection methods, and the analysis process. The list of key questions for beginning readers to ask when reading qualitative research articles (see box 1) is intended not as a finite checklist, but rather as a beginner’s guide to a complex topic. Critical appraisal of particular qualitative articles may differ according to the theories and methodologies used, and achieving a nuanced understanding in this area is fairly complex.

Further reading

Crabtree F, Miller WL, eds. Doing qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 1999.

Denzin NK, Lincoln YS, eds. Handbook of qualitative research . 2nd ed. Thousand Oaks, CA: Sage, 2000.

Finlay L, Ballinger C, eds. Qualitative research for allied health professionals: challenging choices . Chichester: Wiley, 2006.

Flick U. An introduction to qualitative research . 2nd ed. London: Sage, 2002.

Green J, Thorogood N. Qualitative methods for health research . London: Sage, 2004.

Lingard L, Kennedy TJ. Qualitative research in medical education . Edinburgh: Association for the Study of Medical Education, 2007.

Mauthner M, Birch M, Jessop J, Miller T, eds. Ethics in Qualitative Research . Thousand Oaks, CA: Sage, 2002.

Seale C. The quality of qualitative research . London: Sage, 1999.

Silverman D. Doing qualitative research . Thousand Oaks, CA: Sage, 2000.

Journal articles

Greenhalgh T. How to read a paper: papers that go beyond numbers. BMJ 1997;315:740-3.

Mays N, Pope C. Qualitative research: Rigour and qualitative research. BMJ 1995;311:109-12.

Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ 2000;320:50-2.

Popay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res 1998;8:341-51.

Internet resources

National Health Service Public Health Resource Unit. Critical appraisal skills programme: qualitative research appraisal tool . 2006. www.phru.nhs.uk/Doc_Links/Qualitative%20Appraisal%20Tool.pdf

Cite this as: BMJ 2008;337:a1035

• Related to doi: , 10.1136/bmj.a288
• doi: , 10.1136/bmj.39602.690162.47
• doi: , 10.1136/bmj.a1020
• doi: , 10.1136/bmj.a879
• doi: 10.1136/bmj.a949

This is the last in a series of six articles that aim to help readers to critically appraise the increasing number of qualitative research articles in clinical journals. The series editors are Ayelet Kuper and Scott Reeves.

For a definition of general terms relating to qualitative research, see the first article in this series.

Contributors: AK wrote the first draft of the article and collated comments for subsequent iterations. LL and WL made substantial contributions to the structure and content, provided examples, and gave feedback on successive drafts. AK is the guarantor.

Funding: None.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

• ↵ Holden JD. Hawthorne effects and research into professional practice. J Evaluation Clin Pract 2001 ; 7 : 65 -70. OpenUrl CrossRef PubMed Web of Science
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• ↵ Silverman D. Doing qualitative research . Thousand Oaks, CA: Sage, 2000 .
• ↵ Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ 2000 ; 320 : 50 -2. OpenUrl FREE Full Text
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Rethinking Critical Theory and Qualitative Research

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• Joe L. Kincheloe &
• Peter Mclaren  

Part of the book series: Bold Visions in Educational Research ((BVER,volume 32))

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Some 70 years after its development in Frankfurt, Germany, critical theory retains its ability to disrupt and hallenge the status quo. In the process, it elicits highlycharged emotions of all types—fierce loyalty from its roponents, vehement hostility from its detractors. Such vibrantly polar reactions indicate at the very least that critical theory still matters. We can be against critical theory or for it, but, especially at the present historical uncture, we cannot be without it.

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Introduction: What Is Critical Theory?

Critical Theoretical Concerns

Critical Theory in Social Research: A Theoretical and Methodological Outlook

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Kincheloe, J.L., Mclaren, P. (2011). Rethinking Critical Theory and Qualitative Research. In: Hayes, K., Steinberg, S.R., Tobin, K. (eds) Key Works in Critical Pedagogy. Bold Visions in Educational Research, vol 32. SensePublishers. https://doi.org/10.1007/978-94-6091-397-6_23

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• Volume 25, Issue 1
• Critical appraisal of qualitative research: necessity, partialities and the issue of bias
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• http://orcid.org/0000-0001-5660-8224 Veronika Williams ,
• Anne-Marie Boylan ,
• http://orcid.org/0000-0003-4597-1276 David Nunan
• Nuffield Department of Primary Care Health Sciences , University of Oxford, Radcliffe Observatory Quarter , Oxford , UK
• Correspondence to Dr Veronika Williams, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; veronika.williams{at}phc.ox.ac.uk

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• qualitative research

Introduction

Qualitative evidence allows researchers to analyse human experience and provides useful exploratory insights into experiential matters and meaning, often explaining the ‘how’ and ‘why’. As we have argued previously 1 , qualitative research has an important place within evidence-based healthcare, contributing to among other things policy on patient safety, 2 prescribing, 3 4 and understanding chronic illness. 5 Equally, it offers additional insight into quantitative studies, explaining contextual factors surrounding a successful intervention or why an intervention might have ‘failed’ or ‘succeeded’ where effect sizes cannot. It is for these reasons that the MRC strongly recommends including qualitative evaluations when developing and evaluating complex interventions. 6

Critical appraisal of qualitative research

Is it necessary.

Although the importance of qualitative research to improve health services and care is now increasingly widely supported (discussed in paper 1), the role of appraising the quality of qualitative health research is still debated. 8 10 Despite a large body of literature focusing on appraisal and rigour, 9 11–15 often referred to as ‘trustworthiness’ 16 in qualitative research, there remains debate about how to —and even whether to—critically appraise qualitative research. 8–10 17–19 However, if we are to make a case for qualitative research as integral to evidence-based healthcare, then any argument to omit a crucial element of evidence-based practice is difficult to justify. That being said, simply applying the standards of rigour used to appraise studies based on the positivist paradigm (Positivism depends on quantifiable observations to test hypotheses and assumes that the researcher is independent of the study. Research situated within a positivist paradigm isbased purely on facts and consider the world to be external and objective and is concerned with validity, reliability and generalisability as measures of rigour.) would be misplaced given the different epistemological underpinnings of the two types of data.

Given its scope and its place within health research, the robust and systematic appraisal of qualitative research to assess its trustworthiness is as paramount to its implementation in clinical practice as any other type of research. It is important to appraise different qualitative studies in relation to the specific methodology used because the methodological approach is linked to the ‘outcome’ of the research (eg, theory development, phenomenological understandings and credibility of findings). Moreover, appraisal needs to go beyond merely describing the specific details of the methods used (eg, how data were collected and analysed), with additional focus needed on the overarching research design and its appropriateness in accordance with the study remit and objectives.

Poorly conducted qualitative research has been described as ‘worthless, becomes fiction and loses its utility’. 20 However, without a deep understanding of concepts of quality in qualitative research or at least an appropriate means to assess its quality, good qualitative research also risks being dismissed, particularly in the context of evidence-based healthcare where end users may not be well versed in this paradigm.

How is appraisal currently performed?

Appraising the quality of qualitative research is not a new concept—there are a number of published appraisal tools, frameworks and checklists in existence. 21–23  An important and often overlooked point is the confusion between tools designed for appraising methodological quality and reporting guidelines designed to assess the quality of methods reporting. An example is the Consolidate Criteria for Reporting Qualitative Research (COREQ) 24 checklist, which was designed to provide standards for authors when reporting qualitative research but is often mistaken for a methods appraisal tool. 10

Broadly speaking there are two types of critical appraisal approaches for qualitative research: checklists and frameworks. Checklists have often been criticised for confusing quality in qualitative research with ‘technical fixes’ 21 25 , resulting in the erroneous prioritisation of particular aspects of methodological processes over others (eg, multiple coding and triangulation). It could be argued that a checklist approach adopts the positivist paradigm, where the focus is on objectively assessing ‘quality’ where the assumptions is that the researcher is independent of the research conducted. This may result in the application of quantitative understandings of bias in order to judge aspects of recruitment, sampling, data collection and analysis in qualitative research papers. One of the most widely used appraisal tools is the Critical Appraisal Skills Programme (CASP) 26 and along with the JBI QARI (Joanna Briggs Institute Qualitative Assessment and Assessment Instrument) 27 presents examples which tend to mimic the quantitative approach to appraisal. The CASP qualitative tool follows that of other CASP appraisal tools for quantitative research designs developed in the 1990s. The similarities are therefore unsurprising given the status of qualitative research at that time.

Frameworks focus on the overarching concepts of quality in qualitative research, including transparency, reflexivity, dependability and transferability (see box 1 ). 11–13 15 16 20 28 However, unless the reader is familiar with these concepts—their meaning and impact, and how to interpret them—they will have difficulty applying them when critically appraising a paper.

The main issue concerning currently available checklist and framework appraisal methods is that they take a broad brush approach to ‘qualitative’ research as whole, with few, if any, sufficiently differentiating between the different methodological approaches (eg, Grounded Theory, Interpretative Phenomenology, Discourse Analysis) nor different methods of data collection (interviewing, focus groups and observations). In this sense, it is akin to taking the entire field of ‘quantitative’ study designs and applying a single method or tool for their quality appraisal. In the case of qualitative research, checklists, therefore, offer only a blunt and arguably ineffective tool and potentially promote an incomplete understanding of good ‘quality’ in qualitative research. Likewise, current framework methods do not take into account how concepts differ in their application across the variety of qualitative approaches and, like checklists, they also do not differentiate between different qualitative methodologies.

On the need for specific appraisal tools

Current approaches to the appraisal of the methodological rigour of the differing types of qualitative research converge towards checklists or frameworks. More importantly, the current tools do not explicitly acknowledge the prejudices that may be present in the different types of qualitative research.

Concepts of rigour or trustworthiness within qualitative research 31

Transferability: the extent to which the presented study allows readers to make connections between the study’s data and wider community settings, ie, transfer conceptual findings to other contexts.

Credibility: extent to which a research account is believable and appropriate, particularly in relation to the stories told by participants and the interpretations made by the researcher.

Reflexivity: refers to the researchers’ engagement of continuous examination and explanation of how they have influenced a research project from choosing a research question to sampling, data collection, analysis and interpretation of data.

Transparency: making explicit the whole research process from sampling strategies, data collection to analysis. The rationale for decisions made is as important as the decisions themselves.

However, we often talk about these concepts in general terms, and it might be helpful to give some explicit examples of how the ‘technical processes’ affect these, for example, partialities related to:

Selection: recruiting participants via gatekeepers, such as healthcare professionals or clinicians, who may select them based on whether they believe them to be ‘good’ participants for interviews/focus groups.

Data collection: poor interview guide with closed questions which encourage yes/no answers and/leading questions.

Reflexivity and transparency: where researchers may focus their analysis on preconceived ideas rather than ground their analysis in the data and do not reflect on the impact of this in a transparent way.

The lack of tailored, method-specific appraisal tools has potentially contributed to the poor uptake and use of qualitative research for informing evidence-based decision making. To improve this situation, we propose the need for more robust quality appraisal tools that explicitly encompass both the core design aspects of all qualitative research (sampling/data collection/analysis) but also considered the specific partialities that can be presented with different methodological approaches. Such tools might draw on the strengths of current frameworks and checklists while providing users with sufficient understanding of concepts of rigour in relation to the different types of qualitative methods. We provide an outline of such tools in the third and final paper in this series.

As qualitative research becomes ever more embedded in health science research, and in order for that research to have better impact on healthcare decisions, we need to rethink critical appraisal and develop tools that allow differentiated evaluations of the myriad of qualitative methodological approaches rather than continuing to treat qualitative research as a single unified approach.

• Williams V ,
• Boylan AM ,
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• Brawn R , et al
• Van Royen P ,
• Vermeire E , et al
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• ↵ CASP (Critical Appraisal Skills Programme). date unknown . http://www.phru.nhs.uk/Pages/PHD/CASP.htm .
• ↵ The Joanna Briggs Institute . JBI QARI Critical appraisal checklist for interpretive & critical research . Adelaide : The Joanna Briggs Institute , 2014 .
• Stephens J ,

Contributors VW and DN: conceived the idea for this article. VW: wrote the first draft. AMB and DN: contributed to the final draft. All authors approve the submitted article.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Correction notice This article has been updated since its original publication to include a new reference (reference 1.)

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Critical Issues in Qualitative Research Methods

• Janice M. Morse - University of Utah, USA
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An American Journal of Nursing 1994 Book of the Year

Theoretically rich and stimulating, Critical Issues in Qualitative Research Methods targets matters inherent in qualitative research. It addresses some of the lesser-known or explicated qualitative research methods (such as ethology), the essential concepts of rigor and evaluation, dilemmas in data collection, and issues of scientific misconduct. The various schools of phenomenology and their major characteristics of excellence are described. In addition, ethical issues and concerns of scientific integrity are raised: Which set of ethics should a researcher use? Should one divulge their research purposes? Are there potential risks to informants? Each chapter in this volume deals with a matter that has not yet been resolved or addressed in existing literature. The chapters begin with a joint dialogue in which the contributors raise questions and comment upon the concept presented, thus giving a sense of the ongoing controversy these opinions engender. Critical Issues in Qualitative Research Methods is important reading for advanced students and researchers in all disciplines, especially nursing and allied health.

"Are you looking for ideas and techniques that will enhance the integrity, excellence, and spirit of your qualitative research? If so, this is the book for you. [Here], writers clarify not only theoretical, epistemological, and methodological issues but tackle the sensitivity area of issues of the spirit in qualitative research. Discussions are generally written in a crisp, clear, sometimes serious/sometimes whimsical way. Altogether, this makes for a delightful, rich, readable scholarly work. There were few, if any, chapters that did not provide mw with a fresh way of looking at something or a possible answer to a question that I had been harboring. The whimsical nature of some of the chapters was most refreshing. This is an important book for moving the profession along in its capability for conducting qualitative research."

--Lynne Maxwell, Nursing Research Quarterly

"The direct approach taken by the authors in exploring the soundness of qualitative research makes the book valuable for researchers of any inquiry paradigm. . . . The contribution of this book--and where it succeeds brilliantly--is in raising as many questions as it answers. The authors are not afraid to give voice to what qualitative researchers know but often are reluctant to discuss: That exemplary qualitative research is not merely one set of steps that can be learned from a book and applied by all researchers."

--Theory and Methods

"I believe the book is interesting, varied in content, and of high quality. . . . It is simply a fact that many more nurses are undertaking qualitative research, and while the number and quality of qualitative research publications are increasing, there is still a dearth of high-level discussion in the literature about issues in the process and outcome of the research."

--Kit Chesla, R.N., D.N.Sc., University of California, San Francisco

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• Published: 16 May 2024

Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts

• Jeremy Segrott   ORCID: orcid.org/0000-0001-6215-0870 1 ,
• Sue Channon 2 ,
• Amy Lloyd 4 ,
• Eleni Glarou 2 , 3 ,
• Josie Henley 5 ,
• Jacqueline Hughes 2 ,
• Nina Jacob 2 ,
• Sarah Milosevic 2 ,
• Yvonne Moriarty 2 ,
• Bethan Pell 6 ,
• Mike Robling 2 ,
• Heather Strange 2 ,
• Julia Townson 2 ,
• Qualitative Research Group &
• Lucy Brookes-Howell 2  

Trials volume  25 , Article number:  323 ( 2024 ) Cite this article

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Background/aims

The value of using qualitative methods within clinical trials is widely recognised. How qualitative research is integrated within trials units to achieve this is less clear. This paper describes the process through which qualitative research has been integrated within Cardiff University’s Centre for Trials Research (CTR) in Wales, UK. We highlight facilitators of, and challenges to, integration.

We held group discussions on the work of the Qualitative Research Group (QRG) within CTR. The content of these discussions, materials for a presentation in CTR, and documents relating to the development of the QRG were interpreted at a workshop attended by group members. Normalisation Process Theory (NPT) was used to structure analysis. A writing group prepared a document for input from members of CTR, forming the basis of this paper.

Actions to integrate qualitative research comprised: its inclusion in Centre strategies; formation of a QRG with dedicated funding/roles; embedding of qualitative research within operating systems; capacity building/training; monitoring opportunities to include qualitative methods in studies; maximising the quality of qualitative research and developing methodological innovation. Facilitators of these actions included: the influence of the broader methodological landscape within trial/study design and its promotion of the value of qualitative research; and close physical proximity of CTR qualitative staff/students allowing sharing of methodological approaches. Introduction of innovative qualitative methods generated interest among other staff groups. Challenges included: pressure to under-resource qualitative components of research, preference for a statistical stance historically in some research areas and funding structures, and difficulties faced by qualitative researchers carving out individual academic profiles when working across trials/studies.

Conclusions

Given that CTUs are pivotal to the design and conduct of RCTs and related study types across multiple disciplines, integrating qualitative research into trials units is crucial if its contribution is to be fully realised. We have made explicit one trials unit’s experience of embedding qualitative research and present this to open dialogue on ways to operationalise and optimise qualitative research in trials. NPT provides a valuable framework with which to theorise these processes, including the importance of sense-making and legitimisation when introducing new practices within organisations.

Peer Review reports

The value of using qualitative methods within randomised control trials (RCTs) is widely recognised [ 1 , 2 , 3 ]. Qualitative research generates important evidence on factors affecting trial recruitment/retention [ 4 ] and implementation, aiding interpretation of quantitative data [ 5 ]. Though RCTs have traditionally been viewed as sitting within a positivist paradigm, recent methodological innovations have developed new trial designs that draw explicitly on both quantitative and qualitative methods. For instance, in the field of complex public health interventions, realist RCTs seek to understand the mechanisms through which interventions generate hypothesised impacts, and how interactions across different implementation contexts form part of these mechanisms. Proponents of realist RCTs—which integrate experimental and realist paradigms—highlight the importance of using quantitative and qualitative methods to fully realise these aims and to generate an understanding of intervention mechanisms and how context shapes them [ 6 ].

A need for guidance on how to conduct good quality qualitative research is being addressed, particularly in relation to feasibility studies for RCTs [ 7 ] and process evaluations embedded within trials of complex interventions [ 5 ]. There is also guidance on the conduct of qualitative research within trials at different points in the research cycle, including development, conduct and reporting [ 8 , 9 ].

A high proportion of trials are based within or involve clinical trials units (CTUs). In the UK the UKCRC Registered CTU Network describes them as:

… specialist units which have been set up with a specific remit to design, conduct, analyse and publish clinical trials and other well-designed studies. They have the capability to provide specialist expert statistical, epidemiological, and other methodological advice and coordination to undertake successful clinical trials. In addition, most CTUs will have expertise in the coordination of trials involving investigational medicinal products which must be conducted in compliance with the UK Regulations governing the conduct of clinical trials resulting from the EU Directive for Clinical Trials.

Thus, CTUs provide the specialist methodological expertise needed for the conduct of trials, and in the case of trials of investigational medicinal products, their involvement may be mandated to ensure compliance with relevant regulations. As the definition above suggests, CTUs also conduct and support other types of study apart from RCTs, providing a range of methodological and subject-based expertise.

However, despite their central role in the conduct and design of trials, (and other evaluation designs) little has been written about how CTUs have integrated qualitative work within their organisation at a time when such methods are, as stated above, now recognised as an important aspect of RCTs and evaluation studies more generally. This is a significant gap, since integration at the organisational level arguably shapes how qualitative research is integrated within individual studies, and thus it is valuable to understand how CTUs have approached the task. There are different ways of involving qualitative work in trials units, such as partnering with other departments (e.g. social science) or employing qualitative researchers directly. Qualitative research can be imagined and configured in different ways—as a method that generates data to inform future trial and intervention design, as an embedded component within an RCT or other evaluation type, or as a parallel strand of research focusing on lived experiences of illness, for instance. Understanding how trials units have integrated qualitative research is valuable, as it can shed light on which strategies show promise, and in which contexts, and how qualitative research is positioned within the field of trials research, foregrounding the value of qualitative research. However, although much has been written about its use within trials, few accounts exist of how trials units have integrated qualitative research within their systems and structures.

This paper discusses the process of embedding qualitative research within the work of one CTU—Cardiff University’s Centre for Trials Research (CTR). It highlights facilitators of this process and identifies challenges to integration. We use the Normalisation Process Theory (NPT) as a framework to structure our experience and approach. The key gap addressed by this paper is the implementation of strategies to integrate qualitative research (a relatively newly adopted set of practices and processes) within CTU systems and structures. We acknowledge from the outset that there are multiple ways of approaching this task. What follows therefore is not a set of recommendations for a preferred or best way to integrate qualitative research, as this will comprise diverse actions according to specific contexts. Rather, we examine the processes through which integration occurred in our own setting and highlight the potential value of these insights for others engaged in the work of promoting qualitative research within trials units.

Background to the integration of qualitative research within CTR

The CTR was formed in 2015 [ 10 ]. It brought together three existing trials units at Cardiff University: the South East Wales Trials Unit, the Wales Cancer Trials Unit, and the Haematology Clinical Trials Unit. From its inception, the CTR had a stated aim of developing a programme of qualitative research and integrating it within trials and other studies. In the sections below, we map these approaches onto the framework offered by Normalisation Process Theory to understand the processes through which they helped achieve embedding and integration of qualitative research.

CTR’s aims (including those relating to the development of qualitative research) were included within its strategy documents and communicated to others through infrastructure funding applications, annual reports and its website. A Qualitative Research Group (QRG), which had previously existed within the South East Wales Trials Unit, with dedicated funding for methodological specialists and group lead academics, was a key mechanism through which the development of a qualitative portfolio was put into action. Integration of qualitative research within Centre systems and processes occurred through the inclusion of qualitative research in study adoption processes and representation on committees. The CTR’s study portfolio provided a basis to track qualitative methods in new and existing studies, identify opportunities to embed qualitative methods within recently adopted studies (at the funding application stage) and to manage staff resources. Capacity building and training were an important focus of the QRG’s work, including training courses, mentoring, creation of an academic network open to university staff and practitioners working in the field of healthcare, presentations at CTR staff meetings and securing of PhD studentships. Standard operating procedures and methodological guidance on the design and conduct of qualitative research (e.g. templates for developing analysis plans) aimed to create a shared understanding of how to undertake high-quality research, and a means to monitor the implementation of rigorous approaches. As the QRG expanded its expertise it sought to develop innovative approaches, including the use of visual [ 11 ] and ethnographic methods [ 12 ].

Understanding implementation—Normalisation Process Theory (NPT)

Normalisation Process Theory (NPT) provides a model with which to understand the implementation of new sets of practices and their normalisation within organisational settings. The term ‘normalisation’ refers to how new practices become routinised (part of the everyday work of an organisation) through embedding and integration [ 13 , 14 ]. NPT defines implementation as ‘the social organisation of work’ and is concerned with the social processes that take place as new practices are introduced. Embedding involves ‘making practices routine elements of everyday life’ within an organisation. Integration takes the form of ‘sustaining embedded practices in social contexts’, and how these processes lead to the practices becoming (or not becoming) ‘normal and routine’ [ 14 ]. NPT is concerned with the factors which promote or ‘inhibit’ attempts to embed and integrate the operationalisation of new practices [ 13 , 14 , 15 ].

Embedding new practices is therefore achieved through implementation—which takes the form of interactions in specific contexts. Implementation is operationalised through four ‘generative mechanisms’— coherence , cognitive participation , collective action and reflexive monitoring [ 14 ]. Each mechanism is characterised by components comprising immediate and organisational work, with actions of individuals and organisations (or groups of individuals) interdependent. The mechanisms operate partly through forms of investment (i.e. meaning, commitment, effort, and comprehension) [ 14 ].

Coherence refers to how individuals/groups make sense of, and give meaning to, new practices. Sense-making concerns the coherence of a practice—whether it ‘holds together’, and its differentiation from existing activities [ 15 ]. Communal and individual specification involve understanding new practices and their potential benefits for oneself or an organisation. Individuals consider what new practices mean for them in terms of tasks and responsibilities ( internalisation ) [ 14 ].

NPT frames the second mechanism, cognitive participation , as the building of a ‘community of practice’. For a new practice to be initiated, individuals and groups within an organisation must commit to it [ 14 , 15 ]. Cognitive participation occurs through enrolment —how people relate to the new practice; legitimation —the belief that it is right for them to be involved; and activation —defining which actions are necessary to sustain the practice and their involvement [ 14 ]. Making the new practices work may require changes to roles (new responsibilities, altered procedures) and reconfiguring how colleagues work together (changed relationships).

Third, Collective Action refers to ‘the operational work that people do to enact a set of practices’ [ 14 ]. Individuals engage with the new practices ( interactional workability ) reshaping how members of an organisation interact with each other, through creation of new roles and expectations ( relational interaction ) [ 15 ]. Skill set workability concerns how the work of implementing a new set of practices is distributed and the necessary roles and skillsets defined [ 14 ]. Contextual integration draws attention to the incorporation of a practice within social contexts, and the potential for aspects of these contexts, such as systems and procedures, to be modified as a result [ 15 ].

Reflexive monitoring is the final implementation mechanism. Collective and individual appraisal evaluate the value of a set of practices, which depends on the collection of information—formally and informally ( systematisation ). Appraisal may lead to reconfiguration in which procedures of the practice are redefined or reshaped [ 14 , 15 ].

We sought to map the following: (1) the strategies used to embed qualitative research within the Centre, (2) key facilitators, and (3) barriers to their implementation. Through focused group discussions during the monthly meetings of the CTR QRG and in discussion with the CTR senior management team throughout 2019–2020 we identified nine types of documents (22 individual documents in total) produced within the CTR which had relevant information about the integration of qualitative research within its work (Table  1 ). The QRG had an ‘open door’ policy to membership and welcomed all staff/students with an interest in qualitative research. It included researchers who were employed specifically to undertake qualitative research and other staff with a range of study roles, including trial managers, statisticians, and data managers. There was also diversity in terms of career stage, including PhD students, mid-career researchers and members of the Centre’s Executive team. Membership was therefore largely self-selected, and comprised of individuals with a role related to, or an interest in, embedding qualitative research within trials. However, the group brought together diverse methodological perspectives and was not solely comprised of methodological ‘champions’ whose job it was to promote the development of qualitative research within the centre. Thus whilst the group (and by extension, the authors of this paper) had a shared appreciation of the value of qualitative research within a trials centre, they also brought varied methodological perspectives and ways of engaging with it.

All members of the QRG ( n  = 26) were invited to take part in a face-to-face, day-long workshop in February 2019 on ‘How to optimise and operationalise qualitative research in trials: reflections on CTR structure’. The workshop was attended by 12 members of staff and PhD students, including members of the QRG and the CTR’s senior management team. Recruitment to the workshop was therefore inclusive, and to some extent opportunistic, but all members of the QRG were able to contribute to discussions during regular monthly group meetings and the drafting of the current paper.

The aim of the workshop was to bring together information from the documents in Table  1 to generate discussion around the key strategies (and their component activities) that had been adopted to integrate qualitative research into CTR, as well as barriers to, and facilitators of, their implementation. The agenda for the workshop involved four key areas: development and history of the CTR model; mapping the current model within CTR; discussing the structure of other CTUs; and exploring the advantages and disadvantages of the CTR model.

During the workshop, we discussed the use of NPT to conceptualise how qualitative research had been embedded within CTR’s systems and practices. The group produced spider diagrams to map strategies and actions on to the four key domains (or ‘generative mechanisms’ of NPT) summarised above, to aid the understanding of how they had functioned, and the utility of NPT as a framework. This is summarised in Table  2 .

Detailed notes were made during the workshop. A core writing group then used these notes and the documents in Table  1 to develop a draft of the current paper. This was circulated to all members of the CTR QRG ( n  = 26) and stored within a central repository accessible to them to allow involvement and incorporate the views of those who were not able to attend the workshop. This draft was again presented for comments in the monthly CTR QRG meeting in February 2021 attended by n  = 10. The Standards for QUality Improvement Reporting Excellence 2.0 (SQUIRE) guidelines were used to inform the structure and content of the paper (see supplementary material) [ 16 ].

In the following sections, we describe the strategies CTR adopted to integrate qualitative research. These are mapped against NPT’s four generative mechanisms to explore the processes through which the strategies promoted integration, and facilitators of and barriers to their implementation. A summary of the strategies and their functioning in terms of the generative mechanisms is provided in Table  2 .

Coherence—making sense of qualitative research

In CTR, many of the actions taken to build a portfolio of qualitative research were aimed at enabling colleagues, and external actors, to make sense of this set of methodologies. Centre-level strategies and grant applications for infrastructure funding highlighted the value of qualitative research, the added benefits it would bring, and positioned it as a legitimate set of practices alongside existing methods. For example, a 2014 application for renewal of trials unit infrastructure funding stated:

We are currently in the process of undertaking […] restructuring for our qualitative research team and are planning similar for trial management next year. The aim of this restructuring is to establish greater hierarchical management and opportunities for staff development and also provide a structure that can accommodate continuing growth.

Within the CTR, various forms of communication on the development of qualitative research were designed to enable staff and students to make sense of it, and to think through its potential value for them, and ways in which they might engage with it. These included presentations at staff meetings, informal meetings between project teams and the qualitative group lead, and the visibility of qualitative research on the public-facing Centre website and Centre committees and systems. For instance, qualitative methods were included (and framed as a distinct set of practices) within study adoption forms and committee agendas. Information for colleagues described how qualitative methods could be incorporated within funding applications for RCTs and other evaluation studies to generate new insights into questions research teams were already keen to answer, such as influences on intervention implementation fidelity. Where externally based chief investigators approached the Centre to be involved in new grant applications, the existence of the qualitative team and group lead enabled the inclusion of qualitative research to be actively promoted at an early stage, and such opportunities were highlighted in the Centre’s brochure for new collaborators. Monthly qualitative research network meetings—advertised across CTR and to external research collaborators, were also designed to create a shared understanding of qualitative research methods and their utility within trials and other study types (e.g. intervention development, feasibility studies, and observational studies). Training events (discussed in more detail below) also aided sense-making.

Several factors facilitated the promotion of qualitative research as a distinctive and valuable entity. Among these was the influence of the broader methodological landscape within trial design which was promoting the value of qualitative research, such as guidance on the evaluation of complex interventions by the Medical Research Council [ 17 ], and the growing emphasis placed on process evaluations within trials (with qualitative methods important in understanding participant experience and influences on implementation) [ 5 ]. The attention given to lived experience (both through process evaluations and the move to embed public involvement in trials) helped to frame qualitative research within the Centre as something that was appropriate, legitimate, and of value. Recognition by research funders of the value of qualitative research within studies was also helpful in normalising and legitimising its adoption within grant applications.

The inclusion of qualitative methods within influential methodological guidance helped CTR researchers to develop a ‘shared language’ around these methods, and a way that a common understanding of the role of qualitative research could be generated. One barrier to such sense-making work was the varying extent to which staff and teams had existing knowledge or experience of qualitative research. This varied across methodological and subject groups within the Centre and reflected the history of the individual trials units which had merged to form the Centre.

Cognitive participation—legitimising qualitative research

Senior CTR leaders promoted the value and legitimacy of qualitative research. Its inclusion in centre strategies, infrastructure funding applications, and in public-facing materials (e.g. website, investigator brochures), signalled that it was appropriate for individuals to conduct qualitative research within their roles, or to support others in doing so. Legitimisation also took place through informal channels, such as senior leadership support for qualitative research methods in staff meetings and participation in QRG seminars. Continued development of the QRG (with dedicated infrastructure funding) provided a visible identity and equivalence with other methodological groups (e.g. trial managers, statisticians).

Staff were asked to engage with qualitative research in two main ways. First, there was an expansion in the number of staff for whom qualitative research formed part of their formal role and responsibilities. One of the three trials units that merged to form CTR brought with it a qualitative team comprising methodological specialists and a group lead. CTR continued the expansion of this group with the creation of new roles and an enlarged nucleus of researchers for whom qualitative research was the sole focus of their work. In part, this was linked to the successful award of projects that included a large qualitative component, and that were coordinated by CTR (see Table  3 which describes the PUMA study).

Members of the QRG were encouraged to develop their own research ideas and to gain experience as principal investigators, and group seminars were used to explore new ideas and provide peer support. This was communicated through line management, appraisal, and informal peer interaction. Boundaries were not strictly demarcated (i.e. staff located outside the qualitative team were already using qualitative methods), but the new team became a central focus for developing a growing programme of work.

Second, individuals and studies were called upon to engage in new ways with qualitative research, and with the qualitative team. A key goal for the Centre was that groups developing new research ideas should give more consideration in general to the potential value and inclusion of qualitative research within their funding applications. Specifically, they were asked to do this by thinking about qualitative research at an early point in their application’s development (rather than ‘bolting it on’ after other elements had been designed) and to draw upon the expertise and input of the qualitative team. An example was the inclusion of questions on qualitative methods within the Centre’s study adoption form and representation from the qualitative team at the committee which reviewed new adoption requests. Where adoption requests indicated the inclusion of qualitative methods, colleagues were encouraged to liaise with the qualitative team, facilitating the integration of its expertise from an early stage. Qualitative seminars offered an informal and supportive space in which researchers could share initial ideas and refine their methodological approach. The benefits of this included the provision of sufficient time for methodological specialists to be involved in the design of the proposed qualitative component and ensuring adequate costings had been drawn up. At study adoption group meetings, scrutiny of new proposals included consideration of whether new research proposals might be strengthened through the use of qualitative methods where these had not initially been included. Meetings of the QRG—which reviewed the Centre’s portfolio of new studies and gathered intelligence on new ideas—also helped to identify, early on, opportunities to integrate qualitative methods. Communication across teams was useful in identifying new research ideas and embedding qualitative researchers within emerging study development groups.

Actions to promote greater use of qualitative methods in funding applications fed through into a growing number of studies with a qualitative component. This helped to increase the visibility and legitimacy of qualitative methods within the Centre. For example, the PUMA study [ 12 ], which brought together a large multidisciplinary team to develop and evaluate a Paediatric early warning system, drew heavily on qualitative methods, with the qualitative research located within the QRG. The project introduced an extensive network of collaborators and clinical colleagues to qualitative methods and how they could be used during intervention development and the generation of case studies. Further information about the PUMA study is provided in Table  3 .

Increasing the legitimacy of qualitative work across an extensive network of staff, students and collaborators was a complex process. Set within the continuing dominance of quantitative methods with clinical trials, there were variations in the extent to which clinicians and other collaborators embraced the value of qualitative methods. Research funding schemes, which often continued to emphasise the quantitative element of randomised controlled trials, inevitably fed through into the focus of new research proposals. Staff and external collaborators were sometimes uncertain about the added value that qualitative methods would bring to their trials. Across the CTR there were variations in the speed at which qualitative research methods gained legitimacy, partly based on disciplinary traditions and their influences. For instance, population health trials, often located within non-health settings such as schools or community settings, frequently involved collaboration with social scientists who brought with them experience in qualitative methods. Methodological guidance in this field, such as MRC guidance on process evaluations, highlighted the value of qualitative methods and alternatives to the positivist paradigm, such as the value of realist RCTs. In other, more clinical areas, positivist paradigms had greater dominance. Established practices and methodological traditions across different funders also influenced the ease of obtaining funding to include qualitative research within studies. For drugs trials (CTIMPs), the influence of regulatory frameworks on study design, data collection and the allocation of staff resources may have played a role. Over time, teams gained repeated experience of embedding qualitative research (and researchers) within their work and took this learning with them to subsequent studies. For example, the senior clinician quoted within the PUMA case study (Table  3 below) described how they had gained an appreciation of the rigour of qualitative research and an understanding of its language. Through these repeated interactions, embedding of qualitative research within studies started to become the norm rather than the exception.

Collective action—operationalising qualitative research

Collective action concerns the operationalisation of new practices within organisations—the allocation and management of the work, how individuals interact with each other, and the work itself. In CTR the formation of a Qualitative Research Group helped to allocate and organise the work of building a portfolio of studies. Researchers across the Centre were called upon to interact with qualitative research in new ways. Presentations at staff meetings and the inclusion of qualitative research methods in portfolio study adoption forms were examples of this ( interactive workability ). It was operationalised by encouraging study teams to liaise with the qualitative research lead. Development of standard operating procedures, templates for costing qualitative research and methodological guidance (e.g. on analysis plans) also helped encourage researchers to interact with these methods in new ways. For some qualitative researchers who had been trained in the social sciences, working within a trials unit meant that they needed to interact in new and sometimes unfamiliar ways with standard operating procedures, risk assessments, and other trial-based systems. Thus, training needs and capacity-building efforts were multidirectional.

Whereas there had been a tendency for qualitative research to be ‘bolted on’ to proposals for RCTs, the systems described above were designed to embed thinking about the value and design of the qualitative component from the outset. They were also intended to integrate members of the qualitative team with trial teams from an early stage to promote effective integration of qualitative methods within larger trials and build relationships over time.

Standard Operating Procedures (SOPs), formal and informal training, and interaction between the qualitative team and other researchers increased the relational workability of qualitative methods within the Centre—the confidence individuals felt in including these methods within their studies, and their accountability for doing so. For instance, study adoption forms prompted researchers to interact routinely with the qualitative team at an early stage, whilst guidance on costing grants provided clear expectations about the resources needed to deliver a proposed set of qualitative data collection.

Formation of the Qualitative Research Group—comprised of methodological specialists, created new roles and skillsets ( skill set workability ). Research teams were encouraged to draw on these when writing funding applications for projects that included a qualitative component. Capacity-building initiatives were used to increase the number of researchers with the skills needed to undertake qualitative research, and for these individuals to develop their expertise over time. This was achieved through formal training courses, academic seminars, mentoring from experienced colleagues, and informal knowledge exchange. Links with external collaborators and centres engaged in building qualitative research supported these efforts. Within the Centre, the co-location of qualitative researchers with other methodological and trial teams facilitated knowledge exchange and building of collaborative relationships, whilst grouping of the qualitative team within a dedicated office space supported a collective identity and opportunities for informal peer support.

Some aspects of the context in which qualitative research was being developed created challenges to operationalisation. Dependence on project grants to fund qualitative methodologists meant that there was a continuing need to write further grant applications whilst limiting the amount of time available to do so. Similarly, researchers within the team whose role was funded largely by specific research projects could sometimes find it hard to create sufficient time to develop their personal methodological interests. However, the cultivation of a methodologically varied portfolio of work enabled members of the team to build significant expertise in different approaches (e.g. ethnography, discourse analysis) that connected individual studies.

Reflexive monitoring—evaluating the impact of qualitative research

Inclusion of questions/fields relating to qualitative research within the Centre’s study portfolio database was a key way in which information was collected ( systematisation ). It captured numbers of funding applications and funded studies, research design, and income generation. Alongside this database, a qualitative resource planner spreadsheet was used to link individual members of the qualitative team with projects and facilitate resource planning, further reinforcing the core responsibilities and roles of qualitative researchers within CTR. As with all staff in the Centre, members of the qualitative team were placed on ongoing rather than fixed-term contracts, reflecting their core role within CTR. Planning and strategy meetings used the database and resource planner to assess the integration of qualitative research within Centre research, identify opportunities for increasing involvement, and manage staff recruitment and sustainability of researcher posts. Academic meetings and day-to-day interaction fulfilled informal appraisal of the development of the group, and its position within the Centre. Individual appraisal was also important, with members of the qualitative team given opportunities to shape their role, reflect on progress, identify training needs, and further develop their skillset, particularly through line management systems.

These forms of systematisation and appraisal were used to reconfigure the development of qualitative research and its integration within the Centre. For example, group strategies considered how to achieve long-term integration of qualitative research from its initial embedding through further promoting the belief that it formed a core part of the Centre’s business. The visibility and legitimacy of qualitative research were promoted through initiatives such as greater prominence on the Centre’s website. Ongoing review of the qualitative portfolio and discussion at academic meetings enabled the identification of areas where increased capacity would be helpful, both for qualitative staff, and more broadly within the Centre. This prompted the qualitative group to develop an introductory course to qualitative methods open to all Centre staff and PhD students, aimed at increasing understanding and awareness. As the qualitative team built its expertise and experience it also sought to develop new and innovative approaches to conducting qualitative research. This included the use of visual and diary-based methods [ 11 ] and the adoption of ethnography to evaluate system-level clinical interventions [ 12 ]. Restrictions on conventional face-to-face qualitative data collection due to the COVID-19 pandemic prompted rapid adoption of virtual/online methods for interviews, observation, and use of new internet platforms such as Padlet—a form of digital note board.

In this paper, we have described the work undertaken by one CTU to integrate qualitative research within its studies and organisational culture. The parallel efforts of many trials units to achieve these goals arguably come at an opportune time. The traditional designs of RCTs have been challenged and re-imagined by the increasing influence of realist evaluation [ 6 , 18 ] and the widespread acceptance that trials need to understand implementation and intervention theory as well as assess outcomes [ 17 ]. Hence the widespread adoption of embedded mixed methods process evaluations within RCTs. These broad shifts in methodological orthodoxies, the production of high-profile methodological guidance, and the expectations of research funders all create fertile ground for the continued expansion of qualitative methods within trials units. However, whilst much has been written about the importance of developing qualitative research and the possible approaches to integrating qualitative and quantitative methods within studies, much less has been published on how to operationalise this within trials units. Filling this lacuna is important. Our paper highlights how the integration of a new set of practices within an organisation can become embedded as part of its ‘normal’ everyday work whilst also shaping the practices being integrated. In the case of CTR, it could be argued that the integration of qualitative research helped shape how this work was done (e.g. systems to assess progress and innovation).

In our trials unit, the presence of a dedicated research group of methodological specialists was a key action that helped realise the development of a portfolio of qualitative research and was perhaps the most visible evidence of a commitment to do so. However, our experience demonstrates that to fully realise the goal of developing qualitative research, much work focuses on the interaction between this ‘new’ set of methods and the organisation into which it is introduced. Whilst the team of methodological specialists was tasked with, and ‘able’ to do the work, the ‘work’ itself needed to be integrated and embedded within the existing system. Thus, alongside the creation of a team and methodological capacity, promoting the legitimacy of qualitative research was important to communicate to others that it was both a distinctive and different entity, yet similar and equivalent to more established groups and practices (e.g. trial management, statistics, data management). The framing of qualitative research within strategies, the messages given out by senior leaders (formally and informally) and the general visibility of qualitative research within the system all helped to achieve this.

Normalisation Process Theory draws our attention to the concepts of embedding (making a new practice routine, normal within an organisation) and integration —the long-term sustaining of these processes. An important process through which embedding took place in our centre concerned the creation of messages and systems that called upon individuals and research teams to interact with qualitative research. Research teams were encouraged to think about qualitative research and consider its potential value for their studies. Critically, they were asked to do so at specific points, and in particular ways. Early consideration of qualitative methods to maximise and optimise their inclusion within studies was emphasised, with timely input from the qualitative team. Study adoption systems, centre-level processes for managing financial and human resources, creation of a qualitative resource planner, and awareness raising among staff, helped to reinforce this. These processes of embedding and integration were complex and they varied in intensity and speed across different areas of the Centre’s work. In part this depended on existing research traditions, the extent of prior experience of working with qualitative researchers and methods, and the priorities of subject areas and funders. Centre-wide systems, sometimes linked to CTR’s operation as a CTU, also helped to legitimise and embed qualitative research, lending it equivalence with other research activity. For example, like all CTUs, CTR was required to conform with the principles of Good Clinical Practice, necessitating the creation of a quality management system, operationalised through standard operating procedures for all areas of its work. Qualitative research was included, and became embedded, within these systems, with SOPs produced to guide activities such as qualitative analysis.

NPT provides a helpful way of understanding how trials units might integrate qualitative research within their work. It highlights how new practices interact with existing organisational systems and the work needed to promote effective interaction. That is, alongside the creation of a team or programme of qualitative research, much of the work concerns how members of an organisation understand it, engage with it, and create systems to sustain it. Embedding a new set of practices may be just as important as the quality or characteristics of the practices themselves. High-quality qualitative research is of little value if it is not recognised and drawn upon within new studies for instance. NPT also offers a helpful lens with which to understand how integration and embedding occur, and the mechanisms through which they operate. For example, promoting the legitimacy of a new set of practices, or creating systems that embed it, can help sustain these practices by creating an organisational ambition and encouraging (or requiring) individuals to interact with them in certain ways, redefining their roles accordingly. NPT highlights the ways in which integration of new practices involves bi-directional exchanges with the organisation’s existing practices, with each having the potential to re-shape the other as interaction takes place. For instance, in CTR, qualitative researchers needed to integrate and apply their methods within the quality management and other systems of a CTU, such as the formalisation of key processes within standard operating procedures, something less likely to occur outside trials units. Equally, project teams (including those led by externally based chief investigators) increased the integration of qualitative methods within their overall study design, providing opportunities for new insights on intervention theory, implementation and the experiences of practitioners and participants.

We note two aspects of the normalisation processes within CTR that are slightly less well conceptualised by NPT. The first concerns the emphasis within coherence on identifying the distinctiveness of new practices, and how they differ from existing activities. Whilst differentiation was an important aspect of the integration of qualitative research in CTR, such integration could be seen as operating partly through processes of de-differentiation, or at least equivalence. That is, part of the integration of qualitative research was to see it as similar in terms of rigour, coherence, and importance to other forms of research within the Centre. To be viewed as similar, or at least comparable to existing practices, was to be legitimised.

Second, whilst NPT focuses mainly on the interaction between a new set of practices and the organisational context into which it is introduced, our own experience of introducing qualitative research into a trials unit was shaped by broader organisational and methodological contexts. For example, the increasing emphasis placed upon understanding implementation processes and the experiences of research participants in the field of clinical trials (e.g. by funders), created an environment conducive to the development of qualitative research methods within our Centre. Attempts to integrate qualitative research within studies were also cross-organisational, given that many of the studies managed within the CTR drew together multi-institutional teams. This provided important opportunities to integrate qualitative research within a portfolio of studies that extended beyond CTR and build a network of collaborators who increasingly included qualitative methods within their funding proposals. The work of growing and integrating qualitative research within a trials unit is an ongoing one in which ever-shifting macro-level influences can help or hinder, and where the organisations within which we work are never static in terms of barriers and facilitators.

The importance of utilising qualitative methods within RCTs is now widely recognised. Increased emphasis on the evaluation of complex interventions, the influence of realist methods directing greater attention to complexity and the widespread adoption of mixed methods process evaluations are key drivers of this shift. The inclusion of qualitative methods within individual trials is important and previous research has explored approaches to their incorporation and some of the challenges encountered. Our paper highlights that the integration of qualitative methods at the organisational level of the CTU can shape how they are taken up by individual trials. Within CTR, it can be argued that qualitative research achieved high levels of integration, as conceptualised by Normalisation Process Theory. Thus, qualitative research became recognised as a coherent and valuable set of practices, secured legitimisation as an appropriate focus of individual and organisational activity and benefitted from forms of collective action which operationalised these organisational processes. Crucially, the routinisation of qualitative research appeared to be sustained, something which NPT suggests helps define integration (as opposed to initial embedding). However, our analysis suggested that the degree of integration varied by trial area. This variation reflected a complex mix of factors including disciplinary traditions, methodological guidance, existing (un)familiarity with qualitative research, and the influence of regulatory frameworks for certain clinical trials.

NPT provides a valuable framework with which to understand how these processes of embedding and integration occur. Our use of NPT draws attention to the importance of sense-making and legitimisation as important steps in introducing a new set of practices within the work of an organisation. Integration also depends, across each mechanism of NPT, on the building of effective relationships, which allow individuals and teams to work together in new ways. By reflecting on our experiences and the decisions taken within CTR we have made explicit one such process for embedding qualitative research within a trials unit, whilst acknowledging that approaches may differ across trials units. Mindful of this fact, and the focus of the current paper on one trials unit’s experience, we do not propose a set of recommendations for others who are working to achieve similar goals. Rather, we offer three overarching reflections (framed by NPT) which may act as a useful starting point for trials units (and other infrastructures) seeking to promote the adoption of qualitative research.

First, whilst research organisations such as trials units are highly heterogenous, processes of embedding and integration, which we have foregrounded in this paper, are likely to be important across different contexts in sustaining the use of qualitative research. Second, developing a plan for the integration of qualitative research will benefit from mapping out the characteristics of the extant system. For example, it is valuable to know how familiar staff are with qualitative research and any variations across teams within an organisation. Thirdly, NPT frames integration as a process of implementation which operates through key generative mechanisms— coherence , cognitive participation , collective action and reflexive monitoring . These mechanisms can help guide understanding of which actions help achieve embedding and integration. Importantly, they span multiple aspects of how organisations, and the individuals within them, work. The ways in which people make sense of a new set of practices ( coherence ), their commitment towards it ( cognitive participation ), how it is operationalised ( collective action ) and the evaluation of its introduction ( reflexive monitoring ) are all important. Thus, for example, qualitative research, even when well organised and operationalised within an organisation, is unlikely to be sustained if appreciation of its value is limited, or people are not committed to it.

We present our experience of engaging with the processes described above to open dialogue with other trials units on ways to operationalise and optimise qualitative research in trials. Understanding how best to integrate qualitative research within these settings may help to fully realise the significant contribution which it makes the design and conduct of trials.

Availability of data and materials

Some documents cited in this paper are either freely available from the Centre for Trials Research website or can be requested from the author for correspondence.

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Acknowledgements

Members of the Centre for Trials Research (CTR) Qualitative Research Group were collaborating authors: C Drew (Senior Research Fellow—Senior Trial Manager, Brain Health and Mental Wellbeing Division), D Gillespie (Director, Infection, Inflammation and Immunity Trials, Principal Research Fellow), R Hale (now Research Associate, School of Social Sciences, Cardiff University), J Latchem-Hastings (now Lecturer and Postdoctoral Fellow, School of Healthcare Sciences, Cardiff University), R Milton (Research Associate—Trial Manager), B Pell (now PhD student, DECIPHer Centre, Cardiff University), H Prout (Research Associate—Qualitative), V Shepherd (Senior Research Fellow), K Smallman (Research Associate), H Stanton (Research Associate—Senior Data Manager). Thanks are due to Kerry Hood and Aimee Grant for their involvement in developing processes and systems for qualitative research within CTR.

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Segrott, J., Channon, S., Lloyd, A. et al. Integrating qualitative research within a clinical trials unit: developing strategies and understanding their implementation in contexts. Trials 25 , 323 (2024). https://doi.org/10.1186/s13063-024-08124-7

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The methodological integrity of critical qualitative research: Principles to support design and research review

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• DOI: 10.1037/cou0000523

This article articulates principles and practices that support methodological integrity in relation to critical qualitative research. We begin by describing 2 changes that have occurred in psychological methods over the last 15 years. (a) Building on foundational work advocating for epistemological pluralism, guidelines on how to design, review, and report qualitative and mixed methods have been advanced to support methodological integrity in keeping with a diversity of researchers' aims and approaches. (b) There has been an increased use of critical epistemological perspectives and critical methods. In light of these changes, the current article puts forward principles to support critical qualitative researchers when considering methodological rigor and when formulating rationales to support their methods in the journal article review process. Illustrating the principles with an example of critical research, the article describes common problems and issues in the research design process that can be considered in order to strengthen the returns of critical studies. Recommendations are made for editors and reviewers on how to conduct reviews of critical qualitative research, and pressing concerns for publishing critical qualitative research are detailed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

• Qualitative Research*
• Research Design*
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• Review Literature as Topic

• Study Protocol
• Open access
• Published: 30 May 2024

Person-centred care and the work-related health and job satisfaction of health and social care professionals: protocol for a prospective longitudinal cohort study combined with qualitative studies (the PCC@Work project)

• Cornelia van Diepen 1 , 2 ,
• Qarin Lood 2 , 3 , 4 ,
• Kristoffer Gustavsson 2 , 5 ,
• Malin Axelsson 6 ,
• Monica Bertilsson 7 ,
• Gunnel Hensing 7 &
• Andreas Fors 2 , 5 , 8  

BMC Health Services Research volume  24 , Article number:  683 ( 2024 ) Cite this article

Metrics details

The interplay of ethical stress, heavy workloads, and job dissatisfaction poses challenges to both the recruitment and retention of health and social care professionals. Person-centred care, rooted in ethical principles, involves collaborative care, and is expected to improve care and job satisfaction. However, prior research on the impact of person-centred care practices on professionals’ work-related health and job satisfaction has yielded mixed results, and most studies emanate from residential care. Understanding how person-centred care practices influence health and social care professionals across different care settings thus requires further exploration through rigorous methodology. The overall aim of PCC@Work is to follow, describe, assess, and explore the impact of person-centred care practices in hospital wards, primary care centres and municipal care on health and social care professionals’ work-related health and job satisfaction.

PCC@Work is designed as a prospective, longitudinal cohort study combined with qualitative studies. A web-based questionnaire will be distributed on five occasions within two years to health and social care professionals in the three care settings. In addition, focus groups and interviews will be conducted with a selection of health and social care professionals to explore their experiences of work-related health and job satisfaction in relation to person-centred practices.

PCC@Work will highlight some of the knowledge gaps on the impact of person-centred care practices regarding work-related health and job satisfaction of health and social care professionals. The uniqueness of the project lies in the multi-method design, combining a prospective longitudinal cohort study with qualitative studies, and the involvement of various professions and settings. This means we will be able to provide a comprehensive and representative understanding of person-centred care practices as a critical component for effective change in the working conditions of health and social care.

Peer Review reports

There is a growing interest in person-centred care (PCC) since authorities, such as the World Health Organization (WHO), have called for enabling patients to engage in their care and treatment [ 1 ]. PCC has also been endorsed by health and social care professionals and patient organisations [ 2 , 3 ]. In Sweden, PCC stands as a pivotal element in the “Good quality, local healthcare reform” [ 4 ]. This reform necessitates substantial organisational changes to ensure integrated, proactive, and health-promoting PCC across various care settings, responsive to each person’s resources and needs. PCC has been developed to frame care in a holistic and ethical way by establishing a partnership between health and social care professionals and persons in need of care. The concept of PCC is based on ethical principles and has its roots in the holistic paradigm, which highlights the importance of knowing each person as a capable human being with needs and resources [ 5 , 6 , 7 ].

The Gothenburg Centre for Person-Centred Care (GPCC) has developed a PCC framework for applying PCC, i.e., PCC practices, serving as a lens for embodying ethical values, guiding professional actions, and enhancing well-being and work performance [ 6 ]. This framework describes a model, summarising PCC into three main practices [ 6 , 8 ]:

Initiating personal narratives to get to know each patient as a person, to identify their previous experiences, present situation, needs, abilities, and resources.

Co-creating a personal plan in line with identified resources and barriers combined with medical, health, and social research evidence.

Documenting and monitoring the plan and adapting it to changes in the goals and/or other circumstances.

Previous research evaluating PCC has to a large extent focused on patients with chronic conditions, showing that PCC could, e.g., improve patients’ self-efficacy, symptom control, satisfaction with care and reduce length of hospital stay and healthcare costs [ 5 ]. PCC practices have also shown positive associations with work-related health among health and social care professionals, but the vast majority of the studies are performed in residential care and have mainly addressed registered nurses and nurse assistants [ 9 ]. What is less known is to what extent PCC practices are applied, and what impact they have on health and social care professionals’ work-related health and job satisfaction across diverse health and social care settings. This project, PCC@Work, is developed to fill this knowledge gap, focusing on the impact and experiences of applying PCC practices in hospital wards, primary care units, and municipal care.

The work environment for health and social care professionals is characterised by demanding conditions, including high workloads, low control, ethical dilemmas, unclear roles, and demanding schedules which may lead to increased stress and job dissatisfaction [ 10 , 11 , 12 , 13 ]. Additionally, an unsatisfactory and stressful work setting, along with ethically challenging situations, often prompt health and social care professionals to seek alternative employment [ 10 , 12 , 14 , 15 ]. Notably, it is concerning that both newly graduated and experienced professionals show a significant likelihood of considering leaving their current positions [ 10 , 12 , 16 ]. The shortage of skilled professionals has detrimental effects on the workload, quality of care and patient safety [ 10 , 13 , 17 , 18 ]. This situation is untenable and requires immediate attention to ensure adequate staffing in the future of health and social care.

In response, PCC@Work aligns itself with the overarching goal of promoting health and well-being in the workplace, aiming to proactively address mental health challenges and mitigate sickness-related absences. One potential remedy is transitioning towards more PCC practices, which could reduce ethical stress and foster more meaningful human interactions in health and social care [ 7 , 19 ]. PCC practices reportedly foster a heightened ethical consciousness regarding the quality of care, grant greater control over daily tasks, and encourage social collaboration [ 20 ]. This is supposed to empower health and social care professionals to align their actions with their personal and professional values by effectively organising and coordinating care with both colleagues and patients [ 21 ]. However, adopting PCC practices may also present challenges, particularly due to time constraints, with barriers including traditional culture and practices, sceptical attitudes, structural factors, the time-consuming nature of actively listening to patient narratives, and engaging in the co-creation of health and social care plans [ 22 ].

A recent review from our research group [ 23 ] illustrates how the introduction of a new professional role through PCC practices could lead to feelings of disorientation and uncertainty among health and social care professionals. These feelings might initially increase stress, and repeated measures with a longitudinal design are therefore essential to show if PCC practices could influence work-related health and job satisfaction in the long run. Significantly, the results showed positive experiences of job satisfaction, including a sense of meaningfulness, enhanced relationships between professionals and persons in need of health and social care, as well as increased appreciation and collaboration [ 23 ]. These findings, in combination with the findings from a previous review [ 9 ], prompt an inquiry into the degree to which the outcomes were influenced by the specific context of applying PCC practices. This underscores the imperative for comprehensive research in diverse health and social care settings, employing both quantitative and qualitative methodologies, to assess the impact and experiences of PCC practices from the professionals’ perspective. We hypothesise that a development towards increased PCC practises may enhance the work-related health of health and social care professionals, potentially mitigating sources of stress, excessive workloads, and job dissatisfaction.

Providing a comprehensive and transparent protocol is crucial as it enables the conduct and evaluation of research projects by effectively communicating pertinent information to key stakeholders. As such, our intention with this protocol is to convey the complexity of the design of this multi-method project. The longitudinal aspect of the PCC@Work project will ensure that the complex relationship between PCC practices, work-related health, and job satisfaction is thoroughly researched so that fluctuations over time can be captured. This allows for the impact of PCC practices to be monitored and evaluated. Development of PCC may increase health and social care professionals’ perceived levels of stress at an early stage.

Methods/design

Project aim.

The overall aim of PCC@Work is to follow, describe, assess, and explore the impact of PCC practices in hospital wards, primary care centres and municipal care on health and social care professionals’ work-related health and job satisfaction.

Study design and setting

This project has a multi-method design combining a prospective, longitudinal dynamic cohort study with qualitative studies. A web-based questionnaire will be distributed on five occasions within two years to health and social care professionals in hospital wards, primary care centres, and municipal care in Sweden. Employing dynamic cohorts allows participants to leave and enter during the study period. Theoretically and pragmatically, dynamic cohorts are a relevant choice in this project in which we monitor the gradual development of PCC practices. With dynamic cohorts, we can follow the participants at several data collection points. The design allows us to perform repeated cross-sectional analyses using the entire, dynamic, cohort (hospital wards, primary care centres and municipal care) at each data collection point. These different data collection points can be used as cross-sectional studies but can also be compared and give data on changes over time. Moreover, it is possible to make longitudinal analyses by creating a fixed closed cohort identified within the open cohort, to follow participants that stay at the same workplace during the study period. The study design is illustrated in Fig.  1 .

Open cohort study design. The blue arrows represent participants remaining at each care setting during the study period, and the yellow arrows represent examples of several possible scenarios for participants starting and quitting at each care setting during the period

The multi-method design includes focus group discussions [ 24 ] to generate qualitative data from health and social care professionals from the three settings. Based on a social constructivist approach, the focus groups aim to capture the collective understanding of work-related health and job satisfaction in relation to PCC practices among health and social care professionals in diverse care settings. In addition, there is room for individual interviews with key participants to create a deeper understanding of social processes and contextual influences related to PCC practices through grounded theory [ 25 ].

Participants and recruitment process

PCC@Work addresses health and social care professionals working directly with persons in need of health or social care in hospital wards, primary care centres, and municipal care. Study participants are reached through their work e-mail addresses provided to the research group by each care organisation. All potential participants receive an e-mail, including detailed information on study design, what participation entails, and ethical topics such as voluntariness, consent, and the possibility to withdraw at any time without any negative consequences to participants’ employment. The e-mail also includes a personal link to a web-based questionnaire. Three reminders are sent to participants to facilitate and promote participation. The web-based questionnaires are operated in collaboration with a company with vast experience in using web-based questionnaires.

There is a baseline data collection for the longitudinal study which will have followed-up after six, 12, 18 and 24 months. The impact of PCC practices will be measured after the third (12 months follow-up) and fifth data collection point (24 months follow-up). Repeated cross-sectional analyses will be conducted at each data collection point to explore associations between PCC practices, work-related health, and job satisfaction. In addition, a subsample of these participants will be asked to participate in the focus groups.

Prospective longitudinal cohort study measures

Exposure variable.

The Person - Centred Care Assessment Tool (P‐CAT) [ 26 ] is chosen as the exposure variable representing self-reported levels of PCC. P-CAT comprises 13 items aimed at capturing the extent to which professionals perceive PCC practices in their daily work [ 26 ]. P-CAT consists of two subscales: the extent of personalising care (EPC; 8 items) and organisational and environmental support (OES; 5 items) [ 26 , 27 ]. A 5‐point scale from 1 (completely disagree) to 5 (strongly agree) is used for evaluation purposes. The sum score ranges from 13 to 65, with a high score indicating a greater extent of perceived PCC. P‐CAT has shown satisfactory validity and reliability in a Swedish aged care context [ 27 ], and has recently been modified by our research group for use in other care settings showing good internal consistency [ 28 ].

Outcome variables

The Stress of Conscience Questionnaire (SCQ) [ 29 ] is a 9-item measurement for assessing stressful situations and the degree to which they trouble the conscience. This questionnaire was designed in Sweden to explore perceived stress related to not providing the care or activities one wants to provide within a care setting [ 29 ]. It consists of nine items, each divided into two parts: an A question that evaluates the frequency of a selected stressful situation using a scale ranging from 0 (never) to 5 (every day), and a B question that evaluates the perceived degree of troubled conscience generated by the situation using a scale ranging from 0 (no troubled conscience at all) to 5 (a very troubled conscience). The A score is multiplied by the B score to reflect the total stress of conscience, ranging from 0 to 25 for each item. Adding the scores for all items gives a total score ranging from 0 to 225. A higher total score signifies a higher perceived stress of conscience. Satisfactory psychometric properties have been reported for the SCQ in a Swedish healthcare population [ 29 ].

The Copenhagen Psychosocial Questionnaire (COPSOQ III) [ 30 ] is a widely used and scientifically tested questionnaire for examining the organisational and social work environment, covering a broad range of domains which can be adopted depending on the aim [ 30 ]. We focus on the COPSOQ III domains Demands at Work (6 items), Work Organisation and Job Contents (6 items), Interpersonal Relations and Leadership (7 items), and Work-Individual Interface (5 items). These domains include questions on job strain, demand/control, job satisfaction, meaningfulness, and intent to leave. The item response alternatives correspond to a five-point Likert scale where the mean score between 0 and 100 is calculated for included scales. If > 50% of item responses in a scale are not recorded, the scale measurement will be considered missing. Studies across different professions have corroborated the internal consistency reliability and construct validity of the scales [ 30 ].

The Work Ability Index (WAI), developed by [ 31 ], has been widely used in research in different countries and settings and can be used to assess self-reported individual work ability regarding perceived resources, health, and physical and mental demands [ 32 ]. Four out of the seven items from the WAI are applicable to this project and included in the questionnaire. The index has shown very good predictive abilities for measuring nurses’ workability [ 33 ], and satisfactory values in a general Swedish population [ 34 ].

The Capacity to Work index (C2WI-cmd) [ 35 ] was developed for assessing capacity to work in relation to common mental disorders in general working populations. C2WI-cmd consists of 12 items. The items include statements covering the capacity to work the last week. The respondent reports to which degree they agree, with the five response alternatives ‘Not at all’; ‘To a low degree’; ‘To a moderate degree’; ‘To a high degree’; or ‘Not relevant’. Our research group tested the C2WI-cmd for reliability, validity and user-friendliness in a Swedish working sample including healthcare professionals [ 35 ].

The WHO mental well-being index (WHO-5) [ 36 ] is a measure of how the respondent has felt in the last two weeks regarding the more positive aspects of their emotional state. Increasingly, well-being has been shown to be important in relation to health and everyday functioning. WHO-5 has shown validity in assessing well-being over time and comparing well-being between groups. Apart from the positive aspects, WHO-5 also prove validity in screening for depression [ 36 ].

Demographics

Other parts of the questionnaire concern the demographic and confounding factors; gender, age, profession, workplace, type of employment, working hours, shift work, overtime, years working in health or social care and at their organisation, experience and opinion of PCC practices, sickness absence, general health and ongoing implementations or reorganisations in the care setting. All of these will be incorporated into the analyses.

Statistical analyses

Statistical analysis will focus on repeated cross-sectional and longitudinal analyses to assess changes over time within groups. Statistical analysis will be done at each data collection point. Regression analyses (linear, ANOVA, ANCOVA) will be applied. The primary efficacy analysis centres on the baseline to two-year change in SCQ with the P-CAT as exposure, with Fisher’s non-parametric permutation test for paired observations. Results will be presented at a 5% significance level on aggregated levels.

Power calculation

For the quantitative studies, a change of 5 units in the Stress of Conscience Questionnaire (SCQ) was considered an acceptable effect, in each of the three cohorts (hospital wards, primary care centres, and municipal care), from baseline to 24 months with a power of 80% with Fisher’s non-parametric permutation test for paired observations, and a significance level of 0.05. Thus, 285 health and social care professionals must be included in each of the three cohorts (= 855 in total). We expect a response rate of approximately 40% and therefore aim to invite a minimum of 2200 health and social care professionals at baseline to allow for both staff turnover and withdrawals. The standard deviation for change in SCQ (total score range from 0 to 225) has been estimated to be 30 based on the literature [ 37 ].

Qualitative studies

To allow for a deeper and broader understanding of PCC practices in relation to work-related health and job satisfaction, the e-mail sent out for the 12-month follow-up data collection will invite participants to focus group discussions. Participants interested in contributing to a focus group discussion will then be contacted by the research group for more detailed information and for setting up a time and place for the focus group. Homogeneity will be strived for in terms of care setting and profession, and heterogeneity will be strived for in terms of work experience, national background, age, and sex, to capture a diversity of experiences and broaden the discussions [ 24 ].

For the focus group discussions, our intention is to conduct at least two focus groups with health and social care professionals per care setting (a total of at least six focus groups), and we will strive for four to six professionals per group ( n  = 24–36). For the grounded theory study, an open sampling of approximately 15–20 health and social care professionals is estimated.

The focus groups will preferably be conducted in a venue accessible for the participants, or digitally if needed, and they are expected to last 60–90 min. Led by a moderator and co-moderator, discussions centre on key questions formulated by the research group to align with the study’s aim. The moderator guides the discussion, while the co-moderator observes, takes notes, and asks follow-up questions. Sessions begin with an introduction to the study’s aim and structure, followed by open-topic discussions. The moderators’ role is to ensure participant engagement, identify common themes, and pose specific questions to deepen the discussions. All sessions will be audio-recorded and transcribed for subsequent analyses. The grounded theory study will have a similar approach.

The focus groups will be iteratively analysed using a method developed explicitly for focus groups [ 24 ]. Focus group data will undergo multiple stages of analysis. Initially, repeated listening establishes an overall understanding. Each transcript is then independently examined to capture essential data. Preliminary themes are created by the researchers, guided by the study’s aim. Raw data is categorised, and descriptive statements are formed. Systematising data under themes involves aligning discussions with relevant categories. This continuous process ensures meaningful communication of discussion meanings. Finally, data is summarised and interpreted collaboratively to foster shared understanding. This analytical continuum transforms raw discussions into condensed, interpretable summaries, forming the basis for a collectively agreed-upon final interpretation. In addition, the individual interviews will be analysed by applying grounded theory [ 25 ], in which data collection and analysis will be conducted as simultaneous processes characterised by constant comparisons of data.

There are some limitations to this project. Various factors, including time constraints, lack of direct connection to researchers, survey fatigue, and insufficient interest or motivation, impact participation rates in research, particularly among care professionals [ 38 , 39 , 40 ]. Moreover, language barriers contribute to lower questionnaire participation rates for persons born outside the country of residence, affecting municipal care, where over one-third of care professionals are foreign-born [ 41 , 42 ].

For longitudinal research, fixed cohorts are ideal, but the dynamic nature of work-related studies, especially those involving PCC practices, necessitates following groups with similar exposure combinations. Additionally, uneven distribution among health and social care professionals, with assistant nurses being the largest group, poses challenges to achieve representative sampling. Sensitivity analyses comparing assistant nurses with other professionals can address this issue, and oversampling certain groups may be considered.

The definition of PCC varies across organisations and professions, emphasising the importance of using the P-CAT in the questionnaire to establish a common understanding. Ultimately, the study aims to uncover new insights into the impact of PCC practices on work-related health and job satisfaction among health and social care professionals in hospital wards, primary care centres, and municipal care.

Data availability

The datasets produced and analysed in this project are not publicly accessible to uphold the confidentiality commitments made to participants during the informed consent process. However, de-identified data can be provided upon reasonable request for review purposes.

Abbreviations

Person-Centred Care

Gothenburg centre for Person-Centred Care

Person- Centred Care Assessment Tool

Stress of Conscience Questionnaire

Copenhagen Psychosocial Questionnaire

Capacity to Work index

The WHO mental well-being index (5 statement version)

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Cornelia van Diepen, Qarin Lood, Kristoffer Gustavsson & Andreas Fors

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van Diepen, C., Lood, Q., Gustavsson, K. et al. Person-centred care and the work-related health and job satisfaction of health and social care professionals: protocol for a prospective longitudinal cohort study combined with qualitative studies (the PCC@Work project). BMC Health Serv Res 24 , 683 (2024). https://doi.org/10.1186/s12913-024-11148-z

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Preparedness for a first clinical placement in nursing: a descriptive qualitative study

• Philippa H. M. Marriott 1 ,
• Jennifer M. Weller-Newton 2   nAff3 &
• Katharine J. Reid 4  

BMC Nursing volume  23 , Article number:  345 ( 2024 ) Cite this article

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A first clinical placement for nursing students is a challenging period involving translation of theoretical knowledge and development of an identity within the healthcare setting; it is often a time of emotional vulnerability. It can be a pivotal moment for ambivalent nursing students to decide whether to continue their professional training. To date, student expectations prior to their first clinical placement have been explored in advance of the experience or gathered following the placement experience. However, there is a significant gap in understanding how nursing students’ perspectives about their first clinical placement might change or remain consistent following their placement experiences. Thus, the study aimed to explore first-year nursing students’ emotional responses towards and perceptions of their preparedness for their first clinical placement and to examine whether initial perceptions remain consistent or change during the placement experience.

The research utilised a pre-post qualitative descriptive design. Six focus groups were undertaken before the first clinical placement (with up to four participants in each group) and follow-up individual interviews ( n  = 10) were undertaken towards the end of the first clinical placement with first-year entry-to-practice postgraduate nursing students. Data were analysed thematically.

Three main themes emerged: (1) adjusting and managing a raft of feelings, encapsulating participants’ feelings about learning in a new environment and progressing from academia to clinical practice; (2) sinking or swimming, comprising students’ expectations before their first clinical placement and how these perceptions are altered through their clinical placement experience; and (3) navigating placement, describing relationships between healthcare staff, patients, and peers.

Conclusions

This unique study of first-year postgraduate entry-to-practice nursing students’ perspectives of their first clinical placement adds to the extant knowledge. By examining student experience prior to and during their first clinical placement experience, it is possible to explore the consistency and change in students’ narratives over the course of an impactful experience. Researching the narratives of nursing students embarking on their first clinical placement provides tertiary education institutions with insights into preparing students for this critical experience.

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First clinical placements enable nursing students to develop their professional identity through initial socialisation, and where successful, first clinical placement experiences can motivate nursing students to persist with their studies [ 1 , 2 , 3 , 4 ]. Where the transition from the tertiary environment to learning in the healthcare workplace is turbulent, it may impact nursing students’ learning, their confidence and potentially increase attrition rates from educational programs [ 2 , 5 , 6 ]. Attrition from preregistration nursing courses is a global concern, with the COVID-19 pandemic further straining the nursing workforce; thus, the supply of nursing professionals is unlikely to meet demand [ 7 ]. The COVID-19 pandemic has also impacted nursing education, with student nurses augmenting the diminishing nursing workforce [ 7 , 8 ].

The first clinical placement often triggers immense anxiety and fear for nursing students [ 9 , 10 ]. Research suggests that among nursing students, anxiety arises from perceived knowledge deficiencies, role ambiguity, the working environment, caring for ‘real’ people, potentially causing harm, exposure to nudity and death, and ‘not fitting in’ [ 2 , 3 , 11 ]. These stressors are reported internationally and often relate to inadequate preparation for entering the clinical environment [ 2 , 10 , 12 ]. Previous research suggests that high anxiety before the first clinical placement can be related to factors likely to affect patient outcomes, such as self-confidence and efficacy [ 13 ]. High anxiety during clinical placement may impair students’ capacity to learn, thus compromising the value of the clinical environment for learning [ 10 ].

The first clinical placement often occurs soon after commencing nursing training and can challenge students’ beliefs, philosophies, and preconceived ideas about nursing. An experience of cultural or ‘reality’ shock often arises when entering the healthcare setting, creating dissonance between reality and expectations [ 6 , 14 ]. These experiences may be exacerbated by tertiary education providers teaching of ‘ideal’ clinical practice [ 2 , 6 ]. The perceived distance between theoretical knowledge and what is expected in a healthcare placement, as opposed to what occurs on clinical placement, has been well documented as the theory-practice gap or an experience of cognitive dissonance [ 2 , 3 ].

Given the pivotal role of the first clinical placement in nursing students’ trajectories to nursing practice, it is important to understand students’ experiences and to explore how the placement experience shapes initial perceptions. Existing research focusses almost entirely either on describing nursing students’ projected emotions and perceptions prior to undertaking a first clinical placement [ 3 ] or examines student perceptions of reflecting on a completed first placement [ 15 ]. We wished to examine consistency and change in student perception of their first clinical placement by tracking their experiences longitudinally. We focused on a first clinical placement undertaken in a Master of Nursing Science. This two-year postgraduate qualification provides entry-to-practice nursing training for students who have completed any undergraduate qualification. The first clinical placement component of the course aimed to orient students to the clinical environment, support students to acquire skills and develop their clinical reasoning through experiential learning with experienced nursing mentors.

This paper makes a significant contribution to understanding how nursing students’ perceptions might develop over time because of their clinical placement experiences. Our research addresses a further gap in the existing literature, by focusing on students completing an accelerated postgraduate two-year entry-to-practice degree open to students with any prior undergraduate degree. Thus, the current research aimed to understand nursing students’ emotional responses and expectations and their perceptions of preparedness before attending their first clinical placement and to contrast these initial perceptions with their end-of-placement perspectives.

Study design

A descriptive qualitative study was undertaken, utilising a pre- and post-design for data collection. Focus groups with first-year postgraduate entry-to-practice nursing students were conducted before the first clinical placement, with individual semi-structured interviews undertaken during the first clinical placement.

Setting and participants

All first-year students enrolled in the two-year Master of Nursing Science program ( n  = 190) at a tertiary institution in Melbourne, Australia, were eligible to participate. There were no exclusion criteria. At the time of this study, students were enrolled in a semester-long subject focused on nursing assessment and care. They studied the theoretical underpinnings of nursing and science, theoretical and practical nursing clinical skills and Indigenous health over the first six weeks of the course. Students completed a preclinical assessment as a hurdle before commencing a three-week clinical placement in a hospital setting, a subacute or acute environment. Overall, the clinical placement aimed to provide opportunities for experiential learning, skill acquisition, development of clinical reasoning skills and professional socialisation [ 16 , 17 ].

In total, sixteen students participated voluntarily in a focus group of between 60 and 90 min duration; ten of these students also participated in individual interviews of between 30 and 60 min duration, a number sufficient to reach data saturation. Table  1 shows the questions used in the focus groups conducted before clinical placement commenced and the questions for the semi-structured interview questions conducted during clinical placement. Study participants’ undergraduate qualifications included bachelor’s degrees in science, arts and business. A small number of participants had previous healthcare experience (e.g. as healthcare assistants). The participants attended clinical placement in the Melbourne metropolitan, Victorian regional and rural hospital locations.

Data collection

The study comprised two phases. The first phase comprised six focus groups prior to the first clinical placement, and the second phase comprised ten individual semi-structured interviews towards the end of the first clinical placement. Focus groups (with a maximum of four participants) and individual interviews were conducted by the lead author online via Zoom and were audio-recorded. Capping group size to a relatively small number considered diversity of perceptions and opportunities for participants to share their insights and to confirm or contradict their peers, particularly in the online environment [ 18 , 19 ].

Focus groups and interview questions were developed with reference to relevant literature, piloted with volunteer final-year nursing students, and then verified with the coauthors. All focus groups and interviewees received the same structured questions (Table  1 ) to ensure consistency and to facilitate comparison across the placement experience in the development of themes. Selective probing of interviewees’ responses for clarification to gain in-depth responses was undertaken. Nonverbal cues, impressions, or observations were noted.

The lead author was a registered nurse who had a clinical teaching role within the nursing department and was responsible for coordinating clinical placement experiences. To ensure rigour during the data collection process, the lead author maintained a reflective account, exploring her experiences of the discussions, reflecting on her interactions with participants as a researcher and as a clinical educator, and identifying areas for improvement (for instance allowing participants to tell their stories with fewer prompts). These reflections in conjunction with regular discussion with the other authors throughout the data collection period, aided in identifying any researcher biases, feelings and thoughts that possibly influenced the research [ 20 ].

To maintain rigour during the data analysis phase, we adhered to a systematic process involving input from all authors to code the data and to identify, refine and describe the themes and subthemes reported in this work. This comprehensive analytic process, reported in detail in the following section, was designed to ensure that the findings arising from this research were derived from a rigorous approach to analysing the data.

Data analysis

Focus groups and interviews were transcribed using the online transcription service Otter ( https://otter.ai/ ) and then checked and anonymised by the first author. Preliminary data analysis was carried out simultaneously by the first author using thematic content analysis proposed by Braun and Clarke [ 21 ] using NVivo 12 software [ 22 ]. All three authors undertook a detailed reading of the first three transcripts from both the focus groups and interviews and independently identified major themes. This preliminary coding was used as the basis of a discussion session to identify common themes between authors, to clarify sources of disagreement and to establish guidelines for further coding. Subsequent coding of the complete data set by the lead author identified a total of 533 descriptive codes; no descriptive code was duplicated across the themes. Initially, the descriptive codes were grouped into major themes identified from the literature, but with further analysis, themes emerged that were unique to the current study.

The research team met frequently during data analysis to discuss the initial descriptive codes, to confirm the major themes and subthemes, to revise themes on which there was disagreement and to identify any additional themes. Samples of quotes were reviewed by the second and third authors to decide whether these quotes were representative of the identified themes. The process occurred iteratively to refine the thematic categories, to discuss the definitions of each theme and to identify exemplar quotes.

Ethical considerations

The lead author was a clinical teacher and the clinical placement coordinator in the nursing department at the time of the study. Potential risks of perceived coercion and power imbalances were identified because of the lead author’s dual roles as an academic and as a researcher. To manage these potential risks, an academic staff member who was not part of the research study informed students about the study during a face-to-face lecture and ensured that all participants received a plain language statement identifying the lead author’s role and how perceived conflicts of interest would be managed. These included the lead author not undertaking any teaching or assessment role for the duration of the study and ensuring that placement allocations were completed prior to undertaking recruitment for the study. All students who participated in the study provided informed written consent. No financial or other incentives were offered. Approval to conduct the study was granted by the University of Melbourne Human Research Ethics Committee (Ethics ID 1955997.1).

Three main themes emerged describing students’ feelings and perceptions of their first clinical placement. In presenting the findings, before or during has been assigned to participants’ quotes to clarify the timing of students’ perspectives related to the clinical placement.

Major theme 1: Adjusting and managing a raft of feelings

The first theme encompassed the many positive and negative feelings about work-integrated learning expressed by participants before and during their clinical placement. Positive feelings before clinical placement were expressed by participants who were comfortable with the unknown and cautiously optimistic.

I am ready to just go with the flow, roll with the punches (Participant [P]1 before).

Overwhelmingly, however, the majority of feelings and thoughts anticipating the first clinical placement were negatively oriented. Students who expressed feelings of fear, anxiety, lack of knowledge, lack of preparedness, uncertainty about nursing as a career, or strong concerns about being a burden were all classified as conveying negative feelings. These negative feelings were categorised into four subthemes.

Subtheme 1.1 I don’t have enough knowledge

All participants expressed some concerns and anxiety before their first clinical placement. These encompassed concerns about knowledge inadequacy and were linked to a perception of under preparedness. Participants’ fears related to harming patients, responsibility for managing ‘real’ people, medication administration, and incomplete understanding of the language and communication skills within a healthcare setting. Anxiety for many participants merged with the logistics and management of their life during the clinical placement.

I’m scared that they will assume that I have more knowledge than I do (P3 before). I feel quite similar with P10, especially when she said fear of unknown and fear that she might do something wrong (P9 before).

Subtheme 1.2 Worry about judgment, being seen through that lens

Participants voiced concerns that they would be judged negatively by patients or healthcare staff because they perceived that the student nurse belonged to specific social groups related to their cultural background, ethnicity or gender. Affiliation with these groups contributed to students’ sense of self or identity, with students often describing such groups as a community. Before the clinical placement, participants worried that such judgements would impact the support they received on placement and their ability to deliver patient care.

Some older patients might prefer to have nurses from their own background, their own ethnicity, how they would react to me, or if racism is involved (P10 before). I just don’t want to reinforce like, whatever negative perceptions people might have of that community (P16 before).

Participants’ concerns prior to the first clinical placement about judgement or poor treatment because of patients’ preconceived ideas about specific ethnic groups did not eventuate.

I mean, it didn’t really feel like very much of a thing once I was actually there. It is one of those things you stress about, and it does not really amount to anything (P16 during).

Some students’ placement experiences revealed the positive benefits of their cultural background to enhancing patient care. One student affirmed that the placement experience reinforced their commitment to nursing and that this was related to their ability to communicate with patients whose first language was not English.

Yeah, definitely. Like, I can speak a few dialects. You know, I can actually see a difference with a lot of the non-English speaking background people. As soon as you, as soon as they’re aware that you’re trying and you’re trying to speak your language, they, they just open up. Yeah, yes. And it improves the care (P10 during).

However, a perceived lack of judgement was sometimes attributed to wearing the full personal protective equipment required during the COVID-19 pandemic, which meant that their personal features were largely obscured. For this reason, it was more difficult for patients to make assumptions or attributions about students’ ethnic or gender identity based on their appearance.

People tend to assume and call us all girls, which was irritating. It was mostly just because all of us were so covered up, no one could see anyone’s faces (P16 during).

Subtheme 1.3 Is nursing really for me?

Prior to their first clinical placement experience, many participants expressed ambivalence about a nursing career and anticipated that undertaking clinical placement could determine their suitability for the profession. Once exposed to clinical placement, the majority of students were completely committed to their chosen profession, with a minority remaining ambivalent or, in rare cases, choosing to leave the course. Not yet achieving full commitment to a nursing career was related to not wishing to work in the ward they had for their clinical placement, while remaining open to trying different specialities.

I didn’t have an actual idea of what I wanted to do after arts, this wasn’t something that I was aiming towards specifically (P14 before). I think I’m still not 100%, but enough to go on, that I’m happy to continue the course as best as I can (P11 during).

Subtheme 1.4 Being a burden

Before clinical placement, participants had concerns about being burdensome and how this would affect their clinical placement experiences.

If we end up being a burden to them, an extra responsibility for them on top of their day, then we might not be treated as well (P10 before).

A sense of burden remained a theme during the clinical placement for participants for the first five to seven days, after which most participants acknowledged that their role became more active. As students contributed more productively to their placement, their feelings of being a burden reduced.

Major theme 2: Sinking or swimming

The second major theme, sinking or swimming, described participants’ expectations about a successful placement experience and identified themes related to students’ successes (‘swimming’) or difficulties (‘sinking’) during their placement experience. Prior to clinical placement, without a realistic preview of what the experience might entail, participants were uncertain of their role, hoped for ‘nice’ supervising nurses and anticipated an observational role that would keep them afloat.

I will focus on what I want to learn and see if that coincides with what is expected, I guess (P15 before).

During the clinical placement, the reality was very different, with a sense of sinking. Participants discovered, some with shock, that they were expected to participate actively in the healthcare team.

I got the sense that they were not going to muck around, and, you know, they’re ‘gonna’ use the free labour that came with me (P1 during).

Adding to the confusion about the expected placement experience, participants believed that healthcare staff were unclear about students’ scope of practice for a postgraduate entry-to-practice degree, creating misalignment between students’ and supervising nurses’ expectations.

It seems to me like the educators don’t really seem to have a clear picture of what the scope is, and what is actually required or expected of us (P10 during).

In exploring perceived expectations of the clinical placement and the modifying effect of placement on initial expectations, three subthemes were identified: translation to practice is overwhelming, trying to find the rhythm or jigsaw pieces, and individual agency.

Subtheme 2.1 Translation to practice is overwhelming

Before clinical placement, participants described concerns about insufficient knowledge to enable them to engage effectively with the placement experience.

If I am doing an assessment understanding what are those indications and why I would be doing it or not doing it at a certain time (P1 before).

Integrating and applying theoretical content while navigating an unfamiliar clinical environment created a significant gap between theory and practice during clinical placement. As the clinical placement experience proceeded and initial fears dissipated, students became more aware of applying their theoretical knowledge in the clinical context.

We’re learning all this theory and clinical stuff, but then we don’t really have a realistic idea of what it’s like until we’re kind of thrown into it for three weeks (P10 during).

Subtheme 2.2 Trying to find the rhythm or the jigsaw pieces

Before clinical placement, participants described learning theory and clinical skills with contextual unfamiliarity. They had the jigsaw pieces but did not know how to assemble it; they had the music but did not know the final song. When discussing their expectations about clinical placement, the small number of participants with a healthcare background (e.g. as healthcare assistants) proposed realistic answers, whereas others struggled to answer or cited stories from friends or television. With a lack of context, feelings of unpreparedness were exacerbated. Once in the clinical environment, participants further emphasised that they could not identify what they needed to know to successfully prepare for clinical placement.

It was never really pieced together. We’ve learned bits and pieces, and then we’re putting it together ourselves (P8 during). On this course I feel it was this is how you do it, but I did not know how it was supposed to be played, I did not know the rhythm (P4 during).

Subtheme 2.3 Individual agency

Participants’ individual agency, their attitude, self-efficacy, and self-motivation affected their clinical placement experiences. Participant perceptions in advance of the clinical placement experience remained consistent with their perspectives following clinical placement. Before clinical placement, participants who were highly motivated to learn exhibited a growth mindset [ 23 ] and planned to be proactive in delivering patient care. During their clinical placement, initially positive students remained positive and optimistic about their future. Participants who believed that their first clinical placement role would be largely observational and were less proactive about applying their knowledge and skills identified boredom and a lack of learning opportunities on clinical placement.

A shadowing position, we don’t have enough skills and authority to do any work, not do any worthwhile skills (P3 before). I thought it would be a lot busier, because we’re limited with our scope, so there’s not much we can do, it’s just a bit slower than I thought (P12 during).

Individual agency appears to influence a successful first clinical placement; other factors may also be implicated but were not the focus of this study. Further research exploring the relationships between students’ age, life experience, resilience, individual agency, and the use of coping strategies during a first clinical placement would be useful.

Major theme 3: The reality of navigating placement relationships

The third main theme emphasised the reality of navigating clinical placement relationships and explored students’ relationships with healthcare staff, patients, and peers. Before clinical placement, many participants, especially those with healthcare backgrounds, expressed fears about relationships with supervising nurses. They perceived that the dynamics of the team and the healthcare workplace might influence the support they received. Several participants were nervous about attending placement on their own without peers for support, especially if the experience was challenging. Participants identified expectations of being mistreated, believing that it was unavoidable, and prepared themselves to not take it personally.

For me it’s where we’re going to land, are we going to be in a supportive, kind of nurturing environment, or is it just kind of sink or swim? (P5 before). If you don’t really trust them, you’re nervous the entire time and you’ll be like what if I get it wrong (P16 before).

Despite these concerns, students strongly emphasised the value of relationships during their first clinical placement, with these perceptions unchanged by their clinical placement experience. Where relationships were positive, participants felt empowered to be autonomous, and their self-confidence increased.

You get that that instant reaction from the patients. And that makes you feel more confident. So that really got me through the first week (P14 during). I felt like I was intruding, then as I started to build a bit of rapport with the people, and they saw that I was around, I don’t feel that as much now (P1 during).

Such development hinged on the receptiveness and support of supervising nurses, the team on the ward, and patients and could be hindered by poor relationships.

He was the old-style buddy nurse in his fifties, every time I questioned him, he would go ssshh, just listen, no questions, it was very stressful (P10 during). It depends whether the buddy sees us as an extra pair of hands, or we’re learners (P11 during).

Where students experienced poor behaviour from supervising nurses, they described a range of emotional responses to these interactions and also coping strategies including avoiding unfriendly staff and actively seeking out those who were more inclusive.

If they weren’t very nice, it wouldn’t be very enjoyable and if they didn’t trust you, then it would be a bit frustrating, that like I can do this, but you won’t let me (P12 during). If another nurse was not nice to me, and I was their buddy, I would literally just not buddy with them and go and follow whoever was nice to me (P4 during).

Relationships with peers were equally important; students on clinical placement with peers valued the shared experience. In contrast, students who attended clinical placement alone at a regional or rural hospital felt disconnected from the opportunities that learning with peers afforded.

Our research explored the emotional responses and perceptions of preparedness of postgraduate entry-to-practice nursing students prior to and during their first clinical placement. In this study, we described how the perceptions of nursing students remained consistent or were modified by their clinical placement experiences. Our analysis of students’ experiences identified three major themes: adjusting and managing a raft of feelings; sinking or swimming; and the reality of navigating placement relationships. We captured similar themes identified in the literature; however, our study also identified novel aspects of nursing students’ experiences of their first clinical placement.

The key theme, adjusting and managing a raft of feelings, which encapsulates anxiety before clinical placement, is consistent with previous research. This theme included concerns in communicating with healthcare staff and managing registered nurses’ negative attitudes and expectations, in addition to an academic workload [ 11 , 24 ]. Concerns not previously identified in the literature included a fear of judgement or discrimination by healthcare staff or patients that might impact the reputation of marginalised communities. Fortunately, these initial fears largely dissipated during clinical placement. Some students discovered that a diverse cultural background was an asset during their clinical placement. Although these initial fears were ameliorated by clinical placement experiences, evidence of such fears before clinical placement is concerning. Further research to identify appropriate support for nursing students from culturally diverse or marginalised communities is warranted. For example, a Finnish study highlighted the importance of mentoring culturally diverse students, creating a pedagogical atmosphere during clinical placement and integrating cultural diversity into nursing education [ 25 ].

Preclinical expectations of being mistreated can be viewed as an unavoidable phenomenon for nursing students [ 26 ]. The existing literature highlights power imbalances and hierarchical differences within the healthcare system, where student nurses may be marginalised, disrespected, and ignored [ 9 , 27 , 28 ]. During their clinical placement, students in our study reported unintentional incivility by supervising nurses: feeling not wanted, ignored, or asked to remain quiet by supervising nurses who were unfriendly or highly critical. These findings were similar to those of Thomas et al.’s [ 29 ] UK study and were particularly heightened at the beginning of clinical placement. Several students acknowledged that nursing staff fatigue from a high turnover of students on their ward and the COVID-19 pandemic could be contributing factors. In response to such incivility, students reported decreased self-confidence and described becoming quiet and withdrawing from active participation with their patients. Students oriented their behaviour towards repetitive low-level tasks, aiming to please and help their supervising nurse, to the detriment of learning opportunities. Fortunately, these incidents did not appear to impact nursing students’ overall experience of clinical placement. Indeed, students found positive experiences with different supervising nurses and their own self-reflection assisted with coping. Other active strategies to combat incivility identified in the current study that were also identified by Thomas et al. [ 29 ] included avoiding nurses who were uncivil, asking to work with nurses who were ‘nice’ to them, and seeking out support from other staff as a coping strategy. The nursing students in our study were undertaking a postgraduate entry-to-practice qualification and already had an undergraduate degree. The likely greater levels of experience and maturity of this cohort may influence their resilience when working with unsupportive supervising nurses and identifying strategies to manage challenging situations.

The theory-practice gap emerged in the theme of sinking or swimming. A theory-practice gap describes the perceived dissonance between theoretical knowledge and expectations for the first clinical placement, as opposed to the reality of the experience, and has been reported in previous studies (see, for instance, 24 , 30 , 31 , 32 ). Existing research has shown that when the first clinical placement does not meet inexperienced student nurses’ expectations, a disconnect between theory and practice occurs, creating feelings of being lost and insecure within the new environment, potentially impacting students’ motivation and risk of attrition [ 19 , 33 ]. The current study identified further areas exacerbating the theory-practice gap. Before the clinical placement, students without a healthcare background lacked context for their learning. They lacked understanding of nurses’ shift work and were apprehensive about applying clinical skills learned in the classroom. Hence, some students were uncertain if they were prepared for their first clinical placement or even how to prepare, which increased their anxiety. Prior research has demonstrated that applying theoretical knowledge more seamlessly during clinical placement was supported when students knew what to expect [ 6 ]. For instance, a Canadian study exposed students as observers to the healthcare setting before starting clinical placement, enabling early theory to practice connections that minimised misconceptions and false assumptions during clinical placement [ 34 ].

In the current study, the theory-practice gap was further exacerbated during clinical placement, where healthcare staff were confused about students’ scope of practice and the course learning objectives and expectations in a postgraduate entry-to-practice nursing qualification. The central booking system for clinical placements classifies first-year nursing students who participated in this study as equivalent to second-year undergraduate nursing students. Such a classification could create a misalignment between clinical educators’ expectations and their delivery of education versus students’ actual learning needs and capacity [ 3 , 31 ]. Additional communication to healthcare partners is warranted to enhance understanding of the scope of practice and expectations of a first-year postgraduate entry-to-practice nursing student. Educating and empowering students to communicate their learning needs within their scope of practice is also required.

Our research identified a link between students’ personality traits or individual agency and their first clinical placement experience. The importance of a positive orientation towards learning and the nursing profession in preparedness for clinical placement has been highlighted in previous studies [ 31 ]. Students’ experience of their first clinical placement in our study appeared to be strongly influenced by their mindset [ 23 ]. Some students demonstrated motivation to learn, were happy to ‘roll with the punches’, yet remain active in their learning requirements, whereas others perceived their role as observational and expected supervising nurses to provide learning opportunities. Students who anticipated a passive learning approach prior to their first clinical placement reported boredom, limited activity, and lack of opportunities during their first clinical placement. These students could have a lowered sense of self-efficacy, which may lead to a greater risk of doubt, stress, and reduced commitment to the profession [ 35 ]. Self-efficacy theory explores self-perceived confidence and competence around people’s beliefs in their ability to influence events, which is associated with motivation and is key to nursing students progressing in their career path confidently [ 35 , 36 ]. In the current study, students who actively engaged in their learning process used strategies such as self-reflection and sought support from clinical educators, peers and family. Such active approaches to learning appeared to increase their resilience and motivation to learn as they progressed in their first clinical placement.

Important relationships with supervising nurses, peers, or patients were highlighted in the theme of the reality of navigating placement relationships. This theme links with previous research findings about belongingness. Belongingness is a fundamental human need and impacts students’ behaviour, emotions, cognitive processes, overall well-being, and socialisation into the profession [ 37 , 38 ]. Nursing students who experience belongingness feel part of a team and are more likely to report positive experiences. Several students in the current study described how feeling part of a team improved self-confidence and empowered work-integrated learning. Nonetheless, compared with previous literature (see for instance, 2), working as a team and belongingness were infrequent themes. Such infrequency could be related to the short duration of the clinical placement. In shorter clinical placements, nursing students learn a range of technical skills but have less time to develop teamwork skills and experience socialisation to the profession [ 29 , 39 ].

Positive relationships with supervising nurses appeared fundamental to students’ experiences. Previous research has shown that in wards with safe psycho-social climates, where the culture tolerates mistakes, regarding them as learning opportunities, a pedagogical atmosphere prevails [ 25 , 39 ]. Whereas, if nursing students experience insolent behaviours or incivility, this not only impacts learning it can also affect career progression [ 26 ]. Participants who felt safe asking questions were given responsibility, had autonomy to conduct skills within their scope of practice and thrived in their learning. This finding aligns with previous research affirming that a welcoming and supportive clinical placement environment, where staff are caring, approachable and helpful, enables student nurses to flourish [ 36 , 40 , 41 , 42 ]. Related research highlights that students’ perception of a good clinical placement is linked to participation within the community and instructor behaviour over the quality of the clinical environment and opportunities [ 27 , 28 ]. Over a decade ago, a large European study found that the single most important element for students’ clinical learning was the supervisory relationship [ 39 ]. In our study, students identified how supervising nurses impacted their emotions and this was critical to their experience of clinical placement, rather than how effective they were in their teaching, delivery of feedback, or their knowledge base.

Students’ relationships with patients were similarly important for a successful clinical placement. Before the clinical placement, students expressed anxiety and fears in communicating and interacting with patients, particularly if they were dying or acutely unwell, which is reflective of the literature [ 2 , 10 , 11 ]. However, during clinical placement, relationships with patients positively impacted nursing students’ experiences, especially at the beginning when they felt particularly vulnerable in a new environment. Towards the end of clinical placement, feelings of incompetence, nervousness and uncertainty had subsided. Students were more active in patient care, which increased self-confidence, empowerment, and independence, in turn further improving relationships with patients and creating a positive feedback loop [ 36 , 42 , 43 ].

Limitations

This study involved participants from one university and a single course, thus limiting the generalisability of the results. Thus, verification of the major themes identified in this research in future studies is needed. Nonetheless, the purpose of this study was to explore in detail the way in which the experiences of clinical placement for student nurses modified initial emotional responses towards undertaking placement and their perceptions of preparedness. Participants in this study undertook their clinical placement in a variety of different hospital wards in different specialties, which contributed to the rigour of the study in identifying similar themes in nursing students’ experiences across diverse placement contexts.

This study explored the narratives of first-year nursing students undertaking a postgraduate entry-to-practice qualification on their preparedness for clinical placement. Exploring students’ changing perspectives before and during the clinical placement adds to extant knowledge about nursing students’ emotional responses and perceptions of preparedness. Our research highlighted the role that preplacement emotions and expectations may have in shaping nursing students’ clinical placement experiences. Emerging themes from this study highlighted the importance students placed on relationships with peers, patients, and supervising nurses. Significant anxiety and other negative emotions experienced by nursing students prior to the first clinical placement suggests that further research is needed to explore the impact of contextual learning to scaffold students’ transition to the clinical environment. The findings of this research also have significant implications for educational practice. Additional educational support for nursing students prior to entering the clinical environment for the first time might include developing students’ understanding of the clinical environment, such as through increasing students’ understanding of the different roles of nurses in the clinical context through pre-recorded interviews with nurses. Modified approaches to simulated teaching prior to the first clinical placement would also be useful to increase the emphasis on students applying their learning in a team-based, student-led context, rather than emphasising discrete clinical skill competencies. Finally, increasing contact between students and university-based educators throughout the placement would provide further opportunities for students to debrief, to receive support and to manage some of the negative emotions identified in this study. Further supporting the transition to the first clinical placement could be fundamental to reducing the theory-practice gap and allaying anxiety. Such support is crucial during their first clinical placement to reduce attrition and boost the nursing workforce.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the conditions of our ethics approval but may be available from the corresponding author on reasonable request and subject to permission from the Human Research Ethics Committee.

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Acknowledgements

The authors wish to thank the first-year nursing students who participated in this study and generously shared their experiences of undertaking their first clinical placement.

No funding was received for this study.

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Jennifer M. Weller-Newton

Present address: School of Nursing and Midwifery, University of Canberra, Kirinari Drive, Bruce, Canberra, ACT, 2617, Australia

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Department of Nursing, The University of Melbourne, Grattan St, Parkville, VIC, 3010, Australia

Philippa H. M. Marriott

Department of Rural Health, The University of Melbourne, Grattan St, Shepparton, VIC, 3630, Australia

Present address: Department of Medical Education, Melbourne Medical School, The University of Melbourne, Grattan St, Parkville, VIC, 3010, Australia

Katharine J. Reid

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All authors made a substantial contribution to conducting the research and preparing the manuscript for publication. P.M., J.W-N. and K.R. conceptualised the research and designed the study. P.M. undertook the data collection, and all authors were involved in thematic analysis and interpretation. P.M. wrote the first draft of the manuscript, K.R. undertook a further revision and all authors contributed to subsequent versions. All authors approved the final version for submission. Each author is prepared to take public responsibility for the research.

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Marriott, P.H.M., Weller-Newton, J.M. & Reid, K.J. Preparedness for a first clinical placement in nursing: a descriptive qualitative study. BMC Nurs 23 , 345 (2024). https://doi.org/10.1186/s12912-024-01916-x

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Enhancing Postpartum Psychosis Care With Qualitative Research: Current Findings and Future Directions

Lauren A. Kobylski, MPH; Huynh-Nhu Le, PhD; Marlene P. Freeman, MD; Lee S. Cohen, MD; and Rachel Vanderkruik, PhD, MSc

Published: May 29, 2024

P ostpartum psychosis (PP) is considered the most severe of perinatal mental health disorders, particularly when unrecognized or untreated. While affecting a relatively small number of individuals, with estimates ranging from 0.89 to 2.6 per 1,000 births, 1 PP is regarded as a psychiatric emergency necessitating immediate treatment and possible hospitalization. Individuals with PP may present with acute mania, depression, cognitive impairment, disorganized behavior, or lack of insight, in addition to delusions and/or hallucinations. 2 Diagnosis is complicated by the absence of a DSM classification. 3 As this disorder is associated with an increased risk for adverse consequences, including suicide and infanticide, 2 and is typically characterized by rapid onset and deterioration, increased research informing effective and acceptable treatment is essential.

There has been an increasing recognition of the value of qualitative research to inform patient-centered health research. Qualitative methodology offers a distinct path to synthesizing the contexts in which PP occurs, experiences of treatment, and recovery processes. Moreover, qualitative analysis allows for a richer understanding of the PP experience than quantitative studies can alone provide, and may include multiple stakeholder perspectives (eg, individuals with PP, partners, and providers). The past decade of research on PP has thus unsurprisingly been characterized by an increased qualitative focus, particularly seeking to describe the lived experiences of individuals with histories of PP.

Enough literature has accumulated to warrant the first (and to our knowledge, the only) systematic review of qualitative experiences of PP, specifically those related to recovery, from the perspective of both individuals with PP and family members. 4 Synthesizing 15 studies of 103 women and 42 family members, this review described the experience of PP as “unspeakable,” resulting in a disruption of sense of self and a challenge to identity. Recovery was cited as a nonlinear process of integrating and realigning the “old self and new self.” Family relationships and interactions with health care professionals were seen as both barriers and facilitators to recovery.

While this review provides a much needed synthesis of the current qualitative literature on PP, it both directly and indirectly points to significant gaps that remain in the field. To date, little qualitative literature has focused on treatment related experiences for PP. Such information would be particularly valuable for improving existing interventions, enhancing treatment engagement, and developing new treatment programs for individuals with PP. Understanding the lived experiences of patients is critical to determining how health care professionals can best provide effective and acceptable treatment.

Additionally, there is sparse research describing the experiences of health care professionals with respect to identifying and treating PP, which is important in ensuring timely diagnosis and treatment of the disorder. Qualitative research has not yet explored providers’ knowledge of PP and whether barriers to diagnosis and treatment exist at an institutional level; such studies have been conducted on postpartum depression and have shed light on important issues. 5–7 Researchers in the future may also explore the context surrounding onset of PP from a qualitative perspective. Little is known about socioecological factors that could be involved in the precipitation of a PP episode, and qualitative research offers an avenue to begin to explore such contextual and contributing factors to elevated risk for PP.

Finally, the generalizability of existing qualitative literature on PP is limited. The vast majority of studies included in the previously described review (12 of the 15 included studies) were conducted in European countries with primarily white, well-educated participants. The remaining 3 studies were online and conducted in the United States and Canada. Compared to mental health care in the United States, treatment in European countries is qualitatively different, with different levels of access to care, types of health insurance coverage, and cultural considerations than are seen in the United States; comparative qualitative research offers an avenue by which future researchers may explore the impact of different health care systems on PP treatment experiences. Furthermore, the participants included in the review largely had access to and received some level of treatment during their episode.

Wide racial disparities exist in perinatal mental health with respect to diagnosis, treatment, and long-term outcomes. For example, data suggest that ethnic minority, socioeconomically disadvantaged, and unpartnered childbearing individuals are less likely to report being asked about their mental health during the perinatal period. 8 Even when accounting for demographic and clinical factors, Black and Latina individuals are less likely to initiate treatment, receive follow-up treatment, or continue care for postpartum depression. 9 Given low base rates of PP, data on racial and ethnic differences are not yet available. However, broader psychosis literature suggests that Black and Latino individuals are diagnosed with psychotic disorders at rates 3 to 4 times higher than their white counterparts, 10 indicating a potential for higher rates of PP among racial and ethnic minority individuals. Relatedly, PP researchers must recognize the ongoing deleterious effects of stigma, bias, and structural racism, which adversely impact mental health diagnosis and treatment among communities of color. This is an important avenue to explore with respect to improvement of PP care.

Qualitative studies of PP are challenging to conduct for a number of salient reasons. Broad societal stigma against the disorder and oft sensationalized media coverage of select PP cases may discourage some individuals from wanting to participate in research or identify with the diagnosis. Additionally, PP is relatively uncommon compared to other perinatal mental health disorders, requiring unique and targeted recruitment approaches. Despite this, qualitative research has the potential to fill numerous gaps in current understandings of the disorder. Integration of such methodology with quantitative studies (eg, via explanatory sequential designs or exploratory sequential designs) will be critical to mitigating the suffering associated with PP. Understanding the lived experiences of PP can provide researchers with explanations of treatment-seeking behaviors, treatment preferences, and values and priorities in decision-making, all of which have the potential to inform current intervention efforts, facilitate recovery, and improve long term outcomes for mothers and families.

Article Information

Published Online: May 29, 2024. https://doi.org/10.4088/JCP.24com15305 © 2024 Physicians Postgraduate Press, Inc. J Clin Psychiatry 2024;85(2):24com15305 Submitted: February 14, 2024; accepted March 21, 2024. To Cite: Kobylski LA, Le H-N, Freeman MP, et al. Enhancing postpartum psychosis care with qualitative research: current findings and future directions. J Clin Psychiatry . 2024;85(2):24com15305. Author Affiliations: Department of Psychological & Brain Sciences, George Washington University, Washington, DC (Kobylski, Le); Ammon-Pinizzotto Center for Women’s Mental Health, Massachusetts General Hospital, Boston, Massachusetts (Kobylski, Freeman, Cohen, Vanderkruik). Corresponding Author: Lauren A. Kobylski, MPH, Department of Psychological & Brain Sciences, George Washington University, 2013 H St NW, Washington, DC 20006 ( [email protected] ). Relevant Financial Relationships: Dr Freeman (as of July 10, 2023): research support: Dr Freeman is an employee of Massachusetts General Hospital and works with the MGH National Pregnancy Registry. MGH National Pregnancy Registry: current sponsors: Alkermes, Inc (2016- present); Eisai, Inc (2022-present); Johnson & Johnson/ Janssen Pharmaceuticals, Inc (2019-present); Otsuka America Pharmaceutical, Inc (2008-present); Sage Therapeutics (2019-present); Supernus Pharmaceuticals (2021-present); and Teva Pharmaceutical Industries Ltd (2018-present). As an employee of MGH, Dr Freeman works with the MGH CTNI, which has had research funding from multiple pharmaceutical companies and NIMH. Other research support: Sage Therapeutics, JayMac. Advisory/consulting, data safety committees: independent data safety and monitoring committees: Janssen (Johnson& Johnson), Novartis, Neurocrine; advisory boards: Eliem, Sage; Brainify; Everly Health; Tibi Health; Relmada; and Beckley Psytech. Speaking/ honoraria: WebMD, Medscape, Pri-Med, Postpartum Support International. Royalty/patent, other income: scale royalties—through MGH Scale, The Massachusetts Female Reproductive Lifecycle and Hormones Questionnaire (Freeman et al. 2013). Dr Cohen (as of January 20, 2023): research support: Dr Cohen is an employee of Massachusetts General Hospital and works with the MGH National Pregnancy Registry. MGH National Pregnancy Registry: current sponsors: Alkermes, Inc (2016-present); Eisai, Inc (2022-present); Johnson & Johnson/Janssen Pharmaceuticals, Inc (2019-present); Otsuka America Pharmaceutical, Inc (2008-present); Sage Therapeutics (2019-present); Supernus Pharmaceuticals (2021-present); and Teva Pharmaceutical Industries Ltd (2018-present). As an employee of MGH, Dr Cohen works with the MGH CTNI, which has had research funding from multiple pharmaceutical companies and NIMH. Other research support: National Institutes of Health; SAGE Therapeutics. Ms Kobylski and Drs Le and Vanderkruik have no conflicts of interest to disclose. Funding/Support: The authors received no financial support or funding for the research, writing, authorship, and/or publication of this article.

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This paper is in the following e-collection/theme issue:

Published on 28.5.2024 in Vol 8 (2024)

Health Care Professionals’ Experiences With Using Information and Communication Technologies in Patient Care During the COVID-19 Pandemic: Qualitative Study

Authors of this article:

Original Paper

• Carly A Cermak 1, 2 , MClSc, PhD   ; 
• Heather Read 1 , PhD   ; 
• Lianne Jeffs 1, 2, 3 , RN, PhD  

1 Science of Care Institute, Sinai Health, Toronto, ON, Canada

2 Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, ON, Canada

3 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Corresponding Author:

Carly A Cermak, MClSc, PhD

Science of Care Institute

Sinai Health

1 Bridgepoint Drive

Toronto, ON, M4M 2B5

Phone: 1 4165864800

Email: [email protected]

Background: The COVID-19 pandemic acted as a catalyst for the use of information and communication technology (ICT) in inpatient and outpatient health care settings. Digital tools were used to connect patients, families, and providers amid visitor restrictions, while web-based platforms were used to continue care amid COVID-19 lockdowns. What we have yet to learn is the experiences of health care providers (HCPs) regarding the use of ICT that supported changes to clinical care during the COVID-19 pandemic.

Objective: The aim of this paper was to describe the experiences of HCPs in using ICT to support clinical care changes during the COVID-19 pandemic. This paper is reporting on a subset of a larger body of data that examined changes to models of care during the pandemic.

Methods: This study used a qualitative, descriptive study design. In total, 30 HCPs were recruited from 3 hospitals in Canada. One-on-one semistructured interviews were conducted between December 2022 and June 2023. Qualitative data were analyzed using an inductive thematic approach to identify themes across participants.

Results: A total of 30 interviews with HCPs revealed 3 themes related to their experiences using ICT to support changes to clinical care during the COVID-19 pandemic. These included the use of ICT (1) to support in-person communication with patients, (2) to facilitate connection between provider to patient and patient to family, and (3) to provide continuity of care.

Conclusions: HCP narratives revealed the benefits of digital tools to support in-person communication between patient and provider, the need for thoughtful consideration for the use of ICT at end-of-life care, and the decision-making that is needed when choosing service delivery modality (eg, web based or in person). Moving forward, organizations are encouraged to provide education and training on how to support patient-provider communication, find ways to meet patient and family wishes at end-of-life care, and continue to give autonomy to HCPs in their clinical decision-making regarding service delivery modality.

Introduction

The health care workforce had to quickly adapt to the COVID-19 pandemic, with health systems grappling with the provision of COVID-19 care at the same time as non-COVID-19 care. Restrictions to reduce the spread of COVID-19 put an additional strain on the health care system. Health care providers (HCPs) were left to problem-solve how to continue providing compassionate, connected care among layers of personal protective equipment and visitor restrictions. Fortunately, the COVID-19 pandemic was a catalyst for digital health to support the ongoing response to the COVID-19 pandemic, with web-based care emerging as the primary innovation of information and communication technology (ICT) used in medical care [ 1 , 2 ]. Uses of ICT in medical care include remote consultations, digital noninvasive care, and digital platforms for data sharing [ 3 ].

ICT played an important role in supporting changes to clinical care within inpatient and outpatient health care settings. Within inpatient settings, ICT was integral in maintaining connectivity between patients, families, and providers when changes to visitor policies were implemented [ 4 ]. For example, the use of mobile devices and tablets allowed for connection between patient and family and supported knowledge transfer between provider and family [ 5 ]. Within outpatient settings, ICT was integral in continuing care when COVID-19 lockdown restrictions limited in-person visits [ 1 ]. For example, videoconference and telemedicine services (ie, web-based care) emerged as a platform for providers to use to allow for remote care [ 1 ]. In both facets, ICT facilitated connection, acting as an essential link between patients, families, and providers. However, we have yet to learn of HCPs’ experiences in using ICT to support clinical care.

Learning from the experiences of HCPs’ use of ICT will offer valuable insights into how innovative uses of ICT might continue to be used in inpatient and outpatient health care settings moving forward. From here, uses of ICT can inform organizational leadership of the systems or processes that may require further investigation to support ICT use in clinical care in a postpandemic world. The main objective of the study was to examine changes to models of care during the pandemic from the perspectives of HCPs, implementation team members, and leaders across 3 Canadian hospitals. For this paper, we report on a storyline that emerged from this work to describe the experiences of HCPs’ use of ICT that supported changes to clinical care during the COVID-19 pandemic.

Study Design

This qualitative descriptive study was undertaken from March 2022 to June 2023 to understand changes to models of care during the COVID-19 pandemic through the experiences of HCPs, implementation team members, and leaders across 3 hospitals in Canada. This paper is reporting on a subset of data related to HCPs’ experiences of using ICT in supporting changes to clinical care, drawn from the larger study that explored changes to models of care that took place during the COVID-19 pandemic. The reporting of this study was guided by the Standards for Reporting Qualitative Research [ 6 ].

Sampling and Participant Recruitment

In total, 30 HCPs were recruited from critical care, inpatient, and ambulatory services across 3 hospitals in Canada. A purposeful sampling strategy was used where recruiting took place in organizations that were known to have been affected by COVID-19 restrictions and policies. Site leads at participating institutions disseminated study information to HCPs (eg, nurses, physicians, and allied health disciplines) working within their respective health care organizations. From here, interview participants self-referred to this study. Inclusion criteria included current employment as an HCP working at the health care organization over the course of the pandemic and postpandemic recovery.

Data Collection

One-on-one, semistructured interviews were conducted by members of the research team (Kang Kang Margolese, Marina Morris, Lily Zeng, Marie Oliveira, Adebisi Akande, HR, Frances Bruno, or CAC) between December 2022 and June 2023. Demographic information, including age, gender, ethnicity, health discipline, time in profession, time in organization, and time in current role, was collected from all participants before the interview to ensure diversity within the sample. An interview guide was developed by the research team that explored the following five areas: (1) changes to care (eg, “What was your role like before the pandemic? How did care change over the course of the last 3 years?”), (2) provisions of care (eg, “What did you/your team start/stop doing? How did you prioritize care?”), (3) emotions (eg, “How did care change feel for you/your team? What supports were available to you?”), (4) implementation and evaluation (eg, “How were changes implemented and evaluated?”), and (5) lessons that were learned or future recommendations.

Data collection was completed by nonclinical research staff (Kang Kang Margolese, Marina Morris, Lily Zeng, Adebisi Akande, and HR) and clinical research staff (Marie Oliveira, Frances Bruno, and CAC). Data collection was concluded when saturation of themes was reached, meaning that limited new insights emerged from existing themes with the collected data sample [ 7 ]. The interviews were conducted via either a videoconferencing platform or in person and were approximately 45 to 60 minutes in length.

Ethical Considerations

Ethics was formally reviewed and approved by Sinai Health’s Research Ethics Board (REB# 22-0153-E), as well as at each participating site: Sunnybrook Health Sciences Centre (REB# 5571) and Providence Health Care (REB# H22-02792). Participants were informed that participation in this study was completely voluntary and that they could withdraw from the study at any time without penalty. Verbal informed consent was obtained before the start of the interviews, and participants were given an electronic gift card in recognition of their time. The honorarium for participants was CAD $20 (US $26.4). Demographic information was collected from all participants before the interview. These data were anonymized and stored separately from the transcripts, which were deidentified and stored on a secure server.

Data Analysis

The research design was conceived within an interpretivist paradigm, where the researchers’ purpose was to gather insight into how clinical care changed during the COVID-19 pandemic through the learning of the experiences of participants [ 8 ]. Interviews were analyzed using an inductive thematic analysis approach, which included openly coding line by line to organize data in a meaningful, systematic way; examining the codes to identify themes; and reviewing the themes [ 9 ]. Specifically, the entire research team openly coded a small group of interviews (n=3) independently, line by line, and then met as a group to review codes, discuss themes, and develop an initial codebook through consensus. From here, the research team coded the bulk of the interviews in pairs, meeting as needed to ensure the reliability of coding, using the primary investigator (LJ) to triangulate and resolve any discrepancies as needed.

Reflexivity was demonstrated through regular debriefs of interviews and a review of the codebook at 1- to 2-week intervals during the coding process. Primary adjustments were additions of new codes as interviews were collected from new participant subgroups. For example, the initial codebook was derived from nurse interviews, and new codes were required as the project expanded into allied health disciplines. Codes that related to HCPs’ experiences of ICT included disciplinary changes, technical changes and innovations, improvisation, problem-solving, tools, and technology recommendations. NVivo software (QSR International) was used to facilitate the cross-synthesis analysis. As a final step of analysis to ensure saturation and methodological rigor, the primary investigator for the study (LJ) reviewed the emergent coding schema with the original transcripts.

Participant Characteristics

A total of 30 participants (site A: n=4, site B: n=14, and site C: n=12) described their experiences of how ICT supported changes to clinical care. Table 1 presents the demographic characteristics. Themes generated from participants included the use of ICT (1) for supporting in-person communication with patients; (2) for enabling connection between patients, providers, and families; and (3) for providing continuity of care amid COVID-19 restrictions.

a HCP: health care provider.

b Participant self-identified; categories were not provided.

Supporting In-Person Communication With Patients

Participants described how tablets supported in-person communication to mitigate the impact that personal protective equipment (PPE) had on verbal interactions with patients. PPE such as masks, Plexiglas, and visors posed challenges in communicating effectively, particularly for patients who were hard of hearing or who had difficulties with comprehension. Efforts to support communication were essential as communication breakdowns created confusion for the patients with detrimental consequences:

And so when talking to elderly people, when they can’t read your lips or when they can’t really hear you through three layers of protective equipment, they get very confused and multiple confusing events leads to possible more agitation and agitation leads to an automatic write-off from a lot of health care providers as to a reason why not to provide a certain person with care. [Site B, 01, physiotherapist]

Participants described coming up with innovative ways to facilitate communication amid the layers of PPE, with tablets and phones used to break down communication barriers. Applications such as speech to text allowed live transcription of providers’ speech, which can be used as a tool to support comprehension for patients who were hearing impaired. Further, speech-to-text applications provided patients and families a model of how this tool can be used to support communication outside of the hospital setting:

And so, this [iPads] has been a huge help...it helps people, patients who haven’t heard of this...they go home with a brand-new strategy that makes their daily life so much easier. [Site C, 08, social worker]

In addition to using tablets to support communication with patients who were hard of hearing, participants also expressed the value of using tablets for translation services for patients who did not speak English. Benefits included the convenience of dialing translation services from an iPad:

We have translation services on them [iPads]...which has been so, so wonderful to have to just go into someone’s room who doesn’t speak English...And just call up this interpretation service, have a human being there and that was really a key. [Site C, 29, spiritual health practitioner]

Challenges surfaced when both a videoconferencing platform and translation services were required—specifically, the difficulties in handling 2 ICT tools simultaneously and the need to prioritize videoconferencing all the while hoping that family members were relaying information correctly:

...you can’t hold a Zoom, you know, iPad and then hold a translator phone to it, you know what I mean? So then it became family trying to find someone at their end who could relay information. [Site B, 13, occupational therapist]

Enabling Connection Between Patients, Providers, and Families

Participants described how digital devices facilitated the connection between provider to family and provider to patient during visitor restrictions. This included using phones and iPads to connect families to their loved ones in hospitals, especially at end-of-life care. Participants also described that providing a digital connection to families at end-of-life care was a service that could help families move through the grief process.

...we facilitated a FaceTime and all kinds of video calls for people to be able to talk to their loved ones. And even to their religious leaders in certain cases...Families were not able to be with a loved one when they were dying…we were a bridge between them. [Site B, 07, spiritual care]

...we recorded a memorial service that was generic and was put up on YouTube and we could send the link...And so many people just didn’t have the needed ritual to move through grief. And that was something that we could give them and that was—we received so much good feedback and gratitude for that. [Site C, 29, spiritual health practitioner]

While there were benefits of tablet use to connect families to patients at end-of-life care, a digital connection created an internal struggle for HCPs as they witnessed the lack of physical touch and difficulties in accommodating end-of-life rituals:

I feel like I struggled when I had to use an iPad to connect patients to family members and it could be in a very vulnerable situation, like a patient was dying, he doesn’t speak English, the daughter’s on the iPad, she’s crying, she can’t hold her dad, can’t hold his hand...I think we have to recognize that...there is a rite of passage before somebody dies. There are certain steps for religious people and families that need to happen to honour a dying body for them to move on to wherever that place is...So anointing, communion, confession. Those are not things that are amenable to a Zoom method. [Site B, 12, nursing]

Further, participants expressed the challenges with navigating the frequency of communication between patient and family, such as balancing family requests with staffing resources within the hospital:

...when you had multiple family members who each wanted their turn to visit once a week. Well, you know, you don’t have staff to be able to support five Facetimes per resident. So, we started to have to limit it and say...like two Facetimes a week for a family, or for a resident...So, that was a challenge. [Site B, 05, social worker]

Providing Continuity of Care

Participants described how the use of videoconferencing platforms such as Zoom (Zoom Video Communications) enhanced communication between providers and families, such as when needing to provide medical updates or discharge recommendations. Zoom provided accessible options for patients with hearing or comprehension challenges using closed captioning. Furthermore, Zoom enabled more efficient and faster communication between the care team and family, rather than being faced with the complexities of coordinating schedules of team members and families who may be coming in from out of town:

It [Zoom] optimized our efficiency for delivering family meetings...the specialist physicians were able to attend more of these family meetings than in the past, because of the ability to attend virtually. And then, more family were able to attend than...in the past. And it was able to happen faster because we could do it virtually versus waiting several days for a family member to arrive from another city. [Site B, 13, occupational therapist]

Participants also expressed the benefits of web-based care for patient access, particularly for patients with mobility challenges or lack of transportation:

I can actually say that shift [to virtual] was very positive because...it actually eliminated some of the concerns my patients have about transportation, or ways that they’re able to get out there, be it because of their physical impairment post-operation. Or simply just because they don’t have the resources to get transit for whatever reason. [Site A, 23, social worker]

Further, some participants expressed how web-based care positively changed clinical practice for counseling services:

And from all the patients I’ve intervened with...I’d say .01% want to come in person...I find that on Zoom you can sort of see the environment they’re in...I think that COVID has revolutionized social work intervention...I only have good things to say about it. COVID has opened up a whole new world for counseling. [Site B, 15, social worker]

Web-based care was not without its challenges. Clinicians described that greater access to care increased referrals from patients who would historically not come for in-person treatment, particularly for mental health services:

...we found that we were getting more referrals from ... all these different patients who would have not been able to come to hospital to do in-person groups...people with anxiety disorders, like agoraphobia. People who had not seen—have difficulty going outside the house. [Site A, 16, nursing]

...the workload increased enormously, and was impossible to keep up with because before people had to come in to [the hospital] to see me so that actually restricted the number of people that I could see to people who lived in [the city], or in some neighbouring communities. At times, people would come in and come drive like 90 to 120 minutes to come and see me but due to Covid, when we shifted to online therapy...now, everybody in [the province] had access to me who were part of these programs...many people wanted to see the psychologist because they wouldn’t have to drive in. [Site C, 16, psychologist]

Consequently, participants described that more visits over Zoom led to greater fatigue as a result of having to simultaneously navigate Zoom and in-person teaching, resulting in a reduction in group therapy frequency:

We noticed for us clinicians we were just getting so fatigued that it was just too much. Because running a group in-person, and running it over Zoom is very, very different. You’re staring at a screen, you’re looking at all the faces in the room. You’re trying to navigate the PowerPoint, there’s a lot of things happening simultaneously, that when we were doing four groups a week we just noticed this is not sustainable for us. So we had to shift it to three groups. So one less group a week. So I think that’s a huge change in terms of provision of care. [Site A, 16, nursing]

In terms of providing clinical care, clinicians described the challenges of conducting a physical assessment or providing counseling treatment via Zoom or by phone:

We do some physical examination. So it’s hard just to understand the status just by phone, even if you ask them “Any swelling?” Then they say no but actually they have, so the knowledge may not be there. [Site C, 10, registered dietician]

...in Zoom it’s very limited and you mostly see the face. Right? You don’t see what the person is doing with their hands, arms, with their legs, with their feet. [Site B, 07, spiritual care practitioner]

It’s just something about being in the same room with someone when their emotions are high that you don’t actually have to do anything in particular, but just the calming presence makes a difference. I think that people get some of that on Zoom...I don’t know how similar or different, but I’m just assuming that it’s probably a bit watered down...Whereas if I was just in the room, I think just being quiet with the person would be enough and might be even better at times. [Site C, 16, psychologist]

Finally, clinicians described the challenges of using web-based care when working with older patients due to limited experiences with technology or cognitive impairments. Interestingly, some participants felt that the reliance on web-based care reduced the attendance of older populations who were not familiar with the technology.

...our average age is 97, they’re not tech savvy, they’re not necessarily understanding, comprehending, you know, that, you know, as we would understand that you can actually talk to someone who’s not present here, but it’s in the same time...So, I would call it, you’re having a video call. I try and explain it’s that, you’re having a video telephone call. And then, they just think they’re looking at a television, you know, and they’re just watching kind of a show and stuff. [Site B, 10, recreation therapist]

Some of our clients—some people with dementia don’t understand...either they don’t recognize themselves, or they get agitated by the sight of themselves—so having the person facilitating the Zoom understand how to turn off the view that you can see yourself, was important...I think I lost a number of older spouses that used to come to the group, because they...had difficulty understanding the technology, or just their digital literacy, or access to technology wasn’t that great. So currently...and interestingly, that has changed the demographic of people who are coming in my Caregiver Group. [Site B, 08, social worker]

Principal Findings

The aim of this qualitative descriptive study was to describe the experiences of HCPs in how ICT supported changes to clinical care during the COVID-19 pandemic. Participant narratives revealed 3 key findings: the benefits of digital tools to support in-person communication between patient and provider, the need for thoughtful consideration for the use of ICT at end-of-life care, and the support for the continued use of web-based care, when appropriate. We discuss HCPs’ experiences as they relate to the literature and provide recommendations for health care organizations that can make use of ICT in a more collaborative way while reflecting on patient and family values.

Communication between patients and providers is essential for quality care and for reducing preventable adverse medical events [ 10 ]. Patients who have been appropriately supported in their communication have reported to be more satisfied in their hospital stay [ 11 ]. Devices to assist with communication, more commonly referred to as alternative augmentative communication (AAC), have existed in health care for decades. AAC is an intervention approach for individuals who require added support (augmentative) or a replacement (alternative) for their communication [ 12 ]. AAC can be low technology such as communication boards or pictures or high technology such as communication systems on iPads and speech-generation devices and can be used for a short or long period of time depending on the individual’s communication needs [ 12 ].

The COVID-19 pandemic spawned a rapid adoption of digital tools such as tablets, which became an available tool to reduce communication barriers experienced with mask-wearing when speaking to patients and families and allow for participation in conversation. Additionally, tablets enabled access to video language interpretation for patients who were mechanically ventilated and awake [ 13 ], a unique example of reducing language barriers when families were not able to be present for interpretation. However, participant narratives using digital tools within acute care and rehabilitation contrast the literature describing the experiences of patients and families in the intensive care unit. In the intensive care unit, HCPs and families reported barriers to the implementation of communication supports, particularly for patients who were mechanically ventilated and awake [ 14 ]. Nurses reported feeling inadequate and frustrated in trying to support patients [ 14 ], whereas families reported frustration with communication breakdowns, inconsistent availability of tools, and insufficient training by the HCP [ 15 ]. Patients described being mechanically ventilated as a vulnerable, lonely, and fearful experience [ 15 ], particularly as verbal communication was not an option.

The collective experiences of nurses, families, and patients emphasize the impact that a lack of communication supports can have at the bedside. Further, the experiences of nurses, families, and patients shed light on the education and training that is needed for successful patient-provider communication to support participation in conversation, particularly for patients on mechanical ventilation. Reports from speech-language pathologists working with patients who are critically ill revealed positive patient-provider communication outcomes when there was nurse collaboration and readily available communication supports at the bedside [ 13 ]. Thus, the experiences of patients, families, and HCPs highlight the integral role that leadership and hospital policies play in prioritizing communication access, tool availability, and organizational-wide training [ 13 , 16 ]. For system-level change, it is recommended that hospital leaders develop regular staff training on communication supports led by professionals with expertise in this area such as speech-language pathologists [ 14 ]. For increased awareness on the importance of communication supports in health care, it is recommended that education on patient-provider communication starts as early as the undergraduate and postgraduate level for health discipline (ie, clinical) programs [ 14 ].

Videoconferencing tools have been used to connect loved ones for over a decade and have been shown to have positive psychosocial outcomes for nursing home residents when used as an addition to in-person family visits [ 17 ]. Specifically, older residents in nursing homes who received videoconferencing visits with family in addition to in-person family visits had a greater mean change in baseline depressive symptoms and feelings of loneliness when compared to older residents who had in-person visits only [ 17 ]. During the pandemic, however, videoconferencing tools and digital devices were used as a substitute for in-person visits due to visitor restrictions imposed by the COVID-19 pandemic. Although this enabled a connection between patient and family, the reduced frequency of family connections created tensions between both HCPs and family members.

Similar tensions were described by HCPs in the United Kingdom including communicating devastating news to relatives without having ever met them in person and the moral dilemma of what is “best” end-of-life care versus what could be offered given the COVID-19 restrictions [ 18 ]. Further, clinicians in Canada reported that web-based visits at end-of-life care prevented meaningful conversations typically had between family members at the bedside [ 19 ]. One physician described the importance of family connection in end-of-life care: “I’m now convinced that family members at the bedside improves patients’ ability to get better” [ 19 ]. The experiences of bereaved relatives aligned with the internal conflicts of HCPs in the United Kingdom: families wanted frequent communication that was easy to understand, one last chance to say goodbye through physical touch, and speaking to their loved one at bedside [ 20 ]. Similarly in Canada, HCPs, patients, and families all felt that restrictive acute care visitor policies impacted the safety and quality of care, mental health of everyone involved, families as partners in care, and communication and advocacy [ 4 ].

Although COVID-19 visitor restrictions have lifted, the experiences described by clinicians and families highlight the considerations needed for a positive, meaningful, end-of-life experience. One example of an organizational-wide intervention for end-of-life care includes the 3 Wishes Project (3WP), an intervention that gathers 3 wishes from the patient and family to help personalize and humanize end-of-life care [ 21 ]. The 3WP has demonstrated a positive impact on families and clinicians; families had a significantly higher rating of emotional and spiritual support than families who did not receive the 3WP [ 22 ], while clinicians reported greater morale and collaboration in helping families move toward acceptance [ 23 ]. Further, the 3WP has shown to build capacity for compassion at the organization level by facilitating collective noticing, feeling, and responding [ 24 ]. In other words, the implementation of 3WP creates system-level processes and structures to facilitate compassionate care while promoting the connection between patients, families, and HCPs [ 24 ]. Thus, while the use of digital devices will likely continue to be a complement to care [ 25 ], it is important that organizations encourage collective, compassionate care to meet the wishes of patients and families.

Literature describing the benefits and challenges of web-based care aligned with participant narratives. Benefits included faster access to care, greater efficiency, and improved convenience for patients [ 26 ]; challenges included conducting assessments without the ability to complete in-person physical examinations [ 26 ] and offering web-based care to patients with poor digital literacy [ 27 - 29 ]. What was unique to this study’s findings was the increase in referral rates with the implementation of web-based care. Two reasons for an increase in referrals as described by participants included greater access for patients with significant mental health needs who otherwise would not come in for services and greater access for patients living far away from the hospital. Consequently, more referrals increased the workload of HCPs, demonstrating the dichotomy between patient access to care and provider workload. This emphasizes the considerations needed to balance clinician workload with patient preference of service modality as organizations move toward hybrid models of care [ 25 ].

A recent US study examined patient preference for service modality for nonurgent care and found that when out-of-pocket costs were not a factor, slightly more than half of the sample (53%) preferred in-person visits to web-based care, while one-fifth (21%) preferred web-based and one-quarter (26%) had no preference or did not know what they preferred [ 30 ]. For individuals who had video visit experience, this was associated with their preference for video visits [ 30 ]. A closer look at demographic factors revealed that those who did not feel that video calls had a role in their medical care were generally older people, who lived rurally, and who had a lower income and educational level [ 30 ]. Conversely, patients who were younger and had a higher income and education were more likely to choose a video visit over in-person care [ 30 ]. While choice of service modality may be an option for nonurgent care moving forward, some populations may not have the same ability to choose. Rather, it is up to the HCP to decide whether web-based care is appropriate.

HCPs, such as psychiatrists, who work with patients with significant mental health disorders have described the role that contextual factors contribute to decision-making of service modality [ 31 ]. Contextual factors in decision-making included if an in-person visit provided greater therapeutic benefit than a web-based visit, if a general examination was needed, if there were caregivers nearby who could provide information, if insight into the living environment was necessary, and if safety resources were required for in-person visits [ 31 ]. There was no consensus among psychiatrists on the mental health conditions that would best be served, as some respondents felt web-based care offered unique benefits such as improved patient safety and reduced likelihood of escalation [ 31 ]. Taken together, a combination of factors will need to continue to be considered for service delivery modality moving forward, such as patient preference, nature of service provided, and technology literacy. Furthermore, thoughtful planning for the accessibility of technology use for underserved populations will likely be an element of consideration for the field of health care [ 32 ].

Limitations

First, this study is limited to the experiences of the HCP from urban hospitals in Ontario and British Columbia and may not be transferable to the full scope of pandemic hospital worker experiences across the globe. Consequently, there may have been uses of ICT that happened during the pandemic that were particularly novel or interesting but may not have been captured due to the nature of this qualitative study. Second, participants were given an electronic gift card after the interview in recognition of their time, which may have impacted self-referral into the study. Third, there were several research team members involved in interviews, which may have impacted the depth of information provided by the participants across interviews.

Conclusions

Experiences from HCP highlight the uses of ICT to support changes to clinical care during the pandemic. The use of digital tools supported patient-provider communication, enabled a connection between patients and families at end-of-life care, and provided continuity of care amid COVID-19 lockdowns. Moving forward, organizations are encouraged to provide education and training on how to support patient-provider communication in clinical care; find ways to implement collaborative, compassionate, end-of-life care; and continue to give autonomy to HCPs in their clinical decision-making regarding service delivery modality.

Acknowledgments

This study was funded by a grant from the Canadian Institutes of Health Research (W12179927). The authors would like to thank the participants who took time to reflect on the difficult experiences they and their colleagues faced during the COVID-19 pandemic. The authors would also like to thank the research team of Kang Kang Margolese, Marina Morris, Lily Zeng, Marie Oliveira, Adebisi Akande, and Frances Bruno who contributed to the data collection and analysis.

Data Availability

An aggregate summary of data generated and analyzed during this study are included in this published manuscript. Individual data transcripts cannot be publicly shared because of confidentiality.

Authors' Contributions

LJ conceived and designed the study and assisted with data analysis. CAC and HR assisted with data collection and data analysis. CAC drafted the manuscript, and all authors critically reviewed it as well as read and approved the final manuscript.

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 24.09.23; peer-reviewed by A Ševčíková, H Pilabré, A Olsson; comments to author 02.12.23; revised version received 06.03.24; accepted 21.03.24; published 28.05.24.

©Carly A Cermak, Heather Read, Lianne Jeffs. Originally published in JMIR Formative Research (https://formative.jmir.org), 28.05.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

This paper is in the following e-collection/theme issue:

Published on 29.5.2024 in Vol 26 (2024)

Long-Term Emotional Impact of the COVID-19 Pandemic and Barriers and Facilitators to Digital Mental Health Tools in Long-Term Care Workers: Qualitative Study

Authors of this article:

Original Paper

• Leticia González-Spinoglio 1 , MSc   ; 
• Anna Monistrol-Mula 1, 2 , MSc   ; 
• Cecilia Vindrola-Padros 3 , PhD   ; 
• Salvatore Aguilar-Ortiz 1 , PhD   ; 
• Bernat Carreras 4 , MSc   ; 
• Josep Maria Haro 1, 2, 5 , PhD   ; 
• Mireia Felez-Nobrega 1, 2 , PhD  

1 Research and Development Unit, Parc Sanitari Sant Joan de Déu, Institut Sant Joan de Déu, Barcelona, Spain

2 Centre for Biomedical Research on Mental Health, Madrid, Spain

3 Department of Targeted Intervention, University College London, London, United Kingdom

4 Department of Psychiatry and Psychology, Institute of Neuroscience, Hospital Clínic, Barcelona, Spain

5 Departament de Medicina, Universitat de Barcelona, Barcelona, Spain

Corresponding Author:

Josep Maria Haro, PhD

Research and Development Unit, Parc Sanitari Sant Joan de Déu

Institut Sant Joan de Déu

C/Dr Antoni Pujada 42

Sant Boi de Llobregat

Barcelona, 08830

Phone: 34 93 640 63 50

Email: [email protected]

Background: The overall pandemic created enormous pressure on long-term care workers (LTCWs), making them particularly vulnerable to mental disorders. Despite this, most of the available evidence on professional well-being during COVID-19 has exclusively focused on frontline health care workers.

Objective: This study aimed to identify the long-term psychological needs of LTCWs derived from the COVID-19 pandemic and to explore barriers and facilitators related to digital mental health tools. This is part of a project that seeks to develop a digital mental health intervention to reduce psychological distress in this population group.

Methods: We performed a qualitative study with a rapid research approach. Participants were LTCWs of the autonomous community of Catalonia. We conducted 30 semistructured interviews between April and September 2022. We used a qualitative content analysis method with an inductive-deductive approach.

Results: The period of the pandemic with the highest mental health burden was the COVID-19 outbreak, with almost all workers having experienced some form of emotional distress. Emotional distress persisted over time in more than half of the participants, with fatigue and nervousness being the main emotions expressed at the time of the interview. High workload, the feeling that pandemic times are not over, and poor working conditions that have remained since then have been the most frequently expressed determinants of such emotions. Potential barriers and facilitators to engagement with digital tools were also identified in terms of previous experience and beliefs of the target population, possibilities for the integration of a digital tool into daily life, preferences regarding the level of guidance, the possibility of social connectedness through the tool, and privacy and confidentiality. The identified factors may become especially relevant in the context of the pandemic remission phase.

Conclusions: More than 2 years after the pandemic outbreak, emotional distress is still relevant. The persistent burden of psychological distress points to a need for institutions to take action to improve working conditions and promote employees’ well-being. Considering factors that act as barriers and facilitators for the use of digital mental health tools, it is important to develop tailored tools that could offer valuable support to this population during and after a pandemic.

Introduction

Long-term care facilities, such as nursing homes and other assisted living facilities, have been hit particularly hard by the COVID-19 pandemic. By February 2021, approximately 41% of the global COVID-19-associated mortality occurred in long-term care residents [ 1 ]. In Spain, the COVID-19 outbreak entailed especially tragic consequences, mainly caused by the precariousness of these care systems [ 2 ]. According to data from the Spanish Ministry of Health, 27,359 long-term residents died between April 6 and June 20, 2020, which represents approximately 70% of the total COVID-19 deaths. Long-term care workers (LTCWs) have been constantly exposed to anguish and death, have witnessed the social isolation and loneliness of residents due to health restrictions, and have experienced a drastic increase in their working demands [ 3 - 5 ]. Consequently, the mental health and well-being of this population group have been compromised, with clinically relevant levels of stress, anxiety, and depression increasing to nearly 60% from March 2020 to June 2020 [ 4 ].

As we approach the third year of the pandemic, health and care workers continue to respond to uncertainties, potential new waves, and the long-term effects of COVID-19. Importantly, recent evidence highlights increased concerns for burnout in this population [ 6 ], which can ultimately jeopardize the quality of health care as well as patient safety [ 7 ]. While mounting evidence has assessed the mental health experiences, views, and needs of care professionals during the early stages of the pandemic, there is scarce knowledge about the long-term emotional impact. This information is crucial to develop tailored interventions in response to their emotional demands.

Digital mental health tools (DMHTs) are a promising strategy to mitigate psychological consequences in the context of a long-lasting pandemic since they can be delivered remotely, avoiding the risk of transmission of the infection [ 8 ]. Yet, low levels of user engagement have been recognized as important barriers that may compromise the efficacy and scalability of interventions [ 9 ]. Increasing (prepandemic) evidence is beginning to unravel key factors that influence user engagement and the effectiveness of engagement strategies. For instance, positive prior experiences with mental health services and technology, digital literacy, the credibility of content, guidance within the intervention, increased social connectedness, a greater number of engagement features, reminders, and tailored feedback have been identified as potential facilitators for promoting engagement or effectiveness of digital interventions [ 10 - 13 ]. Nonetheless, these are general features reported in studies that included a wide range of different populations (eg, refugees, general population, people who are homeless, and people with a diagnosis of mental disorders), and it is well recognized that understanding the settings and population’s needs (eg, COVID-19 pandemic and long-term care facility characteristics) is a key factor for user engagement and intervention implementation success [ 14 ].

In this context, this study aimed to identify the long-term psychological needs of LTCWs as well as explore barriers and facilitators in relation to DMHTs. These findings will be used to inform and guide the development of a digital intervention to reduce psychological distress in this population group. The effectiveness of the psychological digital intervention will be tested through a randomized clinical trial (ClinicalTrials.gov NCT05526235).

Study Design, Sampling, and Participants

This qualitative study was conducted with a phenomenological orientation, in which we used a rapid research approach. In time-sensitive contexts, such as a pandemic, rapid appraisals allow us to collect and analyze data in a targeted and iterative way within limited time frames and, consequently, adapt and design expedient interventions for improving health care [ 15 ]. For reporting purposes, we adhered to the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist [ 16 ].

Semistructured interviews were conducted with workers from long-term care facilities (including nursing homes and other long-term care facilities), who were on duty during the pandemic in the autonomous community of Catalonia. For the recruitment of participants, we contacted several long-term care facilities and presented the project to each representative. Once the facility agreed to participate, the managerial staff shared the study information sheet among their employees (via their usual official means of communication). When needed, the researcher conducted informative talks (in person or via teleconference) with LTCWs in order to disseminate the study and resolve doubts, if any. A total of 6 long-term care facilities from the metropolitan area of Barcelona participated in the study.

Ethical Considerations

Ethics approval was provided by the Fundació Sant Joan de Déu Ethics Committee, Barcelona, Spain (PIC 214-21). Participants were fully informed about the objectives and procedures of the study prior to signing the informed consent. The data set was pseudoanonymized, and personal data were stored separately and securely on institution servers.

Data Collection

Interviews were conducted between April and September 2022. They were individual, by videoconference, and lasted between 25 and 40 minutes. The interview guide (provided in Multimedia Appendix 1 ) was reviewed by 2 experts in quality-of-life research to ensure its adequacy, and it was then tested with the first 2 interviews. No adaptations had to be made. The interview guide related to the digital mental health section was based on the framework developed by Borghouts et al [ 11 ]. Participants were given the option of conducting the interview in Spanish or Catalan, according to their preferences. Two researchers (AM-M and LG-S) conducted the interviews. Both are female PhD candidates. AM-M conducted the interviews in Catalan (8/30, 27% interviews), and LG-S conducted the interviews in Spanish (22/30, 73%). Both interviewers were previously trained in qualitative interview methods. Participants were informed of the interviewers’ educational and professional background, and no working or personal relationship existed between participants and interviewers. All interviews were audio recorded, and the main points were documented in real-time notes. At the conclusion of each interview, the emerging findings were synthesized using a RREAL (Rapid Research Evaluation and Appraisal Lab) Sheet (provided in Multimedia Appendix 2 ). The RREAL Sheet is a flexible working document, normally presented as a table, designed for the collection, synthesis, reporting, and analysis of data [ 17 ]. It enhances familiarization with the data and facilitates analysis while data collection is still ongoing [ 15 , 17 ]. First, a table organized by categories was designed using the interview script as a guide, and we piloted or amended this RREAL Sheet during initial data collection. Then, after each interview, we registered the key data obtained using real-time notes. In instances where pertinent details were absent, we referred to the audio recordings for further clarification. Importantly, the categories represented in the table were modified whenever considered necessary during data collection. Finally, the RREAL Sheet was used to guide an in-depth analysis [ 17 ]. The sample size was determined by thematic saturation [ 18 ].

Data Analysis

We used a qualitative content analysis method with an inductive-deductive approach. We performed a 1-page table that summarized the core components registered on the RREAL Sheet to identify key themes [ 17 ]. Once key themes and specific issues (subthemes) were recognized, we selected quotes from the interviews that could exemplify these themes. Investigator triangulation ensured that the themes reflected the full range and depth of the data.

Sample Characteristics

A total of 30 LTCWs participated in the study. The mean age was 44 (SD 11.4) years, most of our sample were women (n=26, 87%), and one-third (n=10, 33%) were from foreign nationalities. The vast majority of the participants were geriatric nursing assistants (n=17, 57%), followed by nurses (n=5, 17%). A more detailed description of the sociodemographic and occupational characteristics of the sample can be found in Table 1 .

a Director (n=1), occupational therapist (n=1), social worker (n=1), and cleaning staff (n=1).

Impact of COVID-19 on LTCWs’ Mental Health

Almost all participants identified the COVID-19 outbreak as the worst period for their mental health and reported having experienced emotional distress during this stage. The main emotions expressed were fear, helplessness, abandonment, loneliness, and sadness. Less frequently expressed emotions also included frustration, anger, uncertainty, and exhaustion. Five themes emerged as the main perceived determinants of these emotions:

• Unexpected and sudden nature of the crisis: Most participants expressed problems related to facing something new and completely unknown for which they were not prepared and its consequences. The reported main causes of distress were lack of information and knowledge, shortage of materials and human resources, problems with institutional organization, and the constant change of protocols and having to readjust to them.
• High exposure to emotional anguish and death: Half of the participants referred to high exposure to death and emotional anguish. They mainly mentioned the high mortality among residents and the helplessness of witnessing their isolation due to suspended family visits and reduced interactions resulting from health restrictions. Several participants also referred to the emotional anguish caused by the deaths of colleagues, family members, or friends as well as seeing the anguish in their colleagues on a daily basis.
• Fear of infection: Almost half of the participants mentioned the strong fear of infecting themselves, residents, and family members as well as the potential consequences of infection (eg, the severity of the disease and death).
• Moral distress: Many workers reported feelings of hopelessness, expressing that nothing they did for the residents in terms of care was enough. This was accompanied, in many cases, by a sense of loss of control of the situation during their caregiving duties.
• Lack of support: Many workers referred to a lack of recognition and support from authorities (both at the workplace and from the overall health authorities).

Textbox 1 provides an overview of these themes with example quotes for supporting data.

Unexpected and sudden nature of the crisis

• “We were not prepared; it came from one moment to the next.” [REPICAL (Reducing the psychosocial impact of the Covid-19 pandemic on workers of assisted living facilities)-007]
• “I also had to guide others in my charge, about things that I did not know either.” [REPICAL-004]
• “The protocols that we received were not clear...We were all in a drifting boat.” [REPICAL-008]
• “Overnight we were alone with co-workers. We were very lost; we did not have personal protective equipment and we did not know how to act. There were 4 of us and we managed as best as we could.” [REPICAL-026]

High exposure to emotional anguish and death

• “The worst thing I experienced was seeing so many residents die in such a short time, people who were fine and the next day they were gone.” [REPICAL-019]
• “We were not aware of the magnitude of this until residents began to die, they began to die one after the other, 4 or 5 per day (when before maybe one died every 2 months).” [REPICAL-026]
• “Seeing the loneliness in the residents affected me a lot, seeing that they were going to die alone, that they were not able to be with their family. It also affected me to see my co-workers, the most cheerful ones, defeated.” [REPICAL-021]
• “I felt so helpless seeing the isolated residents. We were asked not to have contact with them, but they needed someone to hold their hand.” [REPICAL-030]

Moral distress

• “We had to take measures that, while necessary, we knew were not good for the residents.” [REPICAL-003]
• “No matter what we did, people kept dying.” [REPICAL-004]
• “We saw that they were unwell and we could not help them...we wanted to address everything, but we could not.” [REPICAL-028]

Fear of infection

• “I even moved and lived in the residence for a while, so as not to infect the residents.” [REPICAL-019]
• “I had to isolate myself at home and I could not be with my child because I was afraid of infecting him. I also used to think: if something happens to me and my husband, who will take care of my child?” [REPICAL-023]

Lack of support

• “What I felt most was abandonment.” [REPICAL-002]
• “Feeling of helplessness of not being able to do anything and not having help from anyone.” [REPICAL-010]

In relation to their current emotional state, over half of the participants expressed some type of persistence of emotional distress over time. Among all participants, a minority reported maintaining intense distress, and a significant portion expressed only some improvement since the outbreak. The emotions most often mentioned were fatigue and nervousness, followed by anger and sadness. Three themes emerged as the main determinants of the persistent emotional distress:

• High workload: Long shifts due to staff shortages and coping with postcrisis backlog.
• Pandemic times are not over: Fatigue and residual discomfort from being under stress for so long as well as the feeling of not being able to completely move forward from COVID-19 due to the nature of their work.
• Still poor working conditions: Although the pandemic clearly highlighted the precariousness of these health care systems, some participants claimed that no measures have been taken to address this situation and that, as a result, working conditions remain poor. Relatedly, LTCWs felt that there is an overall failure in learning from the lessons of the COVID-19 pandemic.

Textbox 2 provides an overview of these themes with example quotes for supporting data.

On the other hand, among those participants who expressed a noticeable improvement over time in their emotional discomfort, hope and relief were the most commonly mentioned emotions. Improvement was associated with an increased sense of control over the situation, confidence in vaccines, decreased measures of isolation, and the feeling of regaining prepandemic working dynamics.

High workload

• “I am overwhelmed. In 2020, they increased my working hours. I was told it would only be during the state of emergency, but I am still not doing my usual schedule. In addition, people have left the workforce, and they have not hired more. I do not have as much time as I would like for other things.” [REPICAL-004]
• “Many projects were stopped because of the pandemic and now they have to be ready overnight. The workload is unreal.” [REPICAL-001]
• “Now we are facing our patients’ pathologies that were neglected during these two years. I am exhausted.” [REPICAL-005]

Pandemic times are not over

• “I am tired and burned out from dragging on for so long in tension, needing it to be over and it will not end.” [REPICAL-003]
• “Everyone has moved on, but I am still there: with the masks, the protective equipment, the heat.” [REPICAL-031]
• “During the crisis, we were alert at night in case a co-worker called us for help, and we always called each other; now I keep waking up even if they do not call me.” [REPICAL-026]

Still poor working conditions

• “With the pandemic, deficits that already existed in our field have come to light, and the thing is that nothing has changed, it’s just going back to the old ways. Nothing has been learned.” [REPICAL-002]

Digital Mental Health Tools

Previous experience and beliefs.

Almost all participants reported having no previous experience with DMHTs and emphasized their lack of confidence in their own digital skills. Nonetheless, the vast majority reported believing that such tools could be helpful in improving their mental health. The minority who reported not having confidence in digital tools mainly referred to their preference for personal, face-to-face contact.

Integration Into Daily Life

When participants were asked about what characteristics a DMHT should have to make it easy for them to integrate it into their daily lives, the majority of participants referred to the importance of accessibility: “easy to use,” “intuitive,” “didactic,” and “visual.” Some respondents also highlighted the importance of flexibility in using the tool in a time-convenient manner as well as being able to access from a mobile phone.

Level of Guidance and Social Connectedness

Regarding the level of guidance or support when using DMHTs, the majority of our sample reported preferring a guided intervention via a coach rather than a self-guided tool, expressing that the figure of a coach generates more confidence in the intervention and a greater sense of “closeness” despite the lack of in-person contact. Others mentioned the possibility of combining both modalities based on preference or demand. As for the profile of the coach, the most frequently mentioned professional role was a psychologist. However, rather than a professional role, most participants placed greater emphasis on the coach’s personal characteristics and skills, mainly highlighting empathy, active listening, receptivity, dynamism, and the ability to inspire confidence. As for the type of communication with the coach, the most preferred modality was videoconferencing, followed by telephone contact, and finally written messages. Some also mentioned the possibility of combining modalities, depending on the content and personal needs. Most of the participants preferred to accessing the content of the tool in stages or organized in modules rather than having it all available from the beginning. They indicated that this organization in modules would increase learnability by helping them navigate the tool in a more structured manner. Regarding content, some participants spontaneously emphasized the importance of having specific mental health content tailored to their needs rather than broad or general information. In addition, most noted that a reminder system, such as alarms, would be useful to aid engagement. Finally, regarding the possibility of being able to communicate with other users of the tool, a majority expressed that it would be a good idea, while a smaller group had doubts, and a few stated they would not use this option even if available.

Privacy and Confidentiality

Most participants reported that they would trust confidentiality protection mainly on the premise that when such an intervention is implemented within the context of a research study and with institutional backing, confidentiality should already be guaranteed. Among the few who expressed concerns, these were related to data privacy (sharing data with third parties), mentioning their concern about a possible link with social networks and the use of private data for advertising. On the other hand, almost all participants preferred nonanonymity with the figure of the coach to further “humanize” the intervention and increase confidence.

Principal Findings

Our results showed that the worst stage of the pandemic in terms of mental health was the outbreak, with almost all workers experiencing some form of emotional distress. The main emotions that participants expressed during this stage, as well as their determinants, are consistent with those reported by other national and international studies conducted on frontline health care workers during the first wave of the pandemic [ 3 - 5 , 19 - 22 ].

Importantly, our results showed that perceived emotional distress, main emotions, and their determinants changed over time. We found that almost half of the sample reported an improvement in their emotional discomfort over time, expressing hope and relief. This improvement was associated with a greater feeling of control over the situation, confidence in vaccines, decreased measures of isolation, and the feeling of regaining prepandemic working dynamics. Nonetheless, more than 2 years after the outbreak, emotional distress persisted for over half of the sample. Fatigue and nervousness were the main expressed emotions, which were determined by a high workload, the feeling that pandemic times are not over, and sustained poor working conditions. This result is consistent with other epidemiological studies, which showed that poor mental health outcomes among health care workers tend to persist over time [ 23 - 25 ] and that the main symptoms of poor mental health tend to change with the different COVID-19 stages as well [ 26 ].

Fatigue, nervousness, and emotional exhaustion, which may occur in response to chronic work stressors, are common signs of burnout [ 27 , 28 ]. Fatigue, which is not only linked to lower job satisfaction and increased rates of absenteeism [ 29 ], can also impair concentration and slow reaction times, elevating the risk of workplace accidents or fatigue-related incidents [ 30 ]. The assessment of the determinants of such emotional distress provides valuable input into potential intervention strategies to respond to such calls. Multifaceted interventions with a holistic approach and implemented in a timely manner are needed to protect the mental health and well-being of these workers during and after the pandemic. Similar to recommendations and claims made for the health care workforce, interventions for care workers should also be targeted at the organizational or institutional level via systematic support and at the individual level by implementing psychological interventions for those workers with emotional distress [ 29 , 31 , 32 ]. It is not enough that the institutions have been reactive to the pandemic with concrete measures to deal with a sudden crisis. They need to implement long-lasting workplace changes to improve working conditions and promote the long-term well-being of their staff. At the individual level, offering tailored digital psychological interventions using cognitive behavioral therapy is a promising option for workers experiencing emotional distress [ 29 ].

Since digital mental health interventions can represent a promising individual-level strategy to improve the mental health of LTCWs, we identified several barriers and facilitators for their successful engagement in the context of the COVID-19 remission phase.

Not only did almost all participants deny having any previous experience in the use of DMHTs, but almost a half of them also spontaneously referred to their lack of skills in the use of digital tools. This is a potential barrier that may be linked to the mean age of the sample (44, SD 11.4 years), since previous studies found that younger people have higher adherence to this type of intervention than older people [ 33 , 34 ]. Despite this lack of experience, the vast majority of participants reported believing that using DMHTs could be helpful in improving their mental health. This is an important facilitator since people’s expectations and preconceived beliefs about whether a tool will be effective positively influence experience and engagement [ 35 - 37 ]. In this regard, addressing the expectations and beliefs of the target population before developing a DMHT (or as an early step during the development process) could help identify and consequently manage early barriers [ 37 ].

Most participants highlighted the importance of accessibility when using a DMHT. Similar to previous studies [ 9 , 37 ], we found that achieving “user-friendly” tools is a key facilitator for engagement. In addition, participants also highlighted the importance of flexibility, which would enable them to use the tool according to their needs and changing working shifts .

Regarding the level of guidance or support, the majority of participants reported a preference for a guided intervention with a human coach rather than a self-guided tool, which is also in line with findings from previous studies [ 11 , 37 ]. Increased support may enhance and extend engagement in DMHTs. In the context of a pandemic, where social contact may be limited, this feature becomes even more relevant. Reminder systems are also important facilitators since they could prevent forgetfulness and encourage users to stay committed [ 37 ]. Furthermore, satisfaction with the type of content and the manner the materials are offered is critical to engagement. Interestingly, most of our participants express a preference for the tool’s content to be delivered in stages or modules, aiming to enhance learnability and facilitate structured navigation. Additionally, some participants underscore the significance of receiving personalized content that fits their needs or interests. Therefore, addressing user needs is key to preventing dropouts and ensuring sustained engagement [ 9 ]. In turn, most of our sample expressed that having the possibility to communicate with other users of the tool would be beneficial. Prior to the pandemic, social connectedness through DMHTs had proven to be not only a facilitator for engagement [ 38 ] but also a tool with therapeutic value per se [ 39 ]. In the current context, where social interactions have changed, this possibility could be even more relevant.

Finally, most participants in our study reported a high level of trust in confidentiality. This places significant responsibility on those developing mental health interventions through DMHTs. Research has indicated that the transmission of data to third parties by mental health smartphone apps is prevalent, thereby denying users an informed choice regarding whether or not to accept such sharing [ 40 ]. This issue may be a consequence of most DMHTs existing outside of health care regulation and also falling outside of health care privacy legislation [ 9 ]. A clear and transparent written privacy policy should always be available to inform users about how their data are going to be used.

At this juncture, it is crucial to contemplate the transferability of our findings to other work environments and populations. Although our research focused on a specific group in a particular context, the emerging themes and shared emotional experiences might resonate in similar situations. The fluctuation in perceptions over time provides a dynamic perspective that can be insightful for understanding long-term impacts in the context of future global pandemics. On the other hand, the impact of variables such as age or digital skills, perceived as potential barriers to the adoption of DMHTs, could be extrapolated to other populations, such as informal carers. The preference for guided interventions and the significance of accessibility and flexibility, among other variables, are also elements that might have broader applications in the design of DMHTs. It is imperative to acknowledge that each work environment and demographic group has its own unique characteristics, and the direct application of our results may necessitate adjustments. Nevertheless, by presenting these findings in a detailed and transparent manner, we aim to provide valuable insights that can guide future research and intervention strategies in diverse settings.

Limitations

This study acknowledges certain limitations that are crucial for contextualizing and evaluating the robustness of the findings. First, we did not account for participants’ preexisting mental health conditions (prior to COVID-19) when we assessed mental health needs. This could bear significant implications, as individuals with preexisting mental disorders are particularly vulnerable to the mental health threat of the pandemic. Second, the uneven gender distribution in our sample, with only 4 men, poses a limitation in terms of generalizing findings to this group. While our sample was not centralized in a single location, it is worth noting that all participating centers are located in the metropolitan area of Barcelona, which may limit the generalizability of our findings to the broader Catalonia region. Future studies should use more heterogeneous samples. Finally, inherent in qualitative research, there may be a potential for selection bias since workers were to some extent self-selected.

Conclusions

We identified that the worst stage of the pandemic in terms of LTCWs’ mental health was the COVID-19 outbreak, in which all workers reported having experienced some form of emotional distress. We also identified a persistence of emotional distress over time in more than a half of the participants, with fatigue and nervousness being the most frequently expressed emotions. This suggests that, although many workers significantly improved their psychological discomfort, mental health problems in this group are still relevant even more than 2 years after the pandemic outbreak. Future studies are needed to determine the factors that promote or hinder resilience among this underrepresented population group in order to shape implementation strategies to promote well-being. Finally, this study also identified new barriers and facilitators to engagement with DMHTs during the remission phase of the COVID-19 pandemic. These findings provide key information for the development of tailored digital mental health interventions among LTCWs.

Acknowledgments

This work was supported by the Instituto de Salud Carlos III (CD20/00036 to MF-N) and by la Fundació La Marato TV3 (202114 to JMH). The funding bodies had no role in study design, data collection and analysis, interpretation of data, or writing the manuscript.

Data Availability

The data sets generated during and analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

LG-S conceptualized the study, conducted methodology, performed formal analysis, and drafted the original manuscript. AM-M conducted methodology and performed formal analysis. CV-P contributed to conceptualization and methodology. SA-O and BC contributed to conceptualization. JMH conceptualized the study, contributed to methodology, and acquired funding. MF-N conceptualized the study, conducted methodology, managed project administration, and participated in writing, reviewing, and editing. LG-S, AM-M, CV-P, SA-O, BC, and JMH participated in reviewing and editing.

Conflicts of Interest

None declared.

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Abbreviations

Edited by T Leung; submitted 24.03.23; peer-reviewed by A AL-Asadi, P Petri-Romao, S Rennick-Egglestone; comments to author 19.01.24; revised version received 08.02.24; accepted 14.02.24; published 29.05.24.

©Leticia González-Spinoglio, Anna Monistrol-Mula, Cecilia Vindrola-Padros, Salvatore Aguilar-Ortiz, Bernat Carreras, Josep Maria Haro, Mireia Felez-Nobrega. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 29.05.2024.

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