hypothesis of the study in qualitative research

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What is a Research Hypothesis: How to Write it, Types, and Examples

Any research begins with a research question and a research hypothesis . A research question alone may not suffice to design the experiment(s) needed to answer it. A hypothesis is central to the scientific method. But what is a hypothesis ? A hypothesis is a testable statement that proposes a possible explanation to a phenomenon, and it may include a prediction. Next, you may ask what is a research hypothesis ? Simply put, a research hypothesis is a prediction or educated guess about the relationship between the variables that you want to investigate.  

It is important to be thorough when developing your research hypothesis. Shortcomings in the framing of a hypothesis can affect the study design and the results. A better understanding of the research hypothesis definition and characteristics of a good hypothesis will make it easier for you to develop your own hypothesis for your research. Let’s dive in to know more about the types of research hypothesis , how to write a research hypothesis , and some research hypothesis examples .  

Table of Contents

What is a hypothesis ?  

A hypothesis is based on the existing body of knowledge in a study area. Framed before the data are collected, a hypothesis states the tentative relationship between independent and dependent variables, along with a prediction of the outcome.  

What is a research hypothesis ?  

Young researchers starting out their journey are usually brimming with questions like “ What is a hypothesis ?” “ What is a research hypothesis ?” “How can I write a good research hypothesis ?”   

A research hypothesis is a statement that proposes a possible explanation for an observable phenomenon or pattern. It guides the direction of a study and predicts the outcome of the investigation. A research hypothesis is testable, i.e., it can be supported or disproven through experimentation or observation.     

Characteristics of a good hypothesis  

Here are the characteristics of a good hypothesis :  

• Clearly formulated and free of language errors and ambiguity  
• Concise and not unnecessarily verbose  
• Has clearly defined variables  
• Testable and stated in a way that allows for it to be disproven  
• Can be tested using a research design that is feasible, ethical, and practical   
• Specific and relevant to the research problem  
• Rooted in a thorough literature search  
• Can generate new knowledge or understanding.  

How to create an effective research hypothesis  

A study begins with the formulation of a research question. A researcher then performs background research. This background information forms the basis for building a good research hypothesis . The researcher then performs experiments, collects, and analyzes the data, interprets the findings, and ultimately, determines if the findings support or negate the original hypothesis.  

Let’s look at each step for creating an effective, testable, and good research hypothesis :  

• Identify a research problem or question: Start by identifying a specific research problem.   
• Review the literature: Conduct an in-depth review of the existing literature related to the research problem to grasp the current knowledge and gaps in the field.   
• Formulate a clear and testable hypothesis : Based on the research question, use existing knowledge to form a clear and testable hypothesis . The hypothesis should state a predicted relationship between two or more variables that can be measured and manipulated. Improve the original draft till it is clear and meaningful.  
• State the null hypothesis: The null hypothesis is a statement that there is no relationship between the variables you are studying.   
• Define the population and sample: Clearly define the population you are studying and the sample you will be using for your research.  
• Select appropriate methods for testing the hypothesis: Select appropriate research methods, such as experiments, surveys, or observational studies, which will allow you to test your research hypothesis .  

Remember that creating a research hypothesis is an iterative process, i.e., you might have to revise it based on the data you collect. You may need to test and reject several hypotheses before answering the research problem.  

How to write a research hypothesis  

When you start writing a research hypothesis , you use an “if–then” statement format, which states the predicted relationship between two or more variables. Clearly identify the independent variables (the variables being changed) and the dependent variables (the variables being measured), as well as the population you are studying. Review and revise your hypothesis as needed.  

An example of a research hypothesis in this format is as follows:  

“ If [athletes] follow [cold water showers daily], then their [endurance] increases.”  

Population: athletes  

Independent variable: daily cold water showers  

Dependent variable: endurance  

You may have understood the characteristics of a good hypothesis . But note that a research hypothesis is not always confirmed; a researcher should be prepared to accept or reject the hypothesis based on the study findings.  

Research hypothesis checklist  

Following from above, here is a 10-point checklist for a good research hypothesis :  

• Testable: A research hypothesis should be able to be tested via experimentation or observation.  
• Specific: A research hypothesis should clearly state the relationship between the variables being studied.  
• Based on prior research: A research hypothesis should be based on existing knowledge and previous research in the field.  
• Falsifiable: A research hypothesis should be able to be disproven through testing.  
• Clear and concise: A research hypothesis should be stated in a clear and concise manner.  
• Logical: A research hypothesis should be logical and consistent with current understanding of the subject.  
• Relevant: A research hypothesis should be relevant to the research question and objectives.  
• Feasible: A research hypothesis should be feasible to test within the scope of the study.  
• Reflects the population: A research hypothesis should consider the population or sample being studied.  
• Uncomplicated: A good research hypothesis is written in a way that is easy for the target audience to understand.  

By following this research hypothesis checklist , you will be able to create a research hypothesis that is strong, well-constructed, and more likely to yield meaningful results.  

Types of research hypothesis  

Different types of research hypothesis are used in scientific research:  

1. Null hypothesis:

A null hypothesis states that there is no change in the dependent variable due to changes to the independent variable. This means that the results are due to chance and are not significant. A null hypothesis is denoted as H0 and is stated as the opposite of what the alternative hypothesis states.   

Example: “ The newly identified virus is not zoonotic .”  

2. Alternative hypothesis:

This states that there is a significant difference or relationship between the variables being studied. It is denoted as H1 or Ha and is usually accepted or rejected in favor of the null hypothesis.  

Example: “ The newly identified virus is zoonotic .”  

3. Directional hypothesis :

This specifies the direction of the relationship or difference between variables; therefore, it tends to use terms like increase, decrease, positive, negative, more, or less.   

Example: “ The inclusion of intervention X decreases infant mortality compared to the original treatment .”   

4. Non-directional hypothesis:

While it does not predict the exact direction or nature of the relationship between the two variables, a non-directional hypothesis states the existence of a relationship or difference between variables but not the direction, nature, or magnitude of the relationship. A non-directional hypothesis may be used when there is no underlying theory or when findings contradict previous research.  

Example, “ Cats and dogs differ in the amount of affection they express .”  

5. Simple hypothesis :

A simple hypothesis only predicts the relationship between one independent and another independent variable.  

Example: “ Applying sunscreen every day slows skin aging .”  

6 . Complex hypothesis :

A complex hypothesis states the relationship or difference between two or more independent and dependent variables.   

Example: “ Applying sunscreen every day slows skin aging, reduces sun burn, and reduces the chances of skin cancer .” (Here, the three dependent variables are slowing skin aging, reducing sun burn, and reducing the chances of skin cancer.)  

7. Associative hypothesis:  

An associative hypothesis states that a change in one variable results in the change of the other variable. The associative hypothesis defines interdependency between variables.  

Example: “ There is a positive association between physical activity levels and overall health .”  

8 . Causal hypothesis:

A causal hypothesis proposes a cause-and-effect interaction between variables.  

Example: “ Long-term alcohol use causes liver damage .”  

Note that some of the types of research hypothesis mentioned above might overlap. The types of hypothesis chosen will depend on the research question and the objective of the study.  

Research hypothesis examples  

Here are some good research hypothesis examples :  

“The use of a specific type of therapy will lead to a reduction in symptoms of depression in individuals with a history of major depressive disorder.”  

“Providing educational interventions on healthy eating habits will result in weight loss in overweight individuals.”  

“Plants that are exposed to certain types of music will grow taller than those that are not exposed to music.”  

“The use of the plant growth regulator X will lead to an increase in the number of flowers produced by plants.”  

Characteristics that make a research hypothesis weak are unclear variables, unoriginality, being too general or too vague, and being untestable. A weak hypothesis leads to weak research and improper methods.   

Some bad research hypothesis examples (and the reasons why they are “bad”) are as follows:  

“This study will show that treatment X is better than any other treatment . ” (This statement is not testable, too broad, and does not consider other treatments that may be effective.)  

“This study will prove that this type of therapy is effective for all mental disorders . ” (This statement is too broad and not testable as mental disorders are complex and different disorders may respond differently to different types of therapy.)  

“Plants can communicate with each other through telepathy . ” (This statement is not testable and lacks a scientific basis.)  

Importance of testable hypothesis  

If a research hypothesis is not testable, the results will not prove or disprove anything meaningful. The conclusions will be vague at best. A testable hypothesis helps a researcher focus on the study outcome and understand the implication of the question and the different variables involved. A testable hypothesis helps a researcher make precise predictions based on prior research.  

To be considered testable, there must be a way to prove that the hypothesis is true or false; further, the results of the hypothesis must be reproducible.  

Frequently Asked Questions (FAQs) on research hypothesis  

1. What is the difference between research question and research hypothesis ?  

A research question defines the problem and helps outline the study objective(s). It is an open-ended statement that is exploratory or probing in nature. Therefore, it does not make predictions or assumptions. It helps a researcher identify what information to collect. A research hypothesis , however, is a specific, testable prediction about the relationship between variables. Accordingly, it guides the study design and data analysis approach.

2. When to reject null hypothesis ?

A null hypothesis should be rejected when the evidence from a statistical test shows that it is unlikely to be true. This happens when the test statistic (e.g., p -value) is less than the defined significance level (e.g., 0.05). Rejecting the null hypothesis does not necessarily mean that the alternative hypothesis is true; it simply means that the evidence found is not compatible with the null hypothesis.  

3. How can I be sure my hypothesis is testable?  

A testable hypothesis should be specific and measurable, and it should state a clear relationship between variables that can be tested with data. To ensure that your hypothesis is testable, consider the following:  

• Clearly define the key variables in your hypothesis. You should be able to measure and manipulate these variables in a way that allows you to test the hypothesis.  
• The hypothesis should predict a specific outcome or relationship between variables that can be measured or quantified.   
• You should be able to collect the necessary data within the constraints of your study.  
• It should be possible for other researchers to replicate your study, using the same methods and variables.   
• Your hypothesis should be testable by using appropriate statistical analysis techniques, so you can draw conclusions, and make inferences about the population from the sample data.  
• The hypothesis should be able to be disproven or rejected through the collection of data.  

4. How do I revise my research hypothesis if my data does not support it?  

If your data does not support your research hypothesis , you will need to revise it or develop a new one. You should examine your data carefully and identify any patterns or anomalies, re-examine your research question, and/or revisit your theory to look for any alternative explanations for your results. Based on your review of the data, literature, and theories, modify your research hypothesis to better align it with the results you obtained. Use your revised hypothesis to guide your research design and data collection. It is important to remain objective throughout the process.  

5. I am performing exploratory research. Do I need to formulate a research hypothesis?  

As opposed to “confirmatory” research, where a researcher has some idea about the relationship between the variables under investigation, exploratory research (or hypothesis-generating research) looks into a completely new topic about which limited information is available. Therefore, the researcher will not have any prior hypotheses. In such cases, a researcher will need to develop a post-hoc hypothesis. A post-hoc research hypothesis is generated after these results are known.  

6. How is a research hypothesis different from a research question?

A research question is an inquiry about a specific topic or phenomenon, typically expressed as a question. It seeks to explore and understand a particular aspect of the research subject. In contrast, a research hypothesis is a specific statement or prediction that suggests an expected relationship between variables. It is formulated based on existing knowledge or theories and guides the research design and data analysis.

7. Can a research hypothesis change during the research process?

Yes, research hypotheses can change during the research process. As researchers collect and analyze data, new insights and information may emerge that require modification or refinement of the initial hypotheses. This can be due to unexpected findings, limitations in the original hypotheses, or the need to explore additional dimensions of the research topic. Flexibility is crucial in research, allowing for adaptation and adjustment of hypotheses to align with the evolving understanding of the subject matter.

8. How many hypotheses should be included in a research study?

The number of research hypotheses in a research study varies depending on the nature and scope of the research. It is not necessary to have multiple hypotheses in every study. Some studies may have only one primary hypothesis, while others may have several related hypotheses. The number of hypotheses should be determined based on the research objectives, research questions, and the complexity of the research topic. It is important to ensure that the hypotheses are focused, testable, and directly related to the research aims.

9. Can research hypotheses be used in qualitative research?

Yes, research hypotheses can be used in qualitative research, although they are more commonly associated with quantitative research. In qualitative research, hypotheses may be formulated as tentative or exploratory statements that guide the investigation. Instead of testing hypotheses through statistical analysis, qualitative researchers may use the hypotheses to guide data collection and analysis, seeking to uncover patterns, themes, or relationships within the qualitative data. The emphasis in qualitative research is often on generating insights and understanding rather than confirming or rejecting specific research hypotheses through statistical testing.

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Related Posts

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Qualitative Study

Affiliations.

• 1 University of Nebraska Medical Center
• 2 GDB Research and Statistical Consulting
• 3 GDB Research and Statistical Consulting/McLaren Macomb Hospital
• PMID: 29262162
• Bookshelf ID: NBK470395

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

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

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore ‘compete’ against each other and the philosophical paradigms associated with each, qualitative and quantitative work are not necessarily opposites nor are they incompatible. While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.

Examples of Qualitative Research Approaches

Ethnography

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

Grounded Theory

Grounded Theory is the “generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior.” As opposed to quantitative research which is deductive and tests or verifies an existing theory, grounded theory research is inductive and therefore lends itself to research that is aiming to study social interactions or experiences. In essence, Grounded Theory’s goal is to explain for example how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

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

Narrative Research

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

Research Paradigm

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

Positivist vs Postpositivist

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

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

Constructivist

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

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

Data Sampling

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

Purposive sampling- selection based on the researcher’s rationale in terms of being the most informative.

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

Snowball sampling- the selection is by referral from other participants or people who know potential participants.

Extreme case sampling- targeted selection of rare cases.

Typical case sampling-selection based on regular or average participants.

Data Collection and Analysis

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

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or in the environment of the participants, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed which may then be coded manually or with the use of Computer Assisted Qualitative Data Analysis Software or CAQDAS such as ATLAS.ti or NVivo.

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

Dissemination

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

Examples of Application

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

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

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

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

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

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

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

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

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

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

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• Introduction
• Issues of Concern
• Clinical Significance
• Enhancing Healthcare Team Outcomes
• Review Questions

Publication types

• Study Guide

What Is A Research (Scientific) Hypothesis? A plain-language explainer + examples

By:  Derek Jansen (MBA)  | Reviewed By: Dr Eunice Rautenbach | June 2020

If you’re new to the world of research, or it’s your first time writing a dissertation or thesis, you’re probably noticing that the words “research hypothesis” and “scientific hypothesis” are used quite a bit, and you’re wondering what they mean in a research context .

“Hypothesis” is one of those words that people use loosely, thinking they understand what it means. However, it has a very specific meaning within academic research. So, it’s important to understand the exact meaning before you start hypothesizing. 

Research Hypothesis 101

• What is a hypothesis ?
• What is a research hypothesis (scientific hypothesis)?
• Requirements for a research hypothesis
• Definition of a research hypothesis
• The null hypothesis

What is a hypothesis?

Let’s start with the general definition of a hypothesis (not a research hypothesis or scientific hypothesis), according to the Cambridge Dictionary:

Hypothesis: an idea or explanation for something that is based on known facts but has not yet been proved.

In other words, it’s a statement that provides an explanation for why or how something works, based on facts (or some reasonable assumptions), but that has not yet been specifically tested . For example, a hypothesis might look something like this:

Hypothesis: sleep impacts academic performance.

This statement predicts that academic performance will be influenced by the amount and/or quality of sleep a student engages in – sounds reasonable, right? It’s based on reasonable assumptions , underpinned by what we currently know about sleep and health (from the existing literature). So, loosely speaking, we could call it a hypothesis, at least by the dictionary definition.

But that’s not good enough…

Unfortunately, that’s not quite sophisticated enough to describe a research hypothesis (also sometimes called a scientific hypothesis), and it wouldn’t be acceptable in a dissertation, thesis or research paper . In the world of academic research, a statement needs a few more criteria to constitute a true research hypothesis .

What is a research hypothesis?

A research hypothesis (also called a scientific hypothesis) is a statement about the expected outcome of a study (for example, a dissertation or thesis). To constitute a quality hypothesis, the statement needs to have three attributes – specificity , clarity and testability .

Let’s take a look at these more closely.

Need a helping hand?

Hypothesis Essential #1: Specificity & Clarity

A good research hypothesis needs to be extremely clear and articulate about both what’ s being assessed (who or what variables are involved ) and the expected outcome (for example, a difference between groups, a relationship between variables, etc.).

Let’s stick with our sleepy students example and look at how this statement could be more specific and clear.

Hypothesis: Students who sleep at least 8 hours per night will, on average, achieve higher grades in standardised tests than students who sleep less than 8 hours a night.

As you can see, the statement is very specific as it identifies the variables involved (sleep hours and test grades), the parties involved (two groups of students), as well as the predicted relationship type (a positive relationship). There’s no ambiguity or uncertainty about who or what is involved in the statement, and the expected outcome is clear.

Contrast that to the original hypothesis we looked at – “Sleep impacts academic performance” – and you can see the difference. “Sleep” and “academic performance” are both comparatively vague , and there’s no indication of what the expected relationship direction is (more sleep or less sleep). As you can see, specificity and clarity are key.

Hypothesis Essential #2: Testability (Provability)

A statement must be testable to qualify as a research hypothesis. In other words, there needs to be a way to prove (or disprove) the statement. If it’s not testable, it’s not a hypothesis – simple as that.

For example, consider the hypothesis we mentioned earlier:

Hypothesis: Students who sleep at least 8 hours per night will, on average, achieve higher grades in standardised tests than students who sleep less than 8 hours a night.  

We could test this statement by undertaking a quantitative study involving two groups of students, one that gets 8 or more hours of sleep per night for a fixed period, and one that gets less. We could then compare the standardised test results for both groups to see if there’s a statistically significant difference. 

Again, if you compare this to the original hypothesis we looked at – “Sleep impacts academic performance” – you can see that it would be quite difficult to test that statement, primarily because it isn’t specific enough. How much sleep? By who? What type of academic performance?

So, remember the mantra – if you can’t test it, it’s not a hypothesis 🙂

Defining A Research Hypothesis

You’re still with us? Great! Let’s recap and pin down a clear definition of a hypothesis.

A research hypothesis (or scientific hypothesis) is a statement about an expected relationship between variables, or explanation of an occurrence, that is clear, specific and testable.

So, when you write up hypotheses for your dissertation or thesis, make sure that they meet all these criteria. If you do, you’ll not only have rock-solid hypotheses but you’ll also ensure a clear focus for your entire research project.

What about the null hypothesis?

You may have also heard the terms null hypothesis , alternative hypothesis, or H-zero thrown around. At a simple level, the null hypothesis is the counter-proposal to the original hypothesis.

For example, if the hypothesis predicts that there is a relationship between two variables (for example, sleep and academic performance), the null hypothesis would predict that there is no relationship between those variables.

At a more technical level, the null hypothesis proposes that no statistical significance exists in a set of given observations and that any differences are due to chance alone.

And there you have it – hypotheses in a nutshell. 

If you have any questions, be sure to leave a comment below and we’ll do our best to help you. If you need hands-on help developing and testing your hypotheses, consider our private coaching service , where we hold your hand through the research journey.

Psst... there’s more!

This post was based on one of our popular Research Bootcamps . If you're working on a research project, you'll definitely want to check this out ...

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16 Comments

Very useful information. I benefit more from getting more information in this regard.

Very great insight,educative and informative. Please give meet deep critics on many research data of public international Law like human rights, environment, natural resources, law of the sea etc

In a book I read a distinction is made between null, research, and alternative hypothesis. As far as I understand, alternative and research hypotheses are the same. Can you please elaborate? Best Afshin

This is a self explanatory, easy going site. I will recommend this to my friends and colleagues.

Very good definition. How can I cite your definition in my thesis? Thank you. Is nul hypothesis compulsory in a research?

It’s a counter-proposal to be proven as a rejection

Please what is the difference between alternate hypothesis and research hypothesis?

It is a very good explanation. However, it limits hypotheses to statistically tasteable ideas. What about for qualitative researches or other researches that involve quantitative data that don’t need statistical tests?

In qualitative research, one typically uses propositions, not hypotheses.

could you please elaborate it more

I’ve benefited greatly from these notes, thank you.

This is very helpful

well articulated ideas are presented here, thank you for being reliable sources of information

Excellent. Thanks for being clear and sound about the research methodology and hypothesis (quantitative research)

I have only a simple question regarding the null hypothesis. – Is the null hypothesis (Ho) known as the reversible hypothesis of the alternative hypothesis (H1? – How to test it in academic research?

this is very important note help me much more

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Chapter 1. Introduction

“Science is in danger, and for that reason it is becoming dangerous” -Pierre Bourdieu, Science of Science and Reflexivity

Why an Open Access Textbook on Qualitative Research Methods?

I have been teaching qualitative research methods to both undergraduates and graduate students for many years.  Although there are some excellent textbooks out there, they are often costly, and none of them, to my mind, properly introduces qualitative research methods to the beginning student (whether undergraduate or graduate student).  In contrast, this open-access textbook is designed as a (free) true introduction to the subject, with helpful, practical pointers on how to conduct research and how to access more advanced instruction.  

Textbooks are typically arranged in one of two ways: (1) by technique (each chapter covers one method used in qualitative research); or (2) by process (chapters advance from research design through publication).  But both of these approaches are necessary for the beginner student.  This textbook will have sections dedicated to the process as well as the techniques of qualitative research.  This is a true “comprehensive” book for the beginning student.  In addition to covering techniques of data collection and data analysis, it provides a road map of how to get started and how to keep going and where to go for advanced instruction.  It covers aspects of research design and research communication as well as methods employed.  Along the way, it includes examples from many different disciplines in the social sciences.

The primary goal has been to create a useful, accessible, engaging textbook for use across many disciplines.  And, let’s face it.  Textbooks can be boring.  I hope readers find this to be a little different.  I have tried to write in a practical and forthright manner, with many lively examples and references to good and intellectually creative qualitative research.  Woven throughout the text are short textual asides (in colored textboxes) by professional (academic) qualitative researchers in various disciplines.  These short accounts by practitioners should help inspire students.  So, let’s begin!

What is Research?

When we use the word research , what exactly do we mean by that?  This is one of those words that everyone thinks they understand, but it is worth beginning this textbook with a short explanation.  We use the term to refer to “empirical research,” which is actually a historically specific approach to understanding the world around us.  Think about how you know things about the world. [1] You might know your mother loves you because she’s told you she does.  Or because that is what “mothers” do by tradition.  Or you might know because you’ve looked for evidence that she does, like taking care of you when you are sick or reading to you in bed or working two jobs so you can have the things you need to do OK in life.  Maybe it seems churlish to look for evidence; you just take it “on faith” that you are loved.

Only one of the above comes close to what we mean by research.  Empirical research is research (investigation) based on evidence.  Conclusions can then be drawn from observable data.  This observable data can also be “tested” or checked.  If the data cannot be tested, that is a good indication that we are not doing research.  Note that we can never “prove” conclusively, through observable data, that our mothers love us.  We might have some “disconfirming evidence” (that time she didn’t show up to your graduation, for example) that could push you to question an original hypothesis , but no amount of “confirming evidence” will ever allow us to say with 100% certainty, “my mother loves me.”  Faith and tradition and authority work differently.  Our knowledge can be 100% certain using each of those alternative methods of knowledge, but our certainty in those cases will not be based on facts or evidence.

For many periods of history, those in power have been nervous about “science” because it uses evidence and facts as the primary source of understanding the world, and facts can be at odds with what power or authority or tradition want you to believe.  That is why I say that scientific empirical research is a historically specific approach to understand the world.  You are in college or university now partly to learn how to engage in this historically specific approach.

In the sixteenth and seventeenth centuries in Europe, there was a newfound respect for empirical research, some of which was seriously challenging to the established church.  Using observations and testing them, scientists found that the earth was not at the center of the universe, for example, but rather that it was but one planet of many which circled the sun. [2]   For the next two centuries, the science of astronomy, physics, biology, and chemistry emerged and became disciplines taught in universities.  All used the scientific method of observation and testing to advance knowledge.  Knowledge about people , however, and social institutions, however, was still left to faith, tradition, and authority.  Historians and philosophers and poets wrote about the human condition, but none of them used research to do so. [3]

It was not until the nineteenth century that “social science” really emerged, using the scientific method (empirical observation) to understand people and social institutions.  New fields of sociology, economics, political science, and anthropology emerged.  The first sociologists, people like Auguste Comte and Karl Marx, sought specifically to apply the scientific method of research to understand society, Engels famously claiming that Marx had done for the social world what Darwin did for the natural world, tracings its laws of development.  Today we tend to take for granted the naturalness of science here, but it is actually a pretty recent and radical development.

To return to the question, “does your mother love you?”  Well, this is actually not really how a researcher would frame the question, as it is too specific to your case.  It doesn’t tell us much about the world at large, even if it does tell us something about you and your relationship with your mother.  A social science researcher might ask, “do mothers love their children?”  Or maybe they would be more interested in how this loving relationship might change over time (e.g., “do mothers love their children more now than they did in the 18th century when so many children died before reaching adulthood?”) or perhaps they might be interested in measuring quality of love across cultures or time periods, or even establishing “what love looks like” using the mother/child relationship as a site of exploration.  All of these make good research questions because we can use observable data to answer them.

What is Qualitative Research?

“All we know is how to learn. How to study, how to listen, how to talk, how to tell.  If we don’t tell the world, we don’t know the world.  We’re lost in it, we die.” -Ursula LeGuin, The Telling

At its simplest, qualitative research is research about the social world that does not use numbers in its analyses.  All those who fear statistics can breathe a sigh of relief – there are no mathematical formulae or regression models in this book! But this definition is less about what qualitative research can be and more about what it is not.  To be honest, any simple statement will fail to capture the power and depth of qualitative research.  One way of contrasting qualitative research to quantitative research is to note that the focus of qualitative research is less about explaining and predicting relationships between variables and more about understanding the social world.  To use our mother love example, the question about “what love looks like” is a good question for the qualitative researcher while all questions measuring love or comparing incidences of love (both of which require measurement) are good questions for quantitative researchers. Patton writes,

Qualitative data describe.  They take us, as readers, into the time and place of the observation so that we know what it was like to have been there.  They capture and communicate someone else’s experience of the world in his or her own words.  Qualitative data tell a story. ( Patton 2002:47 )

Qualitative researchers are asking different questions about the world than their quantitative colleagues.  Even when researchers are employed in “mixed methods” research ( both quantitative and qualitative), they are using different methods to address different questions of the study.  I do a lot of research about first-generation and working-college college students.  Where a quantitative researcher might ask, how many first-generation college students graduate from college within four years? Or does first-generation college status predict high student debt loads?  A qualitative researcher might ask, how does the college experience differ for first-generation college students?  What is it like to carry a lot of debt, and how does this impact the ability to complete college on time?  Both sets of questions are important, but they can only be answered using specific tools tailored to those questions.  For the former, you need large numbers to make adequate comparisons.  For the latter, you need to talk to people, find out what they are thinking and feeling, and try to inhabit their shoes for a little while so you can make sense of their experiences and beliefs.

Examples of Qualitative Research

You have probably seen examples of qualitative research before, but you might not have paid particular attention to how they were produced or realized that the accounts you were reading were the result of hours, months, even years of research “in the field.”  A good qualitative researcher will present the product of their hours of work in such a way that it seems natural, even obvious, to the reader.  Because we are trying to convey what it is like answers, qualitative research is often presented as stories – stories about how people live their lives, go to work, raise their children, interact with one another.  In some ways, this can seem like reading particularly insightful novels.  But, unlike novels, there are very specific rules and guidelines that qualitative researchers follow to ensure that the “story” they are telling is accurate , a truthful rendition of what life is like for the people being studied.  Most of this textbook will be spent conveying those rules and guidelines.  Let’s take a look, first, however, at three examples of what the end product looks like.  I have chosen these three examples to showcase very different approaches to qualitative research, and I will return to these five examples throughout the book.  They were all published as whole books (not chapters or articles), and they are worth the long read, if you have the time.  I will also provide some information on how these books came to be and the length of time it takes to get them into book version.  It is important you know about this process, and the rest of this textbook will help explain why it takes so long to conduct good qualitative research!

Example 1 : The End Game (ethnography + interviews)

Corey Abramson is a sociologist who teaches at the University of Arizona.   In 2015 he published The End Game: How Inequality Shapes our Final Years ( 2015 ). This book was based on the research he did for his dissertation at the University of California-Berkeley in 2012.  Actually, the dissertation was completed in 2012 but the work that was produced that took several years.  The dissertation was entitled, “This is How We Live, This is How We Die: Social Stratification, Aging, and Health in Urban America” ( 2012 ).  You can see how the book version, which was written for a more general audience, has a more engaging sound to it, but that the dissertation version, which is what academic faculty read and evaluate, has a more descriptive title.  You can read the title and know that this is a study about aging and health and that the focus is going to be inequality and that the context (place) is going to be “urban America.”  It’s a study about “how” people do something – in this case, how they deal with aging and death.  This is the very first sentence of the dissertation, “From our first breath in the hospital to the day we die, we live in a society characterized by unequal opportunities for maintaining health and taking care of ourselves when ill.  These disparities reflect persistent racial, socio-economic, and gender-based inequalities and contribute to their persistence over time” ( 1 ).  What follows is a truthful account of how that is so.

Cory Abramson spent three years conducting his research in four different urban neighborhoods.  We call the type of research he conducted “comparative ethnographic” because he designed his study to compare groups of seniors as they went about their everyday business.  It’s comparative because he is comparing different groups (based on race, class, gender) and ethnographic because he is studying the culture/way of life of a group. [4]   He had an educated guess, rooted in what previous research had shown and what social theory would suggest, that people’s experiences of aging differ by race, class, and gender.  So, he set up a research design that would allow him to observe differences.  He chose two primarily middle-class (one was racially diverse and the other was predominantly White) and two primarily poor neighborhoods (one was racially diverse and the other was predominantly African American).  He hung out in senior centers and other places seniors congregated, watched them as they took the bus to get prescriptions filled, sat in doctor’s offices with them, and listened to their conversations with each other.  He also conducted more formal conversations, what we call in-depth interviews, with sixty seniors from each of the four neighborhoods.  As with a lot of fieldwork , as he got closer to the people involved, he both expanded and deepened his reach –

By the end of the project, I expanded my pool of general observations to include various settings frequented by seniors: apartment building common rooms, doctors’ offices, emergency rooms, pharmacies, senior centers, bars, parks, corner stores, shopping centers, pool halls, hair salons, coffee shops, and discount stores. Over the course of the three years of fieldwork, I observed hundreds of elders, and developed close relationships with a number of them. ( 2012:10 )

When Abramson rewrote the dissertation for a general audience and published his book in 2015, it got a lot of attention.  It is a beautifully written book and it provided insight into a common human experience that we surprisingly know very little about.  It won the Outstanding Publication Award by the American Sociological Association Section on Aging and the Life Course and was featured in the New York Times .  The book was about aging, and specifically how inequality shapes the aging process, but it was also about much more than that.  It helped show how inequality affects people’s everyday lives.  For example, by observing the difficulties the poor had in setting up appointments and getting to them using public transportation and then being made to wait to see a doctor, sometimes in standing-room-only situations, when they are unwell, and then being treated dismissively by hospital staff, Abramson allowed readers to feel the material reality of being poor in the US.  Comparing these examples with seniors with adequate supplemental insurance who have the resources to hire car services or have others assist them in arranging care when they need it, jolts the reader to understand and appreciate the difference money makes in the lives and circumstances of us all, and in a way that is different than simply reading a statistic (“80% of the poor do not keep regular doctor’s appointments”) does.  Qualitative research can reach into spaces and places that often go unexamined and then reports back to the rest of us what it is like in those spaces and places.

Example 2: Racing for Innocence (Interviews + Content Analysis + Fictional Stories)

Jennifer Pierce is a Professor of American Studies at the University of Minnesota.  Trained as a sociologist, she has written a number of books about gender, race, and power.  Her very first book, Gender Trials: Emotional Lives in Contemporary Law Firms, published in 1995, is a brilliant look at gender dynamics within two law firms.  Pierce was a participant observer, working as a paralegal, and she observed how female lawyers and female paralegals struggled to obtain parity with their male colleagues.

Fifteen years later, she reexamined the context of the law firm to include an examination of racial dynamics, particularly how elite white men working in these spaces created and maintained a culture that made it difficult for both female attorneys and attorneys of color to thrive. Her book, Racing for Innocence: Whiteness, Gender, and the Backlash Against Affirmative Action , published in 2012, is an interesting and creative blending of interviews with attorneys, content analyses of popular films during this period, and fictional accounts of racial discrimination and sexual harassment.  The law firm she chose to study had come under an affirmative action order and was in the process of implementing equitable policies and programs.  She wanted to understand how recipients of white privilege (the elite white male attorneys) come to deny the role they play in reproducing inequality.  Through interviews with attorneys who were present both before and during the affirmative action order, she creates a historical record of the “bad behavior” that necessitated new policies and procedures, but also, and more importantly , probed the participants ’ understanding of this behavior.  It should come as no surprise that most (but not all) of the white male attorneys saw little need for change, and that almost everyone else had accounts that were different if not sometimes downright harrowing.

I’ve used Pierce’s book in my qualitative research methods courses as an example of an interesting blend of techniques and presentation styles.  My students often have a very difficult time with the fictional accounts she includes.  But they serve an important communicative purpose here.  They are her attempts at presenting “both sides” to an objective reality – something happens (Pierce writes this something so it is very clear what it is), and the two participants to the thing that happened have very different understandings of what this means.  By including these stories, Pierce presents one of her key findings – people remember things differently and these different memories tend to support their own ideological positions.  I wonder what Pierce would have written had she studied the murder of George Floyd or the storming of the US Capitol on January 6 or any number of other historic events whose observers and participants record very different happenings.

This is not to say that qualitative researchers write fictional accounts.  In fact, the use of fiction in our work remains controversial.  When used, it must be clearly identified as a presentation device, as Pierce did.  I include Racing for Innocence here as an example of the multiple uses of methods and techniques and the way that these work together to produce better understandings by us, the readers, of what Pierce studied.  We readers come away with a better grasp of how and why advantaged people understate their own involvement in situations and structures that advantage them.  This is normal human behavior , in other words.  This case may have been about elite white men in law firms, but the general insights here can be transposed to other settings.  Indeed, Pierce argues that more research needs to be done about the role elites play in the reproduction of inequality in the workplace in general.

Example 3: Amplified Advantage (Mixed Methods: Survey Interviews + Focus Groups + Archives)

The final example comes from my own work with college students, particularly the ways in which class background affects the experience of college and outcomes for graduates.  I include it here as an example of mixed methods, and for the use of supplementary archival research.  I’ve done a lot of research over the years on first-generation, low-income, and working-class college students.  I am curious (and skeptical) about the possibility of social mobility today, particularly with the rising cost of college and growing inequality in general.  As one of the few people in my family to go to college, I didn’t grow up with a lot of examples of what college was like or how to make the most of it.  And when I entered graduate school, I realized with dismay that there were very few people like me there.  I worried about becoming too different from my family and friends back home.  And I wasn’t at all sure that I would ever be able to pay back the huge load of debt I was taking on.  And so I wrote my dissertation and first two books about working-class college students.  These books focused on experiences in college and the difficulties of navigating between family and school ( Hurst 2010a, 2012 ).  But even after all that research, I kept coming back to wondering if working-class students who made it through college had an equal chance at finding good jobs and happy lives,

What happens to students after college?  Do working-class students fare as well as their peers?  I knew from my own experience that barriers continued through graduate school and beyond, and that my debtload was higher than that of my peers, constraining some of the choices I made when I graduated.  To answer these questions, I designed a study of students attending small liberal arts colleges, the type of college that tried to equalize the experience of students by requiring all students to live on campus and offering small classes with lots of interaction with faculty.  These private colleges tend to have more money and resources so they can provide financial aid to low-income students.  They also attract some very wealthy students.  Because they enroll students across the class spectrum, I would be able to draw comparisons.  I ended up spending about four years collecting data, both a survey of more than 2000 students (which formed the basis for quantitative analyses) and qualitative data collection (interviews, focus groups, archival research, and participant observation).  This is what we call a “mixed methods” approach because we use both quantitative and qualitative data.  The survey gave me a large enough number of students that I could make comparisons of the how many kind, and to be able to say with some authority that there were in fact significant differences in experience and outcome by class (e.g., wealthier students earned more money and had little debt; working-class students often found jobs that were not in their chosen careers and were very affected by debt, upper-middle-class students were more likely to go to graduate school).  But the survey analyses could not explain why these differences existed.  For that, I needed to talk to people and ask them about their motivations and aspirations.  I needed to understand their perceptions of the world, and it is very hard to do this through a survey.

By interviewing students and recent graduates, I was able to discern particular patterns and pathways through college and beyond.  Specifically, I identified three versions of gameplay.  Upper-middle-class students, whose parents were themselves professionals (academics, lawyers, managers of non-profits), saw college as the first stage of their education and took classes and declared majors that would prepare them for graduate school.  They also spent a lot of time building their resumes, taking advantage of opportunities to help professors with their research, or study abroad.  This helped them gain admission to highly-ranked graduate schools and interesting jobs in the public sector.  In contrast, upper-class students, whose parents were wealthy and more likely to be engaged in business (as CEOs or other high-level directors), prioritized building social capital.  They did this by joining fraternities and sororities and playing club sports.  This helped them when they graduated as they called on friends and parents of friends to find them well-paying jobs.  Finally, low-income, first-generation, and working-class students were often adrift.  They took the classes that were recommended to them but without the knowledge of how to connect them to life beyond college.  They spent time working and studying rather than partying or building their resumes.  All three sets of students thought they were “doing college” the right way, the way that one was supposed to do college.   But these three versions of gameplay led to distinct outcomes that advantaged some students over others.  I titled my work “Amplified Advantage” to highlight this process.

These three examples, Cory Abramson’s The End Game , Jennifer Peirce’s Racing for Innocence, and my own Amplified Advantage, demonstrate the range of approaches and tools available to the qualitative researcher.  They also help explain why qualitative research is so important.  Numbers can tell us some things about the world, but they cannot get at the hearts and minds, motivations and beliefs of the people who make up the social worlds we inhabit.  For that, we need tools that allow us to listen and make sense of what people tell us and show us.  That is what good qualitative research offers us.

How Is This Book Organized?

This textbook is organized as a comprehensive introduction to the use of qualitative research methods.  The first half covers general topics (e.g., approaches to qualitative research, ethics) and research design (necessary steps for building a successful qualitative research study).  The second half reviews various data collection and data analysis techniques.  Of course, building a successful qualitative research study requires some knowledge of data collection and data analysis so the chapters in the first half and the chapters in the second half should be read in conversation with each other.  That said, each chapter can be read on its own for assistance with a particular narrow topic.  In addition to the chapters, a helpful glossary can be found in the back of the book.  Rummage around in the text as needed.

Chapter Descriptions

Chapter 2 provides an overview of the Research Design Process.  How does one begin a study? What is an appropriate research question?  How is the study to be done – with what methods ?  Involving what people and sites?  Although qualitative research studies can and often do change and develop over the course of data collection, it is important to have a good idea of what the aims and goals of your study are at the outset and a good plan of how to achieve those aims and goals.  Chapter 2 provides a road map of the process.

Chapter 3 describes and explains various ways of knowing the (social) world.  What is it possible for us to know about how other people think or why they behave the way they do?  What does it mean to say something is a “fact” or that it is “well-known” and understood?  Qualitative researchers are particularly interested in these questions because of the types of research questions we are interested in answering (the how questions rather than the how many questions of quantitative research).  Qualitative researchers have adopted various epistemological approaches.  Chapter 3 will explore these approaches, highlighting interpretivist approaches that acknowledge the subjective aspect of reality – in other words, reality and knowledge are not objective but rather influenced by (interpreted through) people.

Chapter 4 focuses on the practical matter of developing a research question and finding the right approach to data collection.  In any given study (think of Cory Abramson’s study of aging, for example), there may be years of collected data, thousands of observations , hundreds of pages of notes to read and review and make sense of.  If all you had was a general interest area (“aging”), it would be very difficult, nearly impossible, to make sense of all of that data.  The research question provides a helpful lens to refine and clarify (and simplify) everything you find and collect.  For that reason, it is important to pull out that lens (articulate the research question) before you get started.  In the case of the aging study, Cory Abramson was interested in how inequalities affected understandings and responses to aging.  It is for this reason he designed a study that would allow him to compare different groups of seniors (some middle-class, some poor).  Inevitably, he saw much more in the three years in the field than what made it into his book (or dissertation), but he was able to narrow down the complexity of the social world to provide us with this rich account linked to the original research question.  Developing a good research question is thus crucial to effective design and a successful outcome.  Chapter 4 will provide pointers on how to do this.  Chapter 4 also provides an overview of general approaches taken to doing qualitative research and various “traditions of inquiry.”

Chapter 5 explores sampling .  After you have developed a research question and have a general idea of how you will collect data (Observations?  Interviews?), how do you go about actually finding people and sites to study?  Although there is no “correct number” of people to interview , the sample should follow the research question and research design.  Unlike quantitative research, qualitative research involves nonprobability sampling.  Chapter 5 explains why this is so and what qualities instead make a good sample for qualitative research.

Chapter 6 addresses the importance of reflexivity in qualitative research.  Related to epistemological issues of how we know anything about the social world, qualitative researchers understand that we the researchers can never be truly neutral or outside the study we are conducting.  As observers, we see things that make sense to us and may entirely miss what is either too obvious to note or too different to comprehend.  As interviewers, as much as we would like to ask questions neutrally and remain in the background, interviews are a form of conversation, and the persons we interview are responding to us .  Therefore, it is important to reflect upon our social positions and the knowledges and expectations we bring to our work and to work through any blind spots that we may have.  Chapter 6 provides some examples of reflexivity in practice and exercises for thinking through one’s own biases.

Chapter 7 is a very important chapter and should not be overlooked.  As a practical matter, it should also be read closely with chapters 6 and 8.  Because qualitative researchers deal with people and the social world, it is imperative they develop and adhere to a strong ethical code for conducting research in a way that does not harm.  There are legal requirements and guidelines for doing so (see chapter 8), but these requirements should not be considered synonymous with the ethical code required of us.   Each researcher must constantly interrogate every aspect of their research, from research question to design to sample through analysis and presentation, to ensure that a minimum of harm (ideally, zero harm) is caused.  Because each research project is unique, the standards of care for each study are unique.  Part of being a professional researcher is carrying this code in one’s heart, being constantly attentive to what is required under particular circumstances.  Chapter 7 provides various research scenarios and asks readers to weigh in on the suitability and appropriateness of the research.  If done in a class setting, it will become obvious fairly quickly that there are often no absolutely correct answers, as different people find different aspects of the scenarios of greatest importance.  Minimizing the harm in one area may require possible harm in another.  Being attentive to all the ethical aspects of one’s research and making the best judgments one can, clearly and consciously, is an integral part of being a good researcher.

Chapter 8 , best to be read in conjunction with chapter 7, explains the role and importance of Institutional Review Boards (IRBs) .  Under federal guidelines, an IRB is an appropriately constituted group that has been formally designated to review and monitor research involving human subjects .  Every institution that receives funding from the federal government has an IRB.  IRBs have the authority to approve, require modifications to (to secure approval), or disapprove research.  This group review serves an important role in the protection of the rights and welfare of human research subjects.  Chapter 8 reviews the history of IRBs and the work they do but also argues that IRBs’ review of qualitative research is often both over-inclusive and under-inclusive.  Some aspects of qualitative research are not well understood by IRBs, given that they were developed to prevent abuses in biomedical research.  Thus, it is important not to rely on IRBs to identify all the potential ethical issues that emerge in our research (see chapter 7).

Chapter 9 provides help for getting started on formulating a research question based on gaps in the pre-existing literature.  Research is conducted as part of a community, even if particular studies are done by single individuals (or small teams).  What any of us finds and reports back becomes part of a much larger body of knowledge.  Thus, it is important that we look at the larger body of knowledge before we actually start our bit to see how we can best contribute.  When I first began interviewing working-class college students, there was only one other similar study I could find, and it hadn’t been published (it was a dissertation of students from poor backgrounds).  But there had been a lot published by professors who had grown up working class and made it through college despite the odds.  These accounts by “working-class academics” became an important inspiration for my study and helped me frame the questions I asked the students I interviewed.  Chapter 9 will provide some pointers on how to search for relevant literature and how to use this to refine your research question.

Chapter 10 serves as a bridge between the two parts of the textbook, by introducing techniques of data collection.  Qualitative research is often characterized by the form of data collection – for example, an ethnographic study is one that employs primarily observational data collection for the purpose of documenting and presenting a particular culture or ethnos.  Techniques can be effectively combined, depending on the research question and the aims and goals of the study.   Chapter 10 provides a general overview of all the various techniques and how they can be combined.

The second part of the textbook moves into the doing part of qualitative research once the research question has been articulated and the study designed.  Chapters 11 through 17 cover various data collection techniques and approaches.  Chapters 18 and 19 provide a very simple overview of basic data analysis.  Chapter 20 covers communication of the data to various audiences, and in various formats.

Chapter 11 begins our overview of data collection techniques with a focus on interviewing , the true heart of qualitative research.  This technique can serve as the primary and exclusive form of data collection, or it can be used to supplement other forms (observation, archival).  An interview is distinct from a survey, where questions are asked in a specific order and often with a range of predetermined responses available.  Interviews can be conversational and unstructured or, more conventionally, semistructured , where a general set of interview questions “guides” the conversation.  Chapter 11 covers the basics of interviews: how to create interview guides, how many people to interview, where to conduct the interview, what to watch out for (how to prepare against things going wrong), and how to get the most out of your interviews.

Chapter 12 covers an important variant of interviewing, the focus group.  Focus groups are semistructured interviews with a group of people moderated by a facilitator (the researcher or researcher’s assistant).  Focus groups explicitly use group interaction to assist in the data collection.  They are best used to collect data on a specific topic that is non-personal and shared among the group.  For example, asking a group of college students about a common experience such as taking classes by remote delivery during the pandemic year of 2020.  Chapter 12 covers the basics of focus groups: when to use them, how to create interview guides for them, and how to run them effectively.

Chapter 13 moves away from interviewing to the second major form of data collection unique to qualitative researchers – observation .  Qualitative research that employs observation can best be understood as falling on a continuum of “fly on the wall” observation (e.g., observing how strangers interact in a doctor’s waiting room) to “participant” observation, where the researcher is also an active participant of the activity being observed.  For example, an activist in the Black Lives Matter movement might want to study the movement, using her inside position to gain access to observe key meetings and interactions.  Chapter  13 covers the basics of participant observation studies: advantages and disadvantages, gaining access, ethical concerns related to insider/outsider status and entanglement, and recording techniques.

Chapter 14 takes a closer look at “deep ethnography” – immersion in the field of a particularly long duration for the purpose of gaining a deeper understanding and appreciation of a particular culture or social world.  Clifford Geertz called this “deep hanging out.”  Whereas participant observation is often combined with semistructured interview techniques, deep ethnography’s commitment to “living the life” or experiencing the situation as it really is demands more conversational and natural interactions with people.  These interactions and conversations may take place over months or even years.  As can be expected, there are some costs to this technique, as well as some very large rewards when done competently.  Chapter 14 provides some examples of deep ethnographies that will inspire some beginning researchers and intimidate others.

Chapter 15 moves in the opposite direction of deep ethnography, a technique that is the least positivist of all those discussed here, to mixed methods , a set of techniques that is arguably the most positivist .  A mixed methods approach combines both qualitative data collection and quantitative data collection, commonly by combining a survey that is analyzed statistically (e.g., cross-tabs or regression analyses of large number probability samples) with semi-structured interviews.  Although it is somewhat unconventional to discuss mixed methods in textbooks on qualitative research, I think it is important to recognize this often-employed approach here.  There are several advantages and some disadvantages to taking this route.  Chapter 16 will describe those advantages and disadvantages and provide some particular guidance on how to design a mixed methods study for maximum effectiveness.

Chapter 16 covers data collection that does not involve live human subjects at all – archival and historical research (chapter 17 will also cover data that does not involve interacting with human subjects).  Sometimes people are unavailable to us, either because they do not wish to be interviewed or observed (as is the case with many “elites”) or because they are too far away, in both place and time.  Fortunately, humans leave many traces and we can often answer questions we have by examining those traces.  Special collections and archives can be goldmines for social science research.  This chapter will explain how to access these places, for what purposes, and how to begin to make sense of what you find.

Chapter 17 covers another data collection area that does not involve face-to-face interaction with humans: content analysis .  Although content analysis may be understood more properly as a data analysis technique, the term is often used for the entire approach, which will be the case here.  Content analysis involves interpreting meaning from a body of text.  This body of text might be something found in historical records (see chapter 16) or something collected by the researcher, as in the case of comment posts on a popular blog post.  I once used the stories told by student loan debtors on the website studentloanjustice.org as the content I analyzed.  Content analysis is particularly useful when attempting to define and understand prevalent stories or communication about a topic of interest.  In other words, when we are less interested in what particular people (our defined sample) are doing or believing and more interested in what general narratives exist about a particular topic or issue.  This chapter will explore different approaches to content analysis and provide helpful tips on how to collect data, how to turn that data into codes for analysis, and how to go about presenting what is found through analysis.

Where chapter 17 has pushed us towards data analysis, chapters 18 and 19 are all about what to do with the data collected, whether that data be in the form of interview transcripts or fieldnotes from observations.  Chapter 18 introduces the basics of coding , the iterative process of assigning meaning to the data in order to both simplify and identify patterns.  What is a code and how does it work?  What are the different ways of coding data, and when should you use them?  What is a codebook, and why do you need one?  What does the process of data analysis look like?

Chapter 19 goes further into detail on codes and how to use them, particularly the later stages of coding in which our codes are refined, simplified, combined, and organized.  These later rounds of coding are essential to getting the most out of the data we’ve collected.  As students are often overwhelmed with the amount of data (a corpus of interview transcripts typically runs into the hundreds of pages; fieldnotes can easily top that), this chapter will also address time management and provide suggestions for dealing with chaos and reminders that feeling overwhelmed at the analysis stage is part of the process.  By the end of the chapter, you should understand how “findings” are actually found.

The book concludes with a chapter dedicated to the effective presentation of data results.  Chapter 20 covers the many ways that researchers communicate their studies to various audiences (academic, personal, political), what elements must be included in these various publications, and the hallmarks of excellent qualitative research that various audiences will be expecting.  Because qualitative researchers are motivated by understanding and conveying meaning , effective communication is not only an essential skill but a fundamental facet of the entire research project.  Ethnographers must be able to convey a certain sense of verisimilitude , the appearance of true reality.  Those employing interviews must faithfully depict the key meanings of the people they interviewed in a way that rings true to those people, even if the end result surprises them.  And all researchers must strive for clarity in their publications so that various audiences can understand what was found and why it is important.

The book concludes with a short chapter ( chapter 21 ) discussing the value of qualitative research. At the very end of this book, you will find a glossary of terms. I recommend you make frequent use of the glossary and add to each entry as you find examples. Although the entries are meant to be simple and clear, you may also want to paraphrase the definition—make it “make sense” to you, in other words. In addition to the standard reference list (all works cited here), you will find various recommendations for further reading at the end of many chapters. Some of these recommendations will be examples of excellent qualitative research, indicated with an asterisk (*) at the end of the entry. As they say, a picture is worth a thousand words. A good example of qualitative research can teach you more about conducting research than any textbook can (this one included). I highly recommend you select one to three examples from these lists and read them along with the textbook.

A final note on the choice of examples – you will note that many of the examples used in the text come from research on college students.  This is for two reasons.  First, as most of my research falls in this area, I am most familiar with this literature and have contacts with those who do research here and can call upon them to share their stories with you.  Second, and more importantly, my hope is that this textbook reaches a wide audience of beginning researchers who study widely and deeply across the range of what can be known about the social world (from marine resources management to public policy to nursing to political science to sexuality studies and beyond).  It is sometimes difficult to find examples that speak to all those research interests, however. A focus on college students is something that all readers can understand and, hopefully, appreciate, as we are all now or have been at some point a college student.

Recommended Reading: Other Qualitative Research Textbooks

I’ve included a brief list of some of my favorite qualitative research textbooks and guidebooks if you need more than what you will find in this introductory text.  For each, I’ve also indicated if these are for “beginning” or “advanced” (graduate-level) readers.  Many of these books have several editions that do not significantly vary; the edition recommended is merely the edition I have used in teaching and to whose page numbers any specific references made in the text agree.

Barbour, Rosaline. 2014. Introducing Qualitative Research: A Student’s Guide. Thousand Oaks, CA: SAGE.  A good introduction to qualitative research, with abundant examples (often from the discipline of health care) and clear definitions.  Includes quick summaries at the ends of each chapter.  However, some US students might find the British context distracting and can be a bit advanced in some places.  Beginning .

Bloomberg, Linda Dale, and Marie F. Volpe. 2012. Completing Your Qualitative Dissertation . 2nd ed. Thousand Oaks, CA: SAGE.  Specifically designed to guide graduate students through the research process. Advanced .

Creswell, John W., and Cheryl Poth. 2018 Qualitative Inquiry and Research Design: Choosing among Five Traditions .  4th ed. Thousand Oaks, CA: SAGE.  This is a classic and one of the go-to books I used myself as a graduate student.  One of the best things about this text is its clear presentation of five distinct traditions in qualitative research.  Despite the title, this reasonably sized book is about more than research design, including both data analysis and how to write about qualitative research.  Advanced .

Lareau, Annette. 2021. Listening to People: A Practical Guide to Interviewing, Participant Observation, Data Analysis, and Writing It All Up .  Chicago: University of Chicago Press. A readable and personal account of conducting qualitative research by an eminent sociologist, with a heavy emphasis on the kinds of participant-observation research conducted by the author.  Despite its reader-friendliness, this is really a book targeted to graduate students learning the craft.  Advanced .

Lune, Howard, and Bruce L. Berg. 2018. 9th edition.  Qualitative Research Methods for the Social Sciences.  Pearson . Although a good introduction to qualitative methods, the authors favor symbolic interactionist and dramaturgical approaches, which limits the appeal primarily to sociologists.  Beginning .

Marshall, Catherine, and Gretchen B. Rossman. 2016. 6th edition. Designing Qualitative Research. Thousand Oaks, CA: SAGE.  Very readable and accessible guide to research design by two educational scholars.  Although the presentation is sometimes fairly dry, personal vignettes and illustrations enliven the text.  Beginning .

Maxwell, Joseph A. 2013. Qualitative Research Design: An Interactive Approach .  3rd ed. Thousand Oaks, CA: SAGE. A short and accessible introduction to qualitative research design, particularly helpful for graduate students contemplating theses and dissertations. This has been a standard textbook in my graduate-level courses for years.  Advanced .

Patton, Michael Quinn. 2002. Qualitative Research and Evaluation Methods . Thousand Oaks, CA: SAGE.  This is a comprehensive text that served as my “go-to” reference when I was a graduate student.  It is particularly helpful for those involved in program evaluation and other forms of evaluation studies and uses examples from a wide range of disciplines.  Advanced .

Rubin, Ashley T. 2021. Rocking Qualitative Social Science: An Irreverent Guide to Rigorous Research. Stanford : Stanford University Press.  A delightful and personal read.  Rubin uses rock climbing as an extended metaphor for learning how to conduct qualitative research.  A bit slanted toward ethnographic and archival methods of data collection, with frequent examples from her own studies in criminology. Beginning .

Weis, Lois, and Michelle Fine. 2000. Speed Bumps: A Student-Friendly Guide to Qualitative Research . New York: Teachers College Press.  Readable and accessibly written in a quasi-conversational style.  Particularly strong in its discussion of ethical issues throughout the qualitative research process.  Not comprehensive, however, and very much tied to ethnographic research.  Although designed for graduate students, this is a recommended read for students of all levels.  Beginning .

Patton’s Ten Suggestions for Doing Qualitative Research

The following ten suggestions were made by Michael Quinn Patton in his massive textbooks Qualitative Research and Evaluations Methods . This book is highly recommended for those of you who want more than an introduction to qualitative methods. It is the book I relied on heavily when I was a graduate student, although it is much easier to “dip into” when necessary than to read through as a whole. Patton is asked for “just one bit of advice” for a graduate student considering using qualitative research methods for their dissertation.  Here are his top ten responses, in short form, heavily paraphrased, and with additional comments and emphases from me:

• Make sure that a qualitative approach fits the research question. The following are the kinds of questions that call out for qualitative methods or where qualitative methods are particularly appropriate: questions about people’s experiences or how they make sense of those experiences; studying a person in their natural environment; researching a phenomenon so unknown that it would be impossible to study it with standardized instruments or other forms of quantitative data collection.
• Study qualitative research by going to the original sources for the design and analysis appropriate to the particular approach you want to take (e.g., read Glaser and Straus if you are using grounded theory )
• Find a dissertation adviser who understands or at least who will support your use of qualitative research methods. You are asking for trouble if your entire committee is populated by quantitative researchers, even if they are all very knowledgeable about the subject or focus of your study (maybe even more so if they are!)
• Really work on design. Doing qualitative research effectively takes a lot of planning.  Even if things are more flexible than in quantitative research, a good design is absolutely essential when starting out.
• Practice data collection techniques, particularly interviewing and observing. There is definitely a set of learned skills here!  Do not expect your first interview to be perfect.  You will continue to grow as a researcher the more interviews you conduct, and you will probably come to understand yourself a bit more in the process, too.  This is not easy, despite what others who don’t work with qualitative methods may assume (and tell you!)
• Have a plan for analysis before you begin data collection. This is often a requirement in IRB protocols , although you can get away with writing something fairly simple.  And even if you are taking an approach, such as grounded theory, that pushes you to remain fairly open-minded during the data collection process, you still want to know what you will be doing with all the data collected – creating a codebook? Writing analytical memos? Comparing cases?  Having a plan in hand will also help prevent you from collecting too much extraneous data.
• Be prepared to confront controversies both within the qualitative research community and between qualitative research and quantitative research. Don’t be naïve about this – qualitative research, particularly some approaches, will be derided by many more “positivist” researchers and audiences.  For example, is an “n” of 1 really sufficient?  Yes!  But not everyone will agree.
• Do not make the mistake of using qualitative research methods because someone told you it was easier, or because you are intimidated by the math required of statistical analyses. Qualitative research is difficult in its own way (and many would claim much more time-consuming than quantitative research).  Do it because you are convinced it is right for your goals, aims, and research questions.
• Find a good support network. This could be a research mentor, or it could be a group of friends or colleagues who are also using qualitative research, or it could be just someone who will listen to you work through all of the issues you will confront out in the field and during the writing process.  Even though qualitative research often involves human subjects, it can be pretty lonely.  A lot of times you will feel like you are working without a net.  You have to create one for yourself.  Take care of yourself.
• And, finally, in the words of Patton, “Prepare to be changed. Looking deeply at other people’s lives will force you to look deeply at yourself.”
• We will actually spend an entire chapter ( chapter 3 ) looking at this question in much more detail! ↵
• Note that this might have been news to Europeans at the time, but many other societies around the world had also come to this conclusion through observation.  There is often a tendency to equate “the scientific revolution” with the European world in which it took place, but this is somewhat misleading. ↵
• Historians are a special case here.  Historians have scrupulously and rigorously investigated the social world, but not for the purpose of understanding general laws about how things work, which is the point of scientific empirical research.  History is often referred to as an idiographic field of study, meaning that it studies things that happened or are happening in themselves and not for general observations or conclusions. ↵
• Don’t worry, we’ll spend more time later in this book unpacking the meaning of ethnography and other terms that are important here.  Note the available glossary ↵

An approach to research that is “multimethod in focus, involving an interpretative, naturalistic approach to its subject matter.  This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them.  Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives." ( Denzin and Lincoln 2005:2 ). Contrast with quantitative research .

In contrast to methodology, methods are more simply the practices and tools used to collect and analyze data.  Examples of common methods in qualitative research are interviews , observations , and documentary analysis .  One’s methodology should connect to one’s choice of methods, of course, but they are distinguishable terms.  See also methodology .

A proposed explanation for an observation, phenomenon, or scientific problem that can be tested by further investigation.  The positing of a hypothesis is often the first step in quantitative research but not in qualitative research.  Even when qualitative researchers offer possible explanations in advance of conducting research, they will tend to not use the word “hypothesis” as it conjures up the kind of positivist research they are not conducting.

The foundational question to be addressed by the research study.  This will form the anchor of the research design, collection, and analysis.  Note that in qualitative research, the research question may, and probably will, alter or develop during the course of the research.

An approach to research that collects and analyzes numerical data for the purpose of finding patterns and averages, making predictions, testing causal relationships, and generalizing results to wider populations.  Contrast with qualitative research .

Data collection that takes place in real-world settings, referred to as “the field;” a key component of much Grounded Theory and ethnographic research.  Patton ( 2002 ) calls fieldwork “the central activity of qualitative inquiry” where “‘going into the field’ means having direct and personal contact with people under study in their own environments – getting close to people and situations being studied to personally understand the realities of minutiae of daily life” (48).

The people who are the subjects of a qualitative study.  In interview-based studies, they may be the respondents to the interviewer; for purposes of IRBs, they are often referred to as the human subjects of the research.

The branch of philosophy concerned with knowledge.  For researchers, it is important to recognize and adopt one of the many distinguishing epistemological perspectives as part of our understanding of what questions research can address or fully answer.  See, e.g., constructivism , subjectivism, and  objectivism .

An approach that refutes the possibility of neutrality in social science research.  All research is “guided by a set of beliefs and feelings about the world and how it should be understood and studied” (Denzin and Lincoln 2005: 13).  In contrast to positivism , interpretivism recognizes the social constructedness of reality, and researchers adopting this approach focus on capturing interpretations and understandings people have about the world rather than “the world” as it is (which is a chimera).

The cluster of data-collection tools and techniques that involve observing interactions between people, the behaviors, and practices of individuals (sometimes in contrast to what they say about how they act and behave), and cultures in context.  Observational methods are the key tools employed by ethnographers and Grounded Theory .

Research based on data collected and analyzed by the research (in contrast to secondary “library” research).

The process of selecting people or other units of analysis to represent a larger population. In quantitative research, this representation is taken quite literally, as statistically representative.  In qualitative research, in contrast, sample selection is often made based on potential to generate insight about a particular topic or phenomenon.

A method of data collection in which the researcher asks the participant questions; the answers to these questions are often recorded and transcribed verbatim. There are many different kinds of interviews - see also semistructured interview , structured interview , and unstructured interview .

The specific group of individuals that you will collect data from.  Contrast population.

The practice of being conscious of and reflective upon one’s own social location and presence when conducting research.  Because qualitative research often requires interaction with live humans, failing to take into account how one’s presence and prior expectations and social location affect the data collected and how analyzed may limit the reliability of the findings.  This remains true even when dealing with historical archives and other content.  Who we are matters when asking questions about how people experience the world because we, too, are a part of that world.

The science and practice of right conduct; in research, it is also the delineation of moral obligations towards research participants, communities to which we belong, and communities in which we conduct our research.

An administrative body established to protect the rights and welfare of human research subjects recruited to participate in research activities conducted under the auspices of the institution with which it is affiliated. The IRB is charged with the responsibility of reviewing all research involving human participants. The IRB is concerned with protecting the welfare, rights, and privacy of human subjects. The IRB has the authority to approve, disapprove, monitor, and require modifications in all research activities that fall within its jurisdiction as specified by both the federal regulations and institutional policy.

Research, according to US federal guidelines, that involves “a living individual about whom an investigator (whether professional or student) conducting research:  (1) Obtains information or biospecimens through intervention or interaction with the individual, and uses, studies, or analyzes the information or biospecimens; or  (2) Obtains, uses, studies, analyzes, or generates identifiable private information or identifiable biospecimens.”

One of the primary methodological traditions of inquiry in qualitative research, ethnography is the study of a group or group culture, largely through observational fieldwork supplemented by interviews. It is a form of fieldwork that may include participant-observation data collection. See chapter 14 for a discussion of deep ethnography. 

A form of interview that follows a standard guide of questions asked, although the order of the questions may change to match the particular needs of each individual interview subject, and probing “follow-up” questions are often added during the course of the interview.  The semi-structured interview is the primary form of interviewing used by qualitative researchers in the social sciences.  It is sometimes referred to as an “in-depth” interview.  See also interview and  interview guide .

A method of observational data collection taking place in a natural setting; a form of fieldwork .  The term encompasses a continuum of relative participation by the researcher (from full participant to “fly-on-the-wall” observer).  This is also sometimes referred to as ethnography , although the latter is characterized by a greater focus on the culture under observation.

A research design that employs both quantitative and qualitative methods, as in the case of a survey supplemented by interviews.

An epistemological perspective that posits the existence of reality through sensory experience similar to empiricism but goes further in denying any non-sensory basis of thought or consciousness.  In the social sciences, the term has roots in the proto-sociologist August Comte, who believed he could discern “laws” of society similar to the laws of natural science (e.g., gravity).  The term has come to mean the kinds of measurable and verifiable science conducted by quantitative researchers and is thus used pejoratively by some qualitative researchers interested in interpretation, consciousness, and human understanding.  Calling someone a “positivist” is often intended as an insult.  See also empiricism and objectivism.

A place or collection containing records, documents, or other materials of historical interest; most universities have an archive of material related to the university’s history, as well as other “special collections” that may be of interest to members of the community.

A method of both data collection and data analysis in which a given content (textual, visual, graphic) is examined systematically and rigorously to identify meanings, themes, patterns and assumptions.  Qualitative content analysis (QCA) is concerned with gathering and interpreting an existing body of material.    

A word or short phrase that symbolically assigns a summative, salient, essence-capturing, and/or evocative attribute for a portion of language-based or visual data (Saldaña 2021:5).

Usually a verbatim written record of an interview or focus group discussion.

The primary form of data for fieldwork , participant observation , and ethnography .  These notes, taken by the researcher either during the course of fieldwork or at day’s end, should include as many details as possible on what was observed and what was said.  They should include clear identifiers of date, time, setting, and names (or identifying characteristics) of participants.

The process of labeling and organizing qualitative data to identify different themes and the relationships between them; a way of simplifying data to allow better management and retrieval of key themes and illustrative passages.  See coding frame and  codebook.

A methodological tradition of inquiry and approach to analyzing qualitative data in which theories emerge from a rigorous and systematic process of induction.  This approach was pioneered by the sociologists Glaser and Strauss (1967).  The elements of theory generated from comparative analysis of data are, first, conceptual categories and their properties and, second, hypotheses or generalized relations among the categories and their properties – “The constant comparing of many groups draws the [researcher’s] attention to their many similarities and differences.  Considering these leads [the researcher] to generate abstract categories and their properties, which, since they emerge from the data, will clearly be important to a theory explaining the kind of behavior under observation.” (36).

A detailed description of any proposed research that involves human subjects for review by IRB.  The protocol serves as the recipe for the conduct of the research activity.  It includes the scientific rationale to justify the conduct of the study, the information necessary to conduct the study, the plan for managing and analyzing the data, and a discussion of the research ethical issues relevant to the research.  Protocols for qualitative research often include interview guides, all documents related to recruitment, informed consent forms, very clear guidelines on the safekeeping of materials collected, and plans for de-identifying transcripts or other data that include personal identifying information.

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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7.4 Qualitative Research

Learning objectives.

• List several ways in which qualitative research differs from quantitative research in psychology.
• Describe the strengths and weaknesses of qualitative research in psychology compared with quantitative research.
• Give examples of qualitative research in psychology.

What Is Qualitative Research?

This book is primarily about quantitative research . Quantitative researchers typically start with a focused research question or hypothesis, collect a small amount of data from each of a large number of individuals, describe the resulting data using statistical techniques, and draw general conclusions about some large population. Although this is by far the most common approach to conducting empirical research in psychology, there is an important alternative called qualitative research. Qualitative research originated in the disciplines of anthropology and sociology but is now used to study many psychological topics as well. Qualitative researchers generally begin with a less focused research question, collect large amounts of relatively “unfiltered” data from a relatively small number of individuals, and describe their data using nonstatistical techniques. They are usually less concerned with drawing general conclusions about human behavior than with understanding in detail the experience of their research participants.

Consider, for example, a study by researcher Per Lindqvist and his colleagues, who wanted to learn how the families of teenage suicide victims cope with their loss (Lindqvist, Johansson, & Karlsson, 2008). They did not have a specific research question or hypothesis, such as, What percentage of family members join suicide support groups? Instead, they wanted to understand the variety of reactions that families had, with a focus on what it is like from their perspectives. To do this, they interviewed the families of 10 teenage suicide victims in their homes in rural Sweden. The interviews were relatively unstructured, beginning with a general request for the families to talk about the victim and ending with an invitation to talk about anything else that they wanted to tell the interviewer. One of the most important themes that emerged from these interviews was that even as life returned to “normal,” the families continued to struggle with the question of why their loved one committed suicide. This struggle appeared to be especially difficult for families in which the suicide was most unexpected.

The Purpose of Qualitative Research

Again, this book is primarily about quantitative research in psychology. The strength of quantitative research is its ability to provide precise answers to specific research questions and to draw general conclusions about human behavior. This is how we know that people have a strong tendency to obey authority figures, for example, or that female college students are not substantially more talkative than male college students. But while quantitative research is good at providing precise answers to specific research questions, it is not nearly as good at generating novel and interesting research questions. Likewise, while quantitative research is good at drawing general conclusions about human behavior, it is not nearly as good at providing detailed descriptions of the behavior of particular groups in particular situations. And it is not very good at all at communicating what it is actually like to be a member of a particular group in a particular situation.

But the relative weaknesses of quantitative research are the relative strengths of qualitative research. Qualitative research can help researchers to generate new and interesting research questions and hypotheses. The research of Lindqvist and colleagues, for example, suggests that there may be a general relationship between how unexpected a suicide is and how consumed the family is with trying to understand why the teen committed suicide. This relationship can now be explored using quantitative research. But it is unclear whether this question would have arisen at all without the researchers sitting down with the families and listening to what they themselves wanted to say about their experience. Qualitative research can also provide rich and detailed descriptions of human behavior in the real-world contexts in which it occurs. Among qualitative researchers, this is often referred to as “thick description” (Geertz, 1973). Similarly, qualitative research can convey a sense of what it is actually like to be a member of a particular group or in a particular situation—what qualitative researchers often refer to as the “lived experience” of the research participants. Lindqvist and colleagues, for example, describe how all the families spontaneously offered to show the interviewer the victim’s bedroom or the place where the suicide occurred—revealing the importance of these physical locations to the families. It seems unlikely that a quantitative study would have discovered this.

Data Collection and Analysis in Qualitative Research

As with correlational research, data collection approaches in qualitative research are quite varied and can involve naturalistic observation, archival data, artwork, and many other things. But one of the most common approaches, especially for psychological research, is to conduct interviews . Interviews in qualitative research tend to be unstructured—consisting of a small number of general questions or prompts that allow participants to talk about what is of interest to them. The researcher can follow up by asking more detailed questions about the topics that do come up. Such interviews can be lengthy and detailed, but they are usually conducted with a relatively small sample. This was essentially the approach used by Lindqvist and colleagues in their research on the families of suicide survivors. Small groups of people who participate together in interviews focused on a particular topic or issue are often referred to as focus groups . The interaction among participants in a focus group can sometimes bring out more information than can be learned in a one-on-one interview. The use of focus groups has become a standard technique in business and industry among those who want to understand consumer tastes and preferences. The content of all focus group interviews is usually recorded and transcribed to facilitate later analyses.

Another approach to data collection in qualitative research is participant observation. In participant observation , researchers become active participants in the group or situation they are studying. The data they collect can include interviews (usually unstructured), their own notes based on their observations and interactions, documents, photographs, and other artifacts. The basic rationale for participant observation is that there may be important information that is only accessible to, or can be interpreted only by, someone who is an active participant in the group or situation. An example of participant observation comes from a study by sociologist Amy Wilkins (published in Social Psychology Quarterly ) on a college-based religious organization that emphasized how happy its members were (Wilkins, 2008). Wilkins spent 12 months attending and participating in the group’s meetings and social events, and she interviewed several group members. In her study, Wilkins identified several ways in which the group “enforced” happiness—for example, by continually talking about happiness, discouraging the expression of negative emotions, and using happiness as a way to distinguish themselves from other groups.

Data Analysis in Quantitative Research

Although quantitative and qualitative research generally differ along several important dimensions (e.g., the specificity of the research question, the type of data collected), it is the method of data analysis that distinguishes them more clearly than anything else. To illustrate this idea, imagine a team of researchers that conducts a series of unstructured interviews with recovering alcoholics to learn about the role of their religious faith in their recovery. Although this sounds like qualitative research, imagine further that once they collect the data, they code the data in terms of how often each participant mentions God (or a “higher power”), and they then use descriptive and inferential statistics to find out whether those who mention God more often are more successful in abstaining from alcohol. Now it sounds like quantitative research. In other words, the quantitative-qualitative distinction depends more on what researchers do with the data they have collected than with why or how they collected the data.

But what does qualitative data analysis look like? Just as there are many ways to collect data in qualitative research, there are many ways to analyze data. Here we focus on one general approach called grounded theory (Glaser & Strauss, 1967). This approach was developed within the field of sociology in the 1960s and has gradually gained popularity in psychology. Remember that in quantitative research, it is typical for the researcher to start with a theory, derive a hypothesis from that theory, and then collect data to test that specific hypothesis. In qualitative research using grounded theory, researchers start with the data and develop a theory or an interpretation that is “grounded in” those data. They do this in stages. First, they identify ideas that are repeated throughout the data. Then they organize these ideas into a smaller number of broader themes. Finally, they write a theoretical narrative —an interpretation—of the data in terms of the themes that they have identified. This theoretical narrative focuses on the subjective experience of the participants and is usually supported by many direct quotations from the participants themselves.

As an example, consider a study by researchers Laura Abrams and Laura Curran, who used the grounded theory approach to study the experience of postpartum depression symptoms among low-income mothers (Abrams & Curran, 2009). Their data were the result of unstructured interviews with 19 participants. Table 7.1 “Themes and Repeating Ideas in a Study of Postpartum Depression Among Low-Income Mothers” shows the five broad themes the researchers identified and the more specific repeating ideas that made up each of those themes. In their research report, they provide numerous quotations from their participants, such as this one from “Destiny:”

Well, just recently my apartment was broken into and the fact that his Medicaid for some reason was cancelled so a lot of things was happening within the last two weeks all at one time. So that in itself I don’t want to say almost drove me mad but it put me in a funk.…Like I really was depressed. (p. 357)

Their theoretical narrative focused on the participants’ experience of their symptoms not as an abstract “affective disorder” but as closely tied to the daily struggle of raising children alone under often difficult circumstances.

Table 7.1 Themes and Repeating Ideas in a Study of Postpartum Depression Among Low-Income Mothers

The Quantitative-Qualitative “Debate”

Given their differences, it may come as no surprise that quantitative and qualitative research in psychology and related fields do not coexist in complete harmony. Some quantitative researchers criticize qualitative methods on the grounds that they lack objectivity, are difficult to evaluate in terms of reliability and validity, and do not allow generalization to people or situations other than those actually studied. At the same time, some qualitative researchers criticize quantitative methods on the grounds that they overlook the richness of human behavior and experience and instead answer simple questions about easily quantifiable variables.

In general, however, qualitative researchers are well aware of the issues of objectivity, reliability, validity, and generalizability. In fact, they have developed a number of frameworks for addressing these issues (which are beyond the scope of our discussion). And in general, quantitative researchers are well aware of the issue of oversimplification. They do not believe that all human behavior and experience can be adequately described in terms of a small number of variables and the statistical relationships among them. Instead, they use simplification as a strategy for uncovering general principles of human behavior.

Many researchers from both the quantitative and qualitative camps now agree that the two approaches can and should be combined into what has come to be called mixed-methods research (Todd, Nerlich, McKeown, & Clarke, 2004). (In fact, the studies by Lindqvist and colleagues and by Abrams and Curran both combined quantitative and qualitative approaches.) One approach to combining quantitative and qualitative research is to use qualitative research for hypothesis generation and quantitative research for hypothesis testing. Again, while a qualitative study might suggest that families who experience an unexpected suicide have more difficulty resolving the question of why, a well-designed quantitative study could test a hypothesis by measuring these specific variables for a large sample. A second approach to combining quantitative and qualitative research is referred to as triangulation . The idea is to use both quantitative and qualitative methods simultaneously to study the same general questions and to compare the results. If the results of the quantitative and qualitative methods converge on the same general conclusion, they reinforce and enrich each other. If the results diverge, then they suggest an interesting new question: Why do the results diverge and how can they be reconciled?

Key Takeaways

• Qualitative research is an important alternative to quantitative research in psychology. It generally involves asking broader research questions, collecting more detailed data (e.g., interviews), and using nonstatistical analyses.
• Many researchers conceptualize quantitative and qualitative research as complementary and advocate combining them. For example, qualitative research can be used to generate hypotheses and quantitative research to test them.
• Discussion: What are some ways in which a qualitative study of girls who play youth baseball would be likely to differ from a quantitative study on the same topic?

Abrams, L. S., & Curran, L. (2009). “And you’re telling me not to stress?” A grounded theory study of postpartum depression symptoms among low-income mothers. Psychology of Women Quarterly, 33 , 351–362.

Geertz, C. (1973). The interpretation of cultures . New York, NY: Basic Books.

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research . Chicago, IL: Aldine.

Lindqvist, P., Johansson, L., & Karlsson, U. (2008). In the aftermath of teenage suicide: A qualitative study of the psychosocial consequences for the surviving family members. BMC Psychiatry, 8 , 26. Retrieved from http://www.biomedcentral.com/1471-244X/8/26 .

Todd, Z., Nerlich, B., McKeown, S., & Clarke, D. D. (2004) Mixing methods in psychology: The integration of qualitative and quantitative methods in theory and practice . London, UK: Psychology Press.

Wilkins, A. (2008). “Happier than Non-Christians”: Collective emotions and symbolic boundaries among evangelical Christians. Social Psychology Quarterly, 71 , 281–301.

Research Methods in Psychology Copyright © 2016 by University of Minnesota is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

The Role of Organized Activities in Supporting Youth Social Capital Development: A Qualitative Meta-Synthesis

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• Published: 09 May 2024

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• Ashley A. Boat   ORCID: orcid.org/0000-0001-7504-9608 1 ,
• Heather Poparad 1 ,
• Miray D. Seward 1 ,
• Peter C. Scales 1 &
• Amy K. Syvertsen 2  

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Social capital provides young people with a web of supportive relationships that can be leveraged in pursuit of education, career, and life goals. Organized activities, an umbrella term for extracurricular activities, after-school programs, and youth development programs, are important developmental contexts for building social capital. The purpose of this study was to illuminate the developmental pathway through which social capital development occurs in organized activities. A qualitative meta-synthesis was conducted using 33 articles that met inclusion criteria across five databases (e.g., ERIC, PsycINFO) between June 2022 and May 2023. Thematic analysis was used to identify malleable organized activity features that act as levers for social capital promotion. Seven thematically aligned features were identified, including (1) organizational partnerships, (2) organizational supporting structures, (3) relationally strong climate, (4) staff mindsets and skills, (5) youth mindsets and skills, (6) increased social capital opportunities, and (7) increased social capital activation. These seven themes were used to construct an empirically-grounded model that posits a process through which organized activities support youth social capital development. Implications for intentionally strengthening organized activities’ capacity to support youth social capital are discussed.

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Introduction

Social capital is an important asset that adolescents and emerging adults can leverage while pursuing life course milestones including postsecondary education and employment. Social capital has been positively linked to progress towards education and career goals (Boat, et al., 2022a ), increased support for securing a job (Brown et al., 2016 ), and career advancement including higher compensation levels (Ghosh & Reio, 2013 ; McDonald, 2015 ). And, it may be an especially valuable asset among students from underrepresented groups in higher education, including first-generation college students, students from low-income backgrounds, and students of color, who often experience systemic and institutional barriers that contribute to exclusion and inequitable academic outcomes (Mishra, 2020 ). Because social capital is a malleable asset that all youth possess to some degree and can utilize to reach their full potential, it is important to identify ways in which this critical resource can be intentionally strengthened. The current study defines social capital as the resources that arise out of a web of developmental relationships that young people can access and mobilize to improve their lives and achieve their goals (Scales et al., 2020 ), and examines how organized activities can support social capital development as youth pursue their education and career goals.

Research has largely focused on examining the contribution of family and school environments to youth social capital (Ryan, 2017 ; Stephan, 2013 ), and less emphasis on how organized activities that occur beyond the home and regular school day can be leveraged as forums for social capital development (the literature on school-business partnerships targeting youth from marginalized backgrounds has long been an exception, e.g., Scales et al., 2005 ). Organized activities are defined as structured and supervised activities outside the school curriculum that a group of young people engage in (Bohnert et al., 2010 ). This may include school-based extracurricular activities such as sports and clubs, as well as out-of-school time programming such as faith-based, youth, and workforce development programs. Plentiful research has shown that positive relationships provided through these activities support youth in pursuing their education and career aspirations (National Research Council, 2002 ; Vandell et al., 2015 ), but the literature has been less clear about exactly how structures and relationships in these contexts promote social capital. To address this gap, the current qualitative synthesis identifies and summarizes how organized activities intentionally support young people in strengthening and leveraging their existing social capital as they pursue their goals.

Social Capital Theory

Social capital is a diffuse concept that has been reinvented multiple times over the last 40 years by a myriad of disciplines (e.g., economics, sociology, political science), which has resulted in multiple theoretical frameworks and definitions. While diverse, the majority of these definitions emphasize the value of resources that emerge via social relationships (e.g., Coleman, 1988 ; Freeland-Fisher, 2019 ; McPherson et al., 2014 ). Many of these foundational frameworks illustrate how individuals with more power and who have access to the ‘right’ kinds of capital benefit (Lehmann, 2019 ). For example, some scholars have noted that education and employment systems often value forms of capital (e.g., volunteering, internships) that favor youth from more privileged backgrounds (e.g., youth from higher-income families and/or communities who can do volunteer work without pay, or have transportation to get places easily; Moreau & Leathwood, 2006 ). Scholars have also critiqued these more traditional conceptualizations of social capital noting that these earlier descriptions of social capital are, “overly deterministic and tend to disregard the relevance of youth agency…” while also undervaluing the assets within young people’s communities of origin and suggesting that youth of color experience a “lack of social capital” (Akom et al., 2008 , p. 2).

But there also have been examples over the last 20 years of more expanded definitions of youth social capital that draw from the fields of positive youth development, social justice, community organizing, and youth activism. The Community Cultural Wealth framework, for example, underscores various assets and resources utilized by communities of color while navigating social systems (Yosso, 2005 ). Similarly, critical social capital places a greater emphasis on relationships that engender community change while also centering how racial identity can serve as a resource for youth (Ginwright, 2007 ). These conceptualizations of social capital acknowledge structural constraints while also viewing youth as agents in facilitating change.

The Inequitable Distribution of Social Capital

While social capital can provide a pathway for upward mobility (a goal that may be defined differently and considered more or less important across differing cultural groups), disparities in social capital among youth exist and contribute to unequal opportunities that further perpetuate inequities in postsecondary outcomes and career success (Timpe & Lunkenheimer, 2015 ). Young people of color and/or youth from lower-income communities face social and structural oppressions including disinvestment, poverty, and discrimination, all of which can constrain social capital development (Carpiano, 2006 ). There also are different forms of social capital, namely bonding, bridging, and linking, and each has its own potential to either thwart and/or advance the life trajectories of young people, i.e., either perpetuate or overcome the inequitable distribution of social capital (Scales et al., 2020 ).

Bonding social capital, which Coleman ( 1988 ) made central to his foundational and frequently-critiqued work in defining social capital, refers to connections between groups of individuals who share a group affiliation (e.g., culture, education, social class). This type of social capital can strengthen relationships between individuals who are already demographically similar (e.g., family members, close friends), and as a result can also serve as a basis for exclusion (Grootaert et al., 2004 ). For example, socially advantaged families may use and strengthen bonding social capital within their networks to amass educational opportunities for their own children (Murray et al., 2020 ), further exacerbating educational inequality for those without that same advantage (Calarco, 2018 ). Conversely, bridging and linking social capital both refer to connections across differing groups, with linking social capital more explicitly referring to connections made across power and status differences (Grootaert et al., 2004 ). These forms of social capital may have greater potential to influence equitable outcomes by enabling young people to access resources and information outside of their immediate social networks. Studies, for instance, show how staff, educators, and mentors may serve as ‘institutional agents’ (Stanton-Salazar, 2011 ), as well as how community-based organizations can serve as brokers (Dill & Ozer, 2019 ) by connecting youth from marginalized communities with pathways for opportunity that may not otherwise be available (e.g., internships, professional networking skills).

Due to increased access to individuals and institutions with power and/or prestige, youth from privileged backgrounds may have more bridging and linking forms of social capital (Bridwell-Mitchell, 2017 ). Therefore, these forms of social capital can heighten existing power dynamics, neglect systemic changes that are needed to yield more equitable education and economic opportunities for all youth, and ignore the roles that youth activism and collective efficacy can play in changing systems to be more equitable (Akom et al., 2008 ). Past theoretical work illustrates how young people from marginalized backgrounds often possess and commonly use forms of capital (i.e., aspirational, linguistic, familial, social, navigational, and resistant) that typically go unrecognized, unmeasured, and/or undervalued by dominant groups and institutions (Rabinowitz et al., 2020 ; Yosso, 2005 ). For example, one study found that when Hispanic/Latina/o/x students’ schools failed to provide them with information about postsecondary education opportunities, students tapped into the cultural wealth of their community to access information in other ways (Liou et al., 2009 ). Other studies have highlighted ways that youth of color have used their community cultural wealth to navigate inequitable systems to access higher education information (Welton & Martinez, 2014 ), resist racist policies and practices within institutions in order to reach postsecondary aspirations (O’Shea, 2016 ), and utilized influential support from family members while working towards educational goals (Gonzales, 2012 ). Therefore, understanding how organized activities can leverage young people’s wealth of assets by fostering social capital development may be particularly important for youth who may experience marginalization in school or other spaces that undervalue these forms of capital.

Organized Activities and Youth Social Capital Development

Organized activities may be uniquely positioned to help youth recognize and activate forms of social capital that they already possess, as well as intentionally support young people in strengthening and leveraging their social capital while pursuing life goals. Prior research suggests that participation in organized activities is positively linked with greater academic motivation and achievement (Hughes et al., 2016 ), greater likelihood of employment (Heath & Thornock, 2022 ), and increased civic engagement (Zarrett et al., 2021 ). Additionally, organized activities are known to serve as important contexts for positive youth development and growth, where young people have opportunities to build skills (e.g., relationship-building, social skills), overcome challenges (e.g., peer pressure, academic struggles), and foster prosocial relationships (Scales, 2017 ; Vandell et al., 2015 ).

While participation in organized activities is not in itself social capital, they may provide the conditions in which young people can build and strengthen social capital. For example, participation in organized activities creates opportunities for youth to develop close relationships with peers and supportive adults both in and outside of the activity, which can create new avenues to access additional resources (e.g., knowledge, new connections; Vandell et al., 2015 ). However, organized activities can fall short in providing youth with multiple positive relationships and opportunities to exert agency, pursue deep interests, and enhance skills (Scales, 2017 ). In the worst cases, some organized activities paint a deficit-based portrait of youth, especially youth from historically marginalized backgrounds, as being in need of “saving” (Baldridge, 2014 ). Therefore, it is important to identify the core components of high-quality organized activities that intentionally support the social capital development of all young people from a strengths-based perspective.

National studies conducted by the Afterschool Alliance ( 2020 ) point to alarming (and growing) disparities in young people’s access to organized activities in the afterschool hours. Their most recent 2020 study found that 36% of youth in grades 9 to 12 would participate in an afterschool program if one were available. This unmet need is even more pronounced among low-income Black and Hispanic/Latina/o/x children. Even when programs do exist parents cite cost (57%) and lack of transportation (62%) as barriers to participation. Unequal access to organized activities translates into unequal access to critical developmental contexts and opportunities shown to promote a range of social-emotional, educational, civic, and psychological benefits, and—as posited here—social capital development.

The Current Review

The current review uses qualitative meta-synthesis research methods to synthesize existing qualitative studies in order to develop a theoretical understanding of how organized activities support young people’s social capital development while they pursue education and/or career goals. In this work, we aim to identify the malleable features of organized activities that programs can feasibly influence to intentionally strengthen social capital for all young people, including youth from historically minoritized and marginalized communities. The growing body of qualitative research focused on youth social capital development has matured to a point where we believe that a synthesis of this literature from both youth and staff perspectives would help the field better understand the ways in which organized activities intentionally promote youth social capital. Therefore, the current study aimed to identify the elements within organized activities that intentionally support young people’s social capital development as they pursue education and career goals.

The qualitative meta-synthesis followed a six-step method (Lachal et al., 2017 ): (1) conduct a literature search and define the inclusion/exclusion criteria; (2) use selection criteria to screen studies; (3) conduct a critical appraisal of included studies; (4) extract and present data; (5) conduct a thematic analysis; and (6) report the synthesis. Steps 1–3 are discussed below along with a description of our thematic analysis methodology. Steps 4–6 are presented in the Results.

Literature Search and Inclusion/Exclusion Criteria

Studies included in the review were located through a multi-pronged search process conducted between June 2022—May 2023. First, a literature search was conducted for journal articles written or published between the years 2000 and 2023, utilizing five databases: PsycINFO, ERIC, Sociological Abstracts, Web of Science, and Academic Search Premier. In these database searches, keywords were specified to capture organized activities that focused on building young people’s social capital development while they work towards education and/or career goals.

The keywords used to capture organized activities included: OST, out-of-school time, extracurricular, organized activities, organized program, work-based learning, workforce development, youth development program, youth mentoring, community-based organization, and after school program. Keywords for social capital included: social capital, social network, social support, webs of support, relational support, peer support, and support network. Keywords for education and/or career outcomes included: education aspirations, educational attainment, college enrollment, academic motivation, academic performance, academic achievement, work readiness, employment, career interests, and occupational identity. Boolean search operators were utilized to connect keywords across these three domains. We chose not to apply qualitative filters (i.e., search engine filters that specify qualitative studies only) in order to capture all the possible relevant articles.

Studies needed to meet the following criteria to be eligible for final review: (1) used a qualitative research design such as semi-structured interviews or focus groups; (2) examined a specific organized activity (as previously defined); (3) examined young people’s social capital (which needed to include discussion of resources that arise from relationships); (4) was an original empirical article published between 2000 and 2023; (5) was written in English; (6) derived from data collected in the United States; and (7) focused on adolescents and/or emerging adults (ages 14–24). If the organized activity’s target audience extended outside of the 14–24 age range and was inclusive of this range, the study was still eligible for inclusion.

Studies were excluded from the review if they met any of the following criteria: (1) used only a quantitative research design; (2) occurred only outside of the United States (studies that include multiple countries were eligible if an organized activity in the United States was also included); (3) written in a language other than English; (4) published before 2000 (excepting studies that would reasonably be considered foundational or classic pieces of research, that are judged by the authors to still be relevant. However, none of these types of studies emerged); (5) included only a one-off and/or standalone activity such as a 1-day job fair; and/or, (6) exclusively focused on online social networks or natural mentoring relationships that are not facilitated via an organized activity.

Screen Studies

The initial literature search utilizing the five databases yielded 547 records (see Fig.  1 ). Titles and abstracts from the database search were screened by the first or second author to identify an initial set of 69 unique articles for further review. Subsequently, the first and second author completed a forward search by using the “cited by” function in Google Scholar for each of the 69 unique articles that emerged from the original database search. This forward search yielded 3,784 total records. These authors examined the title and abstracts of these additional forward search records to determine if any of these articles warranted additional review. An additional 55 unique articles were identified from the forward search process. Finally, a backward search was conducted by the first author by searching through the reference list of articles that were selected for further review following both the database and forward search. This resulted in 17 additional articles for further review. Taken together, this search process yielded a total of 141 records that warranted closer review.

PRISMA flow chart for social capital in organized activities meta-synthesis

To ensure interrater reliability in the inclusion/exclusion of potential articles, the first and second author both independently read 50 of the 141 articles in full and recorded which of these studies met inclusion/exclusion criteria (interrater reliability = 94% agreement). The first and second author then read the title, abstract, and Methods section of the remaining 91 articles to determine whether they met inclusion/exclusion criteria. Following this subsequent review, 94 articles were selected for full-text review. Both the first and second author read these articles in their entirety and any disagreements and/or discrepancies about which articles warranted inclusion in the final review were discussed until consensus was reached. During this review process, all types of research methods (i.e., qualitative, quantitative, and mixed methods) were accepted. However, of the few quantitative studies identified through the review process, none provided entirely original or novel information—beyond what was found in the qualitative studies—on the core elements of organized activities that support young people’s social capital development. This process resulted in a final set of 33 articles that were identified for inclusion in the current synthesis.

Critical Appraisal

In addition to screening each article for inclusion, we also used the Critical Appraisal Skills Programme (CASP; 2018) checklist, a 10-item quality assessment tool, to appraise the quality of studies included in the synthesis. The CASP was used because it provides a systematic process for identifying the strengths and weaknesses of qualitative research studies and is considered to be user-friendly (Long et al., 2020 ). The CASP does not have a scoring system, but instead asks users to indicate whether studies address each of the 10 items using the following response options: Yes, No, Can’t Tell . Based on recommendations from past researchers and our own use of the tool, we decided to add a fourth response option: Somewhat (Long et al., 2020 ). The first three authors reviewed each of the 33 studies and based on the CASP criteria they organized the studies into three quality categories: low (scored yes or somewhat on 4 or fewer CASP items), medium (scored yes or somewhat on 5–7 CASP items), and high (reported yes or somewhat on 8 or more CASP items). Of the 33 studies, one was categorized as low quality, 13 were categorized as medium, and 20 were categorized as high. The sole study categorized as “low” was examined a second time in order to determine whether the reasons for this classification were due primarily to missing information (i.e., Can’t tell ) or whether the overall methodology was poor. It was determined that the score was primarily due to missing information. Based on this review, we made the decision to not exclude any studies from our synthesis. While the authors of some of the reviewed studies may have failed to describe their methods in sufficient detail for us to determine whether criteria had been met ( Can’t tell ), we did not believe this lack of reporting necessarily translated into a poorly conducted study and felt that all 33 studies contributed to our understanding of our research question.

Thematic Analysis

The 33 articles that were retained were coded in order to identify themes. Three coders (1st, 2nd, and 3rd author) worked together to code the articles in Dedoose ( 2021 ). Utilizing thematic analysis techniques (Braun & Clarke, 2006 ), the three coders first familiarized themselves with the data by reading through all of the articles. While reviewing, coders paid particular attention to any text relating to social capital in the Results and Discussion sections. This included participant quotes and/or primary author interpretation. A combined deductive and inductive approach was used to identify codes. The coders made note of potential codes that included elements of organized activities that supported youth social capital development, as well as preliminary codes that aligned with the authors past theory-building and social capital research (Boat et al., 2022b ; Scales et al., 2020 ). Yet, authors remained open and allowed for the identification of new codes and themes throughout the coding process. The three coders used this initial set of codes to independently code the same article before meeting to discuss and refine the codebook. From there, each coder was assigned 11 articles to code independently. Coders met weekly to discuss the utility of the existing codes and potential modifications, emergent themes, and to reach consensus on how to code data that was unclear. Codes were then reviewed and organized into broader themes that speak to the mechanisms by which organized activities support youth social capital development.

Description of the Studies

Table  1 provides a description of the 33 studies retained for coding. All of the studies were purely qualitative studies with the exception of two studies that used mixed methods (Bempechat et al., 2014 ; Schwartz et al., 2018 ). Articles examined a range of different types of organized activities—including afterschool programs, work-based learning, STEM enrichment, mentoring programs, sports, and clubs, among others. All of these organized activities were designed for youth in high school and/or college, with many serving youth of color. Table  1 provides more information on who the organized activities served and were designed for.

From the data, seven thematically aligned strategies were identified for how organized activities support youth social capital development, including (1) organizational partnerships, (2) organizational supporting structures, (3) relationally strong climate, (4) staff mindsets and skills, (5) youth mindsets and skills, (6) increased social capital opportunities, and (7) increased social capital activation. Because these seven identified themes are interconnected and suggest a potential pathway through which key elements of organized activities may be leveraged to intentionally build social capital, we constructed an empirically-grounded model that organizes these themes and posits a process through which organized activities support youth social capital development (see Fig.  2 ). The themes of organizational partnerships, organizational supporting structures, relationally strong climate, and staff and youth mindsets and skills feed into creating a social capital promoting organized activity. The themes of increased social capital opportunity and activation illustrate how the elements of a social capital promoting organized activity support youth social capital development as youth pursue life goals. Each of the themes and their corresponding sub-themes are described below with supporting quotes from primary data.

Proposed model for how organized activities support young people’s social capital development

Social Capital Promoting Organized Activity

While primarily interested in the ways that organized activities support individual-level social capital, the synthesis showed the important role and impact of social capital at the organization level. In addition to organizational partnerships, findings underscore several supporting structures that were helpful for cultivating a relationally strong climate that prioritized youth social capital development. This relationally strong climate was characterized as a safe and culturally responsive space where youth feel a strong sense of community and belonging, and are provided opportunities to explore their sparks; i.e., the interests and passions that give them joy, energy, and purpose (Scales et al., 2023 ). Findings also identified staff and youth skills and mindsets that likely nurture this climate.

Organizational Partnerships

The meta-synthesis showcased how social capital does not just exist between people, it also exists at the organization level whereby administrators and directors of organized activities form partnerships with other community-based organizations that allow the youth they serve to access additional value-add resources. For example, a career readiness program built partnerships with a local network of information technology (IT) employers to give youth first-hand exposure to the kind of careers they could pursue in the IT field (Hernandez-Gantes et al., 2018 ). This type of relationship building often resulted in increased opportunities (e.g., internships, informational interviews) for youth and allowed them to imagine themselves in different kinds of careers. Another study of a STEM program serving African American/Black youth highlighted the resources that emerged from the program’s partnerships with community businesses: “in addition to financial support, STEM businesses provided students, teachers, and parents with access to professional scientists and engineers and cutting-edge science research facilities” (Hargrave, 2015 , p. 10). Some organized activities became well-respected institutions within their communities which further allowed their leaders to obtain more partnerships and positions that further increased access to opportunities. For example, the pastor of a community-based church joined the Board of Education in hopes of addressing inequalities in the local education system. The church also created community-wide opportunities including opening a franchised restaurant on the church campus to address community unemployment rates, while giving Black high school students opportunities to gain work experience and see an example of a successful Black man who owns his own business (Barrett, 2010 ).

Organizational Supporting Structures

The extant literature points to the structural supports organized activities rely on when building youth social capital development. These supporting structures include retention of high-quality staff, presence of a shared organizational mission and values, and hiring staff with similar identities and/or life experiences as the youth served.

High-Quality Staff Retention

In order to effectively meet the needs of young people and support their social capital development, it is essential that organized activities retain and support high-quality staff and volunteers (Hall et al., 2020 ). For example, a newcomer program (i.e., programs designed in K-12 settings to support large influxes of refugees and immigrants) that served immigrant and English learner students grappled with low retention of qualified educators, and had to staff classrooms with educators who did not have Teaching English to Speakers of Other Languages (TESOL) training, and who were certified in other subjects than the one they were assigned to teach (Hos et al., 2019 ). Conditions like these make it exceedingly difficult for organized activities to adequately meet young people’s needs. In contrast, when organized activities retain high-quality staff with effective training and experience it can lead to a profound impact for youth participants. For example, the newcomer program described a teacher, Mrs. Smith, who was particularly gifted at supporting student needs by explicitly drawing on students’ lived experiences and using effective modeling techniques (Hos et al., 2019 ). Organized activities with successful staff retention efforts are also better positioned to establish long-term youth-adult relationships and trust within the communities they serve. For example, one community-based program described how their “newest” adult staff member had been at the organization for over 8 years, which led to “long-term relationship building and created institutional memory” (Dill & Ozer, 2019 , p. 1620). This organized activity was likely able to retain staff due to its strong presence in the community and hiring of staff that were both from and committed to supporting youth within the community.

Shared Organizational Mission and Values

Staff enhance their ability to collaborate in service of youth when they embody a set of shared values and a collective commitment toward achieving agreed-upon outcomes. A career readiness program illustrated this alignment among staff when a staff member observed that “everywhere we went, the message was the same: the commitment to work together as a community bridging and linking school- and work-based strategies was crucial in supporting and sustaining the promotion of career readiness for IT Academy students” (Hernandez-Gantes et al., 2018 ). Working together creates a ripple effect that influences relationships with community partners, and the relationships that those community partners develop with the program’s youth. In a high school STEM program with a university affiliate, “… the interactions with university staff and teachers was where program practices and dispositions were shaped to ensure consistency and fidelity between what was said and what was done” (Hargrave, 2015 , p. 358). The interactions between teachers and university staff ultimately influenced the program’s rhetoric and programming, adults’ beliefs about youth potential, and messaging that youth received from staff and community partners. When staff are unified under a shared mission, a cohesive set of goals, values, and supports are amplified for youth.

Staff Share Similar Identities and/or Life Experiences as Youth

Employing staff who share similar identities (e.g., racial, cultural, gender) or life experiences as the youth served can promote a sense of belonging (Garcia et al., 2021 ; Wong, 2008 ). For example, a young person in an academic enrichment program reflected on her relationship with a Hispanic/Latina educator who earned a Doctorate in Education: “[She]… was so inspiring. Wow, I could be you. I look up to you. You look like me. You speak like me. We share a language… and it’s possible” (Habig et al., 2021 , p. 519). When youth are able to identify with and see themselves reflected in the adults in their organized activities, it is easier to dream about pursuing similar futures for themselves. Shared identities and life experiences provide a common ground for adults to connect with, understand, and provide culturally relevant support to young people (Erbstein, 2013 ; Wong, 2008 ), which can yield more trusting youth-adult relationships (Garcia et al., 2021 ). For youth of color, in particular, identification with adult staff from similar backgrounds can support more than a sense of belonging, contributing also to the recognition that their culture is an asset for developing a network of aspirational role models with whom they can relate (Habig et al., 2021 ). As such, employing and hiring staff who share common identities and/or life experiences with youth is fertile ground for developing relationships with positive adults who motivate them to dream big and achieve their goals.

Relationally Strong Climate

The organized activities included in the meta-synthesis highlighted the characteristics of a strong relational climate. Organized activities that were experienced as safe and culturally responsive—where youth have a strong sense of community and belonging, and are given opportunities to explore their interests, passions, and sparks—were identified as ripe for cultivating youth social capital.

Create a Safe Environment

To create a relationship-rich climate, it is important for youth to feel physically and emotionally safe within the organized activity. One way this was achieved, for example, was through coaches creating “safezones,” within organized sports such as basketball and boxing leagues which provided physically safe spaces for Black youth who were living in neighborhoods with high levels of community violence (Richardson, 2012 , p. 190). Coaches noted that these protected social spaces on and off the athletic field/court were used as a “safe haven and buffer from violence within the local community” (Richardson, 2012 , p. 190). While this program highlighted the importance of physical safety, many of the other organized activities reviewed described how through participation in the organized activities, youth felt emotionally safe, which often resulted in them expressing their authentic selves. For example, an afterschool program employed “facilitators [who] were aware that the youth needed to feel that they had a space where they could express themselves and their identities and ideas, and were safe from stereotypes, belittlement, and intimidation” (Woodland et al., 2009 p. 243). Other organized activities created safe spaces for Hispanic/Latina/o/x youth by engaging in initiatives that allowed for the development of “confianza (mutual trust)” between youth and adults enabling youth to “fully embrace all aspects of who they are” (Harris & Kiyama, 2015 p. 194). Creating environments of physical and emotional safety fostered trust and enabled youth to build strong and more meaningful relationships while staying true to their values and beliefs.

Engage in Culturally Responsive Ways

A culturally-responsive climate was manifested through interactions with staff and culturally-grounded instruction and materials that were personally relevant to youth. For example, a community-based program described how its participants who identified as Chinese American commented on how the materials were culturally sensitive (e.g., materials written in multiple languages, resources for engaging families, bilingual and bicultural teachers and lessons), with one participant stating, “I could relate more here [referring to program] but not at school” due to the culturally-relevant materials (Wong, 2008 , p. 190). Black youth in an afterschool program shared that it was the culturally-relevant discussions about topics such as history, popular culture, and their personal experiences that attracted them to the organized activity and encouraged further participation (Woodland et al., 2009 ). Several of the organized activities also described providing a space for youth of color to discuss systematic barriers and experiences of discrimination with staff and others. For instance, one mentoring program illustrates how near-peer mentors of color tried to prepare their mentees for uncomfortable encounters of discrimination and biases that they themselves had experienced (Cox, 2017 ). Organized activities were also sensitive to youths’ needs and context, which was particularly beneficial for supporting youth-adult relationship building across lines of difference (e.g., differences in race and/or socioeconomic status; Ramirez, 2021 ). Examples included bridging parent-school relationships in programs for Hispanic/Latina/o and Chinese American youth (Erbstein, 2013 ; Wong, 2008 ) and providing resources (e.g., access to education and job opportunities, financial support) to help overcome systemic barriers in programs for Thai refugee youth and Chinese American youth (Hos et al., 2019 ; Wong, 2008 ). It is important to note that in some of the organized activities, staff were able to be culturally responsive to youth because they themselves were from the same communities and/or had experienced the same life events (e.g., Cox, 2017 ); whereas in other organized activities, staff who did not share these same life experiences were educated through their interactions with young people (e.g., Ramirez, 2021 ) and/or through explicit training (e.g., Sanchez et al., 2022 ).

Build a Strong Sense of Community and Belonging

Organized activities also created a strong relational climate through fostering community and a sense of belonging. Across the organized activities examined, staff and youth often described their organized activities as a “second home,” a family, and/or a team (Bempechat et al., 2014 ; Powell et al., 2017 ; Tichavakunda, 2019 ). For example, staff in a 14-month program, called Launch, that prepares low-income students of color to attend elite boarding schools through mentorship and academic training referred to staff and participants as a family in stating, “… your fellow crew members are your ‘brothers’ and ‘sisters’ within the larger Launch ‘family’…” (Cox, 2017 p. 54). In some cases, youth joined organized activities to increase their feeling of belonging (e.g., Nolen et al., 2020 ). Organized activities often represented chosen communities, where youth found connections with peers who share similar interests or life experiences as their own. For example, a career readiness program described how it “celebrated their common linkages and bonds,” as all the young people shared a “communal identity” (Hernandez-Gantes et al., 2018 , p. 196). The sense of belonging that was cultivated in organized activities engendered a supportive community that young people could be a part of and rely on.

Provide Opportunities to Explore Sparks

The space that organized activities create for youth to explore their sparks or deep personal interests (Scales et al., 2011 ) sets them apart from other contexts like schools where the curriculum is largely driven by educational standards. One afterschool program did this through field trips that gave youth opportunities to learn more about newfound interests, future possibilities, and other communities and places (Ching et al., 2016 ). Organized activities also allowed youth to explore a variety of different sparks that were tailored to their unique interests. For example, a staff member of an organized activity that focused on developing young entrepreneurs stated, “The most basic goal we have is to help them get in touch with what they’re about. Because everyone has their own unique set of personal gifts. Defining what these gifts are and what the needs of the world are and finding out where they overlap - that’s what we shoot for…” (Miller, 2011 , p. 53). Youth may be more likely to make progress towards their life goals when opportunities and resources within organized activities are aligned with their sparks (Scales et al., 2011 ).

Staff Mindsets and Skills

Staff have specific mindsets and skills that nurture a strong relational climate. These include believing in youth assets and potential, and skills such as authentic relationship-building skills and brokering skills.

Staff Belief in Youth Assets and Potential

In organized activities, staff’s beliefs in the assets and potential of youth are sometimes in stark contrast to what youth experience from other adults in their schools and communities (e.g., Ginwright et al., 2007). In many organized activities, staff were described as acting in ways that affirmed young people’s aspirations (e.g., Lane & Id-Deen, 2020 ; Ramirez, 2021 ). At the same time, they continuously held high expectations for youth and balanced support with autonomy to meet those expectations (e.g., Murillo et al., 2017 ; Sanchez et al., 2022 ). For youth of color, this support inspired them to challenge deficit narratives by working to engender program or community changes that might facilitate their academic and professional success. Illustrating this experience, a Black youth participating in a leadership program shared, “They [staff] see me as an activist or something, and I’m not political like that. But when [the program director] lets me speak my mind to folks like the mayor and political people, it makes you want to live up to that image, you know” (Ginwright, 2007 ). A faith-based organization provides another example where the pastor created a community that held high expectations and belief in Black youths’ value by providing public recognition and celebration of academic success through its academic achievement days (Barrett, 2010 ). When staff demonstrate belief in young people’s potential, they empower youth to imagine other possible selves. Staff also recognized and valued the resources and support that youth, their families, and communities already possessed (e.g., encouragement, high expectations, being held accountable), and found ways to leverage these assets by building strong relationships with youth’s families and communities to further strengthen these existing relationships (Erbstein, 2013 ; Lane & Id-Deen, 2020 ).

Staff Authentic Relationship-Building Skills

Staff who built strong relationships with the youth they served did so by being intentional, equitable, and inclusive in their relationship-building efforts. Staff sometimes found themselves taking on roles beyond what was expected and written down in their job title in order to meet the needs of youth. For example, one sports coach stated, “I wore multiple hats in this setting: social scientist, coach, chaperone, chauffeur, and counselor” (Richardson, 2012 , p. 188). Staff in a community-based program intentionally worked to “​​get to know youth’s family and teachers, they chaperone them [youth] to field trips, they act as interventionists for the youth at their schools and in their neighborhoods” (Dill & Ozer, 2018, p. 1620). In addition to meeting youth needs by playing multiple roles, staff who possessed the skills to establish trusting relationships were able to gain “… access to intimate life details and student knowledge,” which enhanced their ability to provide effective supports (Ramirez, 2021 , p. 1075). This was especially valuable for youth from marginalized backgrounds, as youth were more apt to openly talk to staff about structural barriers that they were facing, enabling staff to advocate for youth and act as “social brokers’’ (Ramirez, 2021 , p. 1075). Because staff had the skills to build these strong relationships with youth, they were better positioned to support young people’s academic, social-emotional, and professional needs (Lane & Id-Deen, 2020 ). In doing so, they could empower youth to believe in themselves and to approach postsecondary goals with the mindset that they deserve to be stretched to develop to their fullest potential.

Staff Brokering Skills

Cultivating trust with youth and providing them with the needed supports opened up opportunities for staff members to act as brokers of relationships and opportunities (e.g., Sanchez et al., 2022 ). In organizations’ attempts to leverage these youth-adult relationships to enhance youth’s social capital, staff were often positioned as institutional agents who assisted youth in navigating unfamiliar systems (e.g., Museus, 2010 ; Ramirez, 2021 ). Consequently, these staff members often served as brokers to access other connections, resources, and opportunities that youth could benefit from (e.g., Hos et al., 2019 ). Most frequently, staff brokered relationships and connected youth with resources that existed outside of the organized activity (e.g., postsecondary related services, admissions personnel, research opportunities; Museus, 2010 ; Ramirez, 2021 ; Sanchez, 2022). Often, this brokering entailed providing youth with the “hook-up” (Dill & Ozer, 2018, p. 1622), and drawing “on the program’s connections to identify potential relationships, and [vouching] for the youth to the community adults (putting their own reputations on the line)” (Jarrett et al., 2005 , p. 53). By vouching for youth in organized activities, staff were able to help youth gain “access to educational opportunities that they otherwise would not have access to” (Garcia et al., 2021 , p. 7).

Youth Mindsets and Skills

Youth also have specific mindsets and skills that contribute to a strong relational climate, and are also likely to contribute to enhanced ability to actively mobilize social capital as they work towards their life goals. These mindsets and skills include having a future-oriented mindset, commitment to paying-it-forward, self-efficacy to reach goals, and strong relationship-building skills.

Youth Future Orientation

Organized activities exposed youth to potential futures under the support of caring staff who helped them navigate their future goals. For example, in a mentoring initiative designed for Hispanic/Latina/o/x students, professionals served as role models for academic and career advancement (Sanchez et al., 2022 ). Through their engagement with adult professionals, youth in another program began to make connections between education, careers, and their economic potential (Cayleff et al., 2011 ). This allowed them to construct a coherent plan that bridged their current activities to a greater sense of purpose and goal-orientation. An alumna of a college and career readiness program for low-income youth from the U.S. and other countries shared, “[My internship] definitely opened up my perspective in figuring out what I needed to get out of college… [This] drove what I would study and prioritize during college” (Detgen et al., 2021 , p. 239). These experiences in organized activities helped youth develop an understanding of the pathways to careers, college, and goal achievement, while motivating them to take action to increase their likelihood of future success.

Youth Commitment to Paying-It-Forward

Participation in organized activities can foster a commitment to paying-it-forward, both within the program and the greater community context. For instance, some organized activities intentionally built in opportunities for the youth to become interns or mentors to incoming cohorts (Ching et al., 2016 ; Cox, 2017 ). Regardless of whether these formal opportunities existed, appreciation for the support received from staff inspired many young people to serve as a positive influence for other youth like them (e.g., Kniess et al., 2020 ; Miller, 2011 ). A youth-mentor in an academic support program shared with his peers: “Keep in mind that whatever you guys do, the next cohort sees… What example are you setting, right? Ask yourselves that. And take it seriously” (Cox, 2017 , p. 54). Taking this sense of reciprocity, a step further, programs designed for African American/Black and Hispanic/Latina/o youth that involved civic engagement facilitated the development of collective consciousness by providing opportunities for youth of color to have a say in community affairs (e.g., Ginwright, 2007 ; Sullivan & Larson, 2010 ). For example, one program that offered support for youth to lobby their local government institutions empowered youth of color to promote systemic changes that would benefit others like them (Sullivan & Larson, 2010 ). Thus, activities that provide opportunities for youth leadership foster high regard for reciprocity and encourage youth to leverage their own social capital in support of their community.

Youth Self-Efficacy in Reaching Goals

Participation in organized activities strengthened youths’ sense of self-efficacy in achieving their goals. Many organized activities supported youths’ self-efficacy in reaching life goals by teaching and encouraging young people’s growth in academic skills (Bempechat et al., 2014 ), relationship-building skills (Schwartz et al., 2016 ), and skills for enacting agency such as professional communication, time management, and leadership (Powell et al., 2017 ). Further, experience in professional settings helped youth develop confidence that they could thrive in these environments (Ching et al., 2016 ), while also providing opportunities for youth to feel accomplished (Dill & Ozer, 2019 ). As youth developed greater self-efficacy, they were more likely to frame their personal characteristics as strengths (Harris & Kiyama, 2015 ) and demonstrated more comfort engaging in potentially daunting tasks (Ching et al., 2016 ; Miller, 2011 ).

Youth Relationship-Building Skills

Youth in organized activities noted how the programs they were involved in helped them develop relationship-building skills, communication skills, social skills, and confidence in interacting with adults and professionals (e.g., Kniess et al., 2020 ; Sullivan & Larson, 2010 ). Other organized activities emphasized the importance of building networks (e.g., Habig et al., 2021 ; Murillo et al., 2017 ), providing more explicit opportunities to build networking skills including social networking events (e.g., Museus, 2010 ), and giving youth specific strategies for maintaining relationships and building new connections (e.g., Schwartz et al., 2016 ). Organized activities supported and encouraged relationship-building skills among youth by providing opportunities for them to initiate and build relationships with many types of individuals. For example, “a key component of the ways in which targeted support programs create early connections is by offering students opportunities to connect and develop meaningful relationships with their college peers, administrators, counselors, and academic advisors…” (Museus, 2010 , p. 26).

Youth Social Capital Development

The proposed model shows that organized activities are well positioned to support youth in strengthening and leveraging their social capital by creating a relationally strong climate, which in turn, contributes to increased social capital opportunity and activation. Social capital opportunity refers to youth experiencing increased and more consistent developmental relationships with adults and peers within the organized activity. It is through these relationships that youth increase their access to valued resources (e.g., financial help, information, guidance) including new connections and relationships outside of organized activities that can be used as youth pursue life goals (i.e., social capital activation).

Increased Social Capital Opportunities

Increased social capital opportunities were promoted by organized activities that facilitated developmental relationships between staff and youth, which in turn increased access to valuable resources and connections that were not previously available.

Developmental Relationships with Staff and Peers

The relationally strong climate fostered by staff and youth mindsets and skills resulted in youth experiencing stronger relationships with program peers and staff, which contributed to a web of support. For example, one youth described how through their program they have a lot more people to challenge and support them, “… I don’t think I would have as much passion as I do because I know so many people… know that I can do it and like, I will make them proud” (Lane & Id-Deen, 2020 , p. 18). Similarly, youth in a school-based club for girls described how they now talk to peers that they would not have previously, but the program “opens up room for us to get to know each other better” (Cayleff et al., 2011 , p. 34). A study of an entrepreneur program similarly noted how every young person interviewed emphasized the important role that relationships with multiple staff members and mentors played in their personal growth and in expanding their network (Miller, 2011 ). Many of these relationships extended beyond the life of the program and served as important sources of support later on. For example, a college and career readiness program described how “lifelong friendships” among peers in the program were formed and served as a support group (Detgen et al., 2021 , p. 242). Youth in organized activities consistently emphasized the web of developmental relationships with staff and program peers that they built through their participation in their respective programs.

Increased Access to Resources

It was through the developmental relationships formed within organized activities that youth gained increased access to a variety of resources. Some of the organized activities provided financial assistance to young people (e.g., Dill & Ozer, 2019 ; Erbstein, 2013 ), whereas others learned about financial assistance and other funding opportunities through staff (e.g., Garcia et al., 2021 ; Sullivan & Larson, 2010 ). Many of the organized activities were designed to give young people opportunities to explore potential postsecondary opportunities or to provide access to these opportunities through internships, work-based learning, and near-peer mentoring (e.g., Ching et al., 2016 ; Koch et al., 2019 ). Organized activities also gave youth opportunities to practice and learn new professional and interpersonal skills that would be valuable for their future goals including communication, time management, organization, study skills, and social and networking skills (e.g., Bempechat et al., 2014 ; Hernandez-Gantes et al., 2018 ). Through relationships with staff and peers, young people also often gathered advice and information on navigating the education and employment system. This often included understanding college jargon, assistance with filling out paperwork, and connecting with mentors for advice on applying to jobs and/or greater education. Finally, organized activities often connected youth to others outside of the organization who were useful for reaching life goals. This could include connecting young people with individuals within the community, professional mentors, professors and educators, and potential employers, among others.

Increased Social Capital Activation

Through the mindsets and skills youth developed in organized activities, they learned how to capitalize on the social capital opportunities afforded by these activities in support of pursuing their interests and postsecondary and/or life goals, often by taking the initiative to engage or seek help, even outside of their involvement in the activity. For example, one program highlighted how a young person “shared that she sustained her relationship with Ashley [staff member] beyond high school by seeking out help during the summer before her first semester in college” (Ramirez, 2021 , p. 1073). Several other organized activities described how youth secure their own mentors, seek help from educators, intentionally build new relationships and professional connections, and learn skills to advocate for oneself (e.g., Ching et al., 2016 ; Schwartz et al., 2018 ; Tichavakunda, 2019 ). It is through this activation process that young people recognized that they can “leverage these resources [gained through participation in an organized activity] for long-term success” (Dill & Ozer, 2019 ; p. 1622).

Little is known about the role and malleable features of organized activities that can be leveraged to support youth social capital development. Therefore, the current study provided a meta-synthesis of extant qualitative research that illuminates the developmental pathway through which social capital development occurs in organized activities. The synthesis revealed a tangible set of malleable organized activity features that act as levers for social capital promotion. These included elements at the organization level (e.g., organizational partnerships), strategies that foster a relationally strong climate (e.g., creating a safe space), and key skills and mindsets that both youth and staff possess that contribute to this climate. As illustrated in the proposed model (see Fig.  2 ), all of these elements synergistically work together to cultivate opportunities for youth to build relationships within and outside the organized activity that provide access to resources which youth, in turn, can activate as they work towards their education and career goals. In addition to activity features that support social capital development, youth engage in behaviors (e.g., actively and strategically reaching out to their web of support, securing resources needed to reach specific goals) that catalyze their ability to reach these life goals. This finding is consistent with past research that suggests the use of social capital requires a level of agency or mobilization on the part of the young person (Boat, et al., 2022a ).

The meta-synthesis showcased the important role and impact of social capital at the organization level. This finding is consistent with social capital theory, which highlights social capital beyond individuals to include social capital at organizational and community levels (Payne et al., 2011 ). For example, past research has shown how institutions in low-income neighborhoods can serve as resource brokers and provide bridging and linking forms of social capital through their ties to other organizations (Small, 2006 ). In addition to organizational partnerships, findings highlight several supporting structures that were helpful for cultivating a climate that prioritized youth social capital development. These included inputs like a shared commitment to the organized activity’s mission and/or values, staff retention, and hiring staff that share similar racial/ethnic identities and/or life experiences as youth participating in the program. It is also possible that there are other valuable structures that went unmentioned in the reviewed articles. Past research in the positive youth development field has long shown that family engagement, staff professional development, staff recognition, and resource allocation may also be important supporting structures for creating a strong organizational climate (National Research Council, 2002 ).

The synthesis identified several elements that are characteristic of a relationally strong climate, including creating a safe and culturally responsive space where youth have a strong sense of community and belonging and are provided opportunities to explore their sparks and deep, personal interests. Furthermore, the themes showed that both staff and youth have specific skills and mindsets that likely nurture this climate. For staff, this involves believing in youth as assets and potential and exhibiting the skills needed to build positive relationships with youth while also brokering resources on their behalf. For youth, the studies highlighted how participation in organized activities strengthened relationship-building skills and mindsets such as future orientation, self-efficacy, and commitment to paying-it-forward to others. These youth mindsets and skills are also likely to strengthen youth’s ability to actively mobilize relationships and resources as they work towards their life goals (i.e., increased social capital activation).

Organized Activity Elements that May Be Particularly Important for Youth from Marginalized Communities

While this study aimed to synthesize the factors among organized activities that contribute to the social capital development of all youth, we identified factors that may be particularly important for youth from marginalized backgrounds. These features included building positive relationships with staff members and other roles models who share the same racial and ethnic identity as youth participants, providing culturally responsive programming and a safe space to discuss systematic barriers, and supporting youth with larger-purpose goals such as changing systems of inequity and paying-it-forward to others from similar backgrounds or communities.

Several organized activities noted how it was beneficial for youth of color in their programs to experience positive relationships with staff members with the same racial or ethnic identity. When youth see staff members and/or build connections with mentors who look like them, it can reinforce youth’s belief that they too can succeed in pathways similar to these role models (e.g., Richardson, 2012 ; Woodland et al., 2009 ), and may empower youth to embrace and explore their own racial or ethnic identity leading to a stronger sense of self and pride in their identity (Ginwright, 2007 ; Harris & Kiyama, 2015 ).

Staff members who share the same racial and ethnic identity as youth participants possess a common lived experience and may as a result have a deeper understanding of the cultural nuances and challenges that youth from that background may face, and therefore may be more likely to develop “culturally-relevant relationships’’ (Dill & Ozer, 2018). The synthesis highlighted several examples (e.g., culturally-relevant content, attending to language needs, family-program partnerships) of culturally-relevant relationships leading to staff being more attuned to the cultural and social needs of youth and the provision of more effective and culturally-relevant support (Wong, 2008 ; Woodland et al., 2009 ). Strategies for creating a culturally-responsive environment for youth varied across the organized activities with some providing explicit cultural competence training to staff and mentors (Ramirez, 2021 ; Sanchez et al., 2022 ) and others intentionally providing safe spaces for staff and program youth to talk about systemic barriers and experiences of discrimination (Cox, 2017 ). In some cases, organized activities also inspired and supported youth to challenge deficit-based narratives around their racial or ethnic identity and to engage in social change efforts. One leadership program designed for Black youth, for example, aimed to create a “collective Black youth identity” that equipped Black youth within the program to address social issues within their community (Ginwright, 2007 ).

The social capital literature traditionally has focused on the individual’s pursuit of educational and/or career goals (e.g., reviewed in Scales et al., 2020 ), and has for the most part given far less attention to what might be called larger-purpose social capital development goals beyond the individual youth’s achievements. Yet this synthesis has shown that social capital development, particularly for youth from marginalized communities, often involves two other integral, larger purpose “goals”: namely, helping youth change/dismantle systems of inequity, and helping youth pay-it-forward or give back to their communities and those who follow them.

Staff and mentors in the organized activities also helped instill these larger purpose goals. For example, a young person in a mentoring program described the impact it had on them that their mentor who came from a low-income family went on to college and then decided to come back to their community to help other youth (Murillo et al., 2017 ). Organized activities that recognize and embed these larger purpose goals into their programming may be increasing social capital development effectiveness both for individual youth and society (Case, 2017 ). Future research should continue to examine culturally-specific themes or elements of organized activities that may be particularly important for youth from a variety of racial and ethnic identities and social class backgrounds (see similar calls in Case, 2017 ; Travis & Leech, 2013 ). These findings will likely lead to higher-quality youth programming that better meets the needs of youth served.

The Social Context of Organized Activities

It would be remiss to not acknowledge the social context in which organized activities and young people are embedded (see Fig.  2 ). Previous research shows that both participation in organized activities and access to social capital is not equitably distributed, especially among young people from marginalized communities (Carpiano, 2006 ; Vandell et al., 2015 ). For example, there are an estimated 25 million young people who are unable to access a high-quality afterschool program, a figure that is more pronounced among youth of color and young people from lower-income communities (Afterschool Alliance, 2020 ). The Afterschool Alliance’s America After 3PM survey (a nationally representative sample of over 31,000 parents/guardians) documents some of the most commonly reported barriers that prevent youth from accessing these types of programs, including program costs, availability in the community, and access to safe transportation to and from programs, all of which were disproportionately identified by Black and Hispanic/Latina/o/x parents and parents from lower-income communities (Afterschool Alliance, 2020 ). The same dynamics have been found to result in much lower youth sports program participation by youth of color and from lower-income communities (Aspen Institute, 2022 ), with inequitable participation, access, and mental health getting worse over the course of the COVID-19 pandemic (Aspen Institute, 2022 ; Prime et al., 2020 ).

While the social context can limit access to social capital promoting organized activities, it can also nurture and thwart social capital development at any point across the proposed model including access to high quality staff who truly believe in youth’s potential, access to the appropriate resources needed to reach one’s goals, and access to the skills needed to mobilize one’s web of support. Even when all the conditions appear to align, there are dynamics of power, privilege, and discrimination that may still prevent young people from reaching or even pursuing their education and/or career goals. Therefore, while organized activities are one promising avenue from supporting social capital development among youth, researchers and practitioners alike need to continue to explore ways to further support youth, and in particular youth from marginalized backgrounds, in leveraging and building social capital and additional assets within their families, schools, and communities, while working to change systems that hinder this development.

Implications for Practice

The current synthesis has important implications for the resource management and program design of organized activities committed to intentionally promoting youth social capital. The proposed model underscores a number of malleable elements that organized activities can intentionally strengthen in order to more effectively support the youth they serve. Perhaps one of the most malleable and impactful levers for supporting youth social capital development is the youth-adult developmental relationships that are formed within organized activities.

The current review highlighted the many different roles that staff play within organized activities including as institutional agents . Staff’s status as authority figures in their organizations positions them to provide bridging and linking forms of social capital by serving as brokers to their organization’s network of relationships and resources (Stanton-Salazar, 2011 ). Staff’s ability to broker resources that youth actually desire is determined by the resources that are available within the organization’s network. Yet, not all staff have the mindsets and skills needed to effectively build strong developmental relationships and broker resources on young people’s behalf, especially across lines of difference (e.g., cultural, racial, and ethnic identity). In this sense, organized activities hold more power than individual staff do to create systems level change. Therefore, it is essential that organized activities hire and retain staff that can meet these needs of young people and/or provide the training needed to support staff in building these skills and mindsets.

The synthesis also highlights the importance of organizational partnerships. When organized activities partner with youth’s families and other community organizations, they enhance the capacity of their staff by expanding their network of resources (Stanton-Salazar, 2011 ). Through this expanded network, organized activities are better able to provide wraparound supports that meet the holistic needs of the youth (Syvertsen et al., 2021 ). Additionally, these partnerships can operate as coalitions in service of community change, particularly when focusing on the needs of marginalized populations (Small, 2006 ). As such, they can increase collective efficacy and action to redress the many systematic barriers and inequities that prevent young people from marginalized communities from reaching their life goals. Yet, it is important to note that the ability to participate in organized activities is also often inequitably distributed and influenced by economic status, race/ethnicity, gender and other social factors. By virtue of participating in a high-quality organized activity, young people may have greater opportunity to strengthen their social capital.

Limitations and Future Directions

Several potential limitations should be considered in future research. Although our search strategy was comprehensive, articles written in languages other than English were not included. We also recognize the limitation of language or terminology in the usage of the term social capital . It is possible that articles examining organized activities that support young people’s social capital may use other terms beyond what was included in our search terms. The current meta-synthesis also did not limit studies to a particular type of organized activity. Rather, many different types of organized activities were included such as mentoring programs, afterschool programs, sports, and community-based organizations. Future research may consider examining whether there are elements that are particularly important in these distinct contexts for promoting young people’s social capital development (e.g., authentic learning opportunities; youth-initiated tasks; working towards a shared goal; see Boat et al., 2022 ). We have put forth a proposed model for how organized activities may support youth social capital development. Future research should further refine this model as new empirical findings emerge and begin to empirically test these proposed pathways and linkages.

Despite an increasing interest and value placed on organized activities and how the social relationships fostered within them can support youth in reaching their future goals, relatively few studies have attempted to capture the core elements that are needed in order to not only promote positive youth development in general, but to fully support youth social capital development. The current review sought to address this by reviewing and synthesizing the related literature on organized activities and social capital. The thematic analysis identified seven themes relating to the development of young people’s social capital. These themes were used to create a proposed model for how organized activities may support youth social capital development. These findings suggest potential strategies that organized activities and staff may implement into their practice. Moreover, these findings serve as a call for action for organized activities to consider how they might increase collective efficacy and action to redress the systematic barriers and inequities that prevent many young people from reaching their full potential.

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Boat, A.A., Poparad, H., Seward, M.D. et al. The Role of Organized Activities in Supporting Youth Social Capital Development: A Qualitative Meta-Synthesis. Adolescent Res Rev (2024). https://doi.org/10.1007/s40894-024-00235-1

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Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates

• Jacqueline Maria Dias 1 ,
• Muhammad Arsyad Subu 1 ,
• Nabeel Al-Yateem 1 ,
• Fatma Refaat Ahmed 1 ,
• Syed Azizur Rahman 1 , 2 ,
• Mini Sara Abraham 1 ,
• Sareh Mirza Forootan 1 ,
• Farzaneh Ahmad Sarkhosh 1 &
• Fatemeh Javanbakh 1  

BMC Nursing volume  23 , Article number:  322 ( 2024 ) Cite this article

Metrics details

Understanding the stressors and coping strategies of nursing students in their first clinical training is important for improving student performance, helping students develop a professional identity and problem-solving skills, and improving the clinical teaching aspects of the curriculum in nursing programmes. While previous research have examined nurses’ sources of stress and coping styles in the Arab region, there is limited understanding of these stressors and coping strategies of nursing students within the UAE context thereby, highlighting the novelty and significance of the study.

A qualitative study was conducted using semi-structured interviews. Overall 30 students who were undergoing their first clinical placement in Year 2 at the University of Sharjah between May and June 2022 were recruited. All interviews were recorded and transcribed verbatim and analyzed for themes.

During their first clinical training, nursing students are exposed to stress from different sources, including the clinical environment, unfriendly clinical tutors, feelings of disconnection, multiple expectations of clinical staff and patients, and gaps between the curriculum of theory classes and labatories skills and students’ clinical experiences. We extracted three main themes that described students’ stress and use of coping strategies during clinical training: (1) managing expectations; (2) theory-practice gap; and (3) learning to cope. Learning to cope, included two subthemes: positive coping strategies and negative coping strategies.

Conclusions

This qualitative study sheds light from the students viewpoint about the intricate interplay between managing expectations, theory practice gap and learning to cope. Therefore, it is imperative for nursing faculty, clinical agencies and curriculum planners to ensure maximum learning in the clinical by recognizing the significance of the stressors encountered and help students develop positive coping strategies to manage the clinical stressors encountered. Further research is required look at the perspective of clinical stressors from clinical tutors who supervise students during their first clinical practicum.

Peer Review reports

Nursing education programmes aim to provide students with high-quality clinical learning experiences to ensure that nurses can provide safe, direct care to patients [ 1 ]. The nursing baccalaureate programme at the University of Sharjah is a four year program with 137 credits. The programmes has both theoretical and clinical components withs nine clinical courses spread over the four years The first clinical practicum which forms the basis of the study takes place in year 2 semester 2.

Clinical practice experience is an indispensable component of nursing education and links what students learn in the classroom and in skills laboratories to real-life clinical settings [ 2 , 3 , 4 ]. However, a gap exists between theory and practice as the curriculum in the classroom differs from nursing students’ experiences in the clinical nursing practicum [ 5 ]. Clinical nursing training places (or practicums, as they are commonly referred to), provide students with the necessary experiences to ensure that they become proficient in the delivery of patient care [ 6 ]. The clinical practicum takes place in an environment that combines numerous structural, psychological, emotional and organizational elements that influence student learning [ 7 ] and may affect the development of professional nursing competencies, such as compassion, communication and professional identity [ 8 ]. While clinical training is a major component of nursing education curricula, stress related to clinical training is common among students [ 9 ]. Furthermore, the nursing literature indicates that the first exposure to clinical learning is one of the most stressful experiences during undergraduate studies [ 8 , 10 ]. Thus, the clinical component of nursing education is considered more stressful than the theoretical component. Students often view clinical learning, where most learning takes place, as an unsupportive environment [ 11 ]. In addition, they note strained relationships between themselves and clinical preceptors and perceive that the negative attitudes of clinical staff produce stress [ 12 ].

The effects of stress on nursing students often involve a sense of uncertainty, uneasiness, or anxiety. The literature is replete with evidence that nursing students experience a variety of stressors during their clinical practicum, beginning with the first clinical rotation. Nursing is a complex profession that requires continuous interaction with a variety of individuals in a high-stress environment. Stress during clinical learning can have multiple negative consequences, including low academic achievement, elevated levels of burnout, and diminished personal well-being [ 13 , 14 ]. In addition, both theoretical and practical research has demonstrated that increased, continual exposure to stress leads to cognitive deficits, inability to concentrate, lack of memory or recall, misinterpretation of speech, and decreased learning capacity [ 15 ]. Furthermore, stress has been identified as a cause of attrition among nursing students [ 16 ].

Most sources of stress have been categorized as academic, clinical or personal. Each person copes with stress differently [ 17 ], and utilizes deliberate, planned, and psychological efforts to manage stressful demands [ 18 ]. Coping mechanisms are commonly termed adaptation strategies or coping skills. Labrague et al. [ 19 ] noted that students used critical coping strategies to handle stress and suggested that problem solving was the most common coping or adaptation mechanism used by nursing students. Nursing students’ coping strategies affect their physical and psychological well-being and the quality of nursing care they offer. Therefore, identifying the coping strategies that students use to manage stressors is important for early intervention [ 20 ].

Studies on nursing students’ coping strategies have been conducted in various countries. For example, Israeli nursing students were found to adopt a range of coping mechanisms, including talking to friends, engaging in sports, avoiding stress and sadness/misery, and consuming alcohol [ 21 ]. Other studies have examined stress levels among medical students in the Arab region. Chaabane et al. [ 15 ], conducted a systematic review of sudies in Arab countries, including Saudi Arabia, Egypt, Jordan, Iraq, Pakistan, Oman, Palestine and Bahrain, and reported that stress during clinical practicums was prevalent, although it could not be determined whether this was limited to the initial clinical course or occurred throughout clinical training. Stressors highlighted during the clinical period in the systematic review included assignments and workload during clinical practice, a feeling that the requirements of clinical practice exceeded students’ physical and emotional endurance and that their involvement in patient care was limited due to lack of experience. Furthermore, stress can have a direct effect on clinical performance, leading to mental disorders. Tung et al. [ 22 ], reported that the prevalence of depression among nursing students in Arab countries is 28%, which is almost six times greater than the rest of the world [ 22 ]. On the other hand, Saifan et al. [ 5 ], explored the theory-practice gap in the United Arab Emirates and found that clinical stressors could be decreased by preparing students better for clinical education with qualified clinical faculty and supportive preceptors.

The purpose of this study was to identify the stressors experienced by undergraduate nursing students in the United Arab Emirates during their first clinical training and the basic adaptation approaches or coping strategies they used. Recognizing or understanding different coping processes can inform the implementation of corrective measures when students experience clinical stress. The findings of this study may provide valuable information for nursing programmes, nurse educators, and clinical administrators to establish adaptive strategies to reduce stress among students going clinical practicums, particularly stressors from their first clinical training in different healthcare settings.

A qualitative approach was adopted to understand clinical stressors and coping strategies from the perspective of nurses’ lived experience. Qualitative content analysis was employed to obtain rich and detailed information from our qualitative data. Qualitative approaches seek to understand the phenomenon under study from the perspectives of individuals with lived experience [ 23 ]. Qualitative content analysis is an interpretive technique that examines the similarities and differences between and within different areas of text while focusing on the subject [ 24 ]. It is used to examine communication patterns in a repeatable and systematic way [ 25 ] and yields rich and detailed information on the topic under investigation [ 23 ]. It is a method of systematically coding and categorizing information and comprises a process of comprehending, interpreting, and conceptualizing the key meanings from qualitative data [ 26 ].

Setting and participants

This study was conducted after the clinical rotations ended in April 2022, between May and June in the nursing programme at the College of Health Sciences, University of Sharjah, in the United Arab Emirates. The study population comprised undergraduate nursing students who were undergoing their first clinical training and were recruited using purposive sampling. The inclusion criteria for this study were second-year nursing students in the first semester of clinical training who could speak English, were willing to participate in this research, and had no previous clinical work experience. The final sample consisted of 30 students.

Research instrument

The research instrument was a semi structured interview guide. The interview questions were based on an in-depth review of related literature. An intensive search included key words in Google Scholar, PubMed like the terms “nursing clinical stressors”, “nursing students”, and “coping mechanisms”. Once the questions were created, they were validated by two other faculty members who had relevant experience in mental health. A pilot test was conducted with five students and based on their feedback the following research questions, which were addressed in the study.

How would you describe your clinical experiences during your first clinical rotations?

In what ways did you find the first clinical rotation to be stressful?

What factors hindered your clinical training?

How did you cope with the stressors you encountered in clinical training?

Which strategies helped you cope with the clinical stressors you encountered?

Data collection

Semi-structured interviews were chosen as the method for data collection. Semi structured interviews are a well-established approach for gathering data in qualitative research and allow participants to discuss their views, experiences, attitudes, and beliefs in a positive environment [ 27 ]. This approach allows for flexibility in questioning thereby ensuring that key topics related to clinical learning stressors and coping strategies would be explored. Participants were given the opportunity to express their views, experiences, attitudes, and beliefs in a positive environment, encouraging open communication. These semi structured interviews were conducted by one member of the research team (MAS) who had a mental health background, and another member of the research team who attended the interviews as an observer (JMD). Neither of these researchers were involved in teaching the students during their clinical practicum, which helped to minimize bias. The interviews took place at the University of Sharjah, specifically in building M23, providing a familiar and comfortable environment for the participant. Before the interviews were all students who agreed to participate were provided with an explanation of the study’s purpose. The time and location of each interview were arranged. Before the interviews were conducted, all students who provided consent to participate received an explanation of the purpose of the study, and the time and place of each interview were arranged to accommodate the participants’ schedules and preferences. The interviews were conducted after the clinical rotation had ended in April, and after the final grades had been submitted to the coordinator. The timings of the interviews included the month of May and June which ensured that participants have completed their practicum experience and could reflect on the stressors more comprehensively. The interviews were audio-recorded with the participants’ consent, and each interview lasted 25–40 min. The data were collected until saturation was reached for 30 students. Memos and field notes were also recorded as part of the data collection process. These additional data allowed for triangulation to improve the credibility of the interpretations of the data [ 28 ]. Memos included the interviewers’ thoughts and interpretations about the interviews, the research process (including questions and gaps), and the analytic progress used for the research. Field notes were used to record the interviewers’ observations and reflections on the data. These additional data collection methods were important to guide the researchers in the interpretation of the data on the participants’ feelings, perspectives, experiences, attitudes, and beliefs. Finally, member checking was performed to ensure conformability.

Data analysis

The study used the content analysis method proposed by Graneheim and Lundman [ 24 ]. According to Graneheim and Lundman [ 24 ], content analysis is an interpretive technique that examines the similarities and differences between distinct parts of a text. This method allows researchers to determine exact theoretical and operational definitions of words, phrases, and symbols by elucidating their constituent properties [ 29 ]. First, we read the interview transcripts several times to reach an overall understanding of the data. All verbatim transcripts were read several times and discussed among all authors. We merged and used line-by-line coding of words, sentences, and paragraphs relevant to each other in terms of both the content and context of stressors and coping mechanisms. Next, we used data reduction to assess the relationships among themes using tables and diagrams to indicate conceptual patterns. Content related to stress encountered by students was extracted from the transcripts. In a separate document, we integrated and categorized all words and sentences that were related to each other in terms of both content and context. We analyzed all codes and units of meaning and compared them for similarities and differences in the context of this study. Furthermore, the emerging findings were discussed with other members of the researcher team. The final abstractions of meaningful subthemes into themes were discussed and agreed upon by the entire research team. This process resulted in the extraction of three main themes in addition to two subthemes related to stress and coping strategies.

Ethical considerations

The University of Sharjah Research Ethics Committee provided approval to conduct this study (Reference Number: REC 19-12-03-01-S). Before each interview, the goal and study procedures were explained to each participant, and written informed consent was obtained. The participants were informed that participation in the study was voluntary and that they could withdraw from the study at any time. In the event they wanted to withdraw from the study, all information related to the participant would be removed. No participant withdrew from the study. Furthermore, they were informed that their clinical practicum grade would not be affected by their participation in this study. We chose interview locations in Building M23that were private and quiet to ensure that the participants felt at ease and confident in verbalizing their opinions. No participant was paid directly for involvement in this study. In addition, participants were assured that their data would remain anonymous and confidential. Confidentiality means that the information provided by participants was kept private with restrictions on how and when data can be shared with others. The participants were informed that their information would not be duplicated or disseminated without their permission. Anonymity refers to the act of keeping people anonymous with respect to their participation in a research endeavor. No personal identifiers were used in this study, and each participant was assigned a random alpha-numeric code (e.g., P1 for participant 1). All digitally recorded interviews were downloaded to a secure computer protected by the principal investigator with a password. The researchers were the only people with access to the interview material (recordings and transcripts). All sensitive information and materials were kept secure in the principal researcher’s office at the University of Sharjah. The data will be maintained for five years after the study is completed, after which the material will be destroyed (the transcripts will be shredded, and the tapes will be demagnetized).

In total, 30 nursing students who were enrolled in the nursing programme at the Department of Nursing, College of Health Sciences, University of Sharjah, and who were undergoing their first clinical practicum participated in the study. Demographically, 80% ( n  = 24) were females and 20% ( n  = 6) were male participants. The majority (83%) of study participants ranged in age from 18 to 22 years. 20% ( n  = 6) were UAE nationals, 53% ( n  = 16) were from Gulf Cooperation Council countries, while 20% ( n  = 6) hailed from Africa and 7% ( n  = 2) were of South Asian descent. 67% of the respondents lived with their families while 33% lived in the hostel. (Table  1 )

Following the content analysis, we identified three main themes: (1) managing expectations, (2) theory-practice gap and 3)learning to cope. Learning to cope had two subthemes: positive coping strategies and negative coping strategies. An account of each theme is presented along with supporting excerpts for the identified themes. The identified themes provide valuable insight into the stressors encountered by students during their first clinical practicum. These themes will lead to targeted interventions and supportive mechanisms that can be built into the clinical training curriculum to support students during clinical practice.

Theme 1: managing expectations

In our examination of the stressors experienced by nursing students during their first clinical practicum and the coping strategies they employed, we identified the first theme as managing expectations.

The students encountered expectations from various parties, such as clinical staff, patients and patients’ relatives which they had to navigate. They attempted to fulfil their expectations as they progressed through training, which presented a source of stress. The students noted that the hospital staff and patients expected them to know how to perform a variety of tasks upon request, which made the students feel stressed and out of place if they did not know how to perform these tasks. Some participants noted that other nurses in the clinical unit did not allow them to participate in nursing procedures, which was considered an enormous impediment to clinical learning, as noted in the excerpt below:

“…Sometimes the nurses… They will not allow us to do some procedures or things during clinical. And sometimes the patients themselves don’t allow us to do procedures” (P5).

Some of the students noted that they felt they did not belong and felt like foreigners in the clinical unit. Excerpts from the students are presented in the following quotes;

“The clinical environment is so stressful. I don’t feel like I belong. There is too little time to build a rapport with hospital staff or the patient” (P22).

“… you ask the hospital staff for some guidance or the location of equipment, and they tell us to ask our clinical tutor …but she is not around … what should I do? It appears like we do not belong, and the sooner the shift is over, the better” (P18).

“The staff are unfriendly and expect too much from us students… I feel like I don’t belong, or I am wasting their (the hospital staff’s) time. I want to ask questions, but they have loads to do” (P26).

Other students were concerned about potential failure when working with patients during clinical training, which impacted their confidence. They were particularly afraid of failure when performing any clinical procedures.

“At the beginning, I was afraid to do procedures. I thought that maybe the patient would be hurt and that I would not be successful in doing it. I have low self-confidence in doing procedures” (P13).

The call bell rings, and I am told to answer Room No. XXX. The patient wants help to go to the toilet, but she has two IV lines. I don’t know how to transport the patient… should I take her on the wheelchair? My eyes glance around the room for a wheelchair. I am so confused …I tell the patient I will inform the sister at the nursing station. The relative in the room glares at me angrily … “you better hurry up”…Oh, I feel like I don’t belong, as I am not able to help the patient… how will I face the same patient again?” (P12).

Another major stressor mentioned in the narratives was related to communication and interactions with patients who spoke another language, so it was difficult to communicate.

“There was a challenge with my communication with the patients. Sometimes I have communication barriers because they (the patients) are of other nationalities. I had an experience with a patient [who was] Indian, and he couldn’t speak my language. I did not understand his language” (P9).

Thus, a variety of expectations from patients, relatives, hospital staff, and preceptors acted as sources of stress for students during their clinical training.

Theme 2: theory-practice gap

Theory-practice gaps have been identified in previous studies. In our study, there was complete dissonance between theory and actual clinical practice. The clinical procedures or practices nursing students were expected to perform differed from the theory they had covered in their university classes and skills lab. This was described as a theory–practice gap and often resulted in stress and confusion.

“For example …the procedures in the hospital are different. They are different from what we learned or from theory on campus. Or… the preceptors have different techniques than what we learned on campus. So, I was stress[ed] and confused about it” (P11).

Furthermore, some students reported that they did not feel that they received adequate briefing before going to clinical training. A related source of stress was overload because of the volume of clinical coursework and assignments in addition to clinical expectations. Additionally, the students reported that a lack of time and time management were major sources of stress in their first clinical training and impacted their ability to complete the required paperwork and assignments:

“…There is not enough time…also, time management at the hospital…for example, we start at seven a.m., and the handover takes 1 hour to finish. They (the nurses at the hospital) are very slow…They start with bed making and morning care like at 9.45 a.m. Then, we must fill [out] our assessment tool and the NCP (nursing care plan) at 10 a.m. So, 15 only minutes before going to our break. We (the students) cannot manage this time. This condition makes me and my friends very stressed out. -I cannot do my paperwork or assignments; no time, right?” (P10).

“Stressful. There is a lot of work to do in clinical. My experiences are not really good with this course. We have a lot of things to do, so many assignments and clinical procedures to complete” (P16).

The participants noted that the amount of required coursework and number of assignments also presented a challenge during their first clinical training and especially affected their opportunity to learn.

“I need to read the file, know about my patient’s condition and pathophysiology and the rationale for the medications the patient is receiving…These are big stressors for my learning. I think about assignments often. Like, we are just focusing on so many assignments and papers. We need to submit assessments and care plans for clinical cases. We focus our time to complete and finish the papers rather than doing the real clinical procedures, so we lose [the] chance to learn” (P25).

Another participant commented in a similar vein that there was not enough time to perform tasks related to clinical requirements during clinical placement.

“…there is a challenge because we do not have enough time. Always no time for us to submit papers, to complete assessment tools, and some nurses, they don’t help us. I think we need more time to get more experiences and do more procedures, reduce the paperwork that we have to submit. These are challenges …” (P14).

There were expectations that the students should be able to carry out their nursing duties without becoming ill or adversely affected. In addition, many students reported that the clinical environment was completely different from the skills laboratory at the college. Exposure to the clinical setting added to the theory-practice gap, and in some instances, the students fell ill.

One student made the following comment:

“I was assisting a doctor with a dressing, and the sight and smell from the oozing wound was too much for me. I was nauseated. As soon as the dressing was done, I ran to the bathroom and threw up. I asked myself… how will I survive the next 3 years of nursing?” (P14).

Theme 3: learning to cope

The study participants indicated that they used coping mechanisms (both positive and negative) to adapt to and manage the stressors in their first clinical practicum. Important strategies that were reportedly used to cope with stress were time management, good preparation for clinical practice, and positive thinking as well as engaging in physical activity and self-motivation.

“Time management. Yes, it is important. I was encouraging myself. I used time management and prepared myself before going to the clinical site. Also, eating good food like cereal…it helps me very much in the clinic” (P28).

“Oh yeah, for sure positive thinking. In the hospital, I always think positively. Then, after coming home, I get [to] rest and think about positive things that I can do. So, I will think something good [about] these things, and then I will be relieved of stress” (P21).

Other strategies commonly reported by the participants were managing their breathing (e.g., taking deep breaths, breathing slowly), taking breaks to relax, and talking with friends about the problems they encountered.

“I prefer to take deep breaths and breathe slowly and to have a cup of coffee and to talk to my friends about the case or the clinical preceptor and what made me sad so I will feel more relaxed” (P16).

“Maybe I will take my break so I feel relaxed and feel better. After clinical training, I go directly home and take a long shower, going over the day. I will not think about anything bad that happened that day. I just try to think about good things so that I forget the stress” (P27).

“Yes, my first clinical training was not easy. It was difficult and made me stressed out…. I felt that it was a very difficult time for me. I thought about leaving nursing” (P7).

I was not able to offer my prayers. For me, this was distressing because as a Muslim, I pray regularly. Now, my prayer time is pushed to the end of the shift” (P11).

“When I feel stress, I talk to my friends about the case and what made me stressed. Then I will feel more relaxed” (P26).

Self-support or self-motivation through positive self-talk was also used by the students to cope with stress.

“Yes, it is difficult in the first clinical training. When I am stress[ed], I go to the bathroom and stand in the front of the mirror; I talk to myself, and I say, “You can do it,” “you are a great student.” I motivate myself: “You can do it”… Then, I just take breaths slowly several times. This is better than shouting or crying because it makes me tired” (P11).

Other participants used physical activity to manage their stress.

“How do I cope with my stress? Actually, when I get stressed, I will go for a walk on campus” (P4).

“At home, I will go to my room and close the door and start doing my exercises. After that, I feel the negative energy goes out, then I start to calm down… and begin my clinical assignments” (P21).

Both positive and negative coping strategies were utilized by the students. Some participants described using negative coping strategies when they encountered stress during their clinical practice. These negative coping strategies included becoming irritable and angry, eating too much food, drinking too much coffee, and smoking cigarettes.

“…Negative adaptation? Maybe coping. If I am stressed, I get so angry easily. I am irritable all day also…It is negative energy, right? Then, at home, I am also angry. After that, it is good to be alone to think about my problems” (P12).

“Yeah, if I…feel stress or depressed, I will eat a lot of food. Yeah, ineffective, like I will be eating a lot, drinking coffee. Like I said, effective, like I will prepare myself and do breathing, ineffective, I will eat a lot of snacks in between my free time. This is the bad side” (P16).

“…During the first clinical practice? Yes, it was a difficult experience for us…not only me. When stressed, during a break at the hospital, I will drink two or three cups of coffee… Also, I smoke cigarettes… A lot. I can drink six cups [of coffee] a day when I am stressed. After drinking coffee, I feel more relaxed, I finish everything (food) in the refrigerator or whatever I have in the pantry, like chocolates, chips, etc” (P23).

These supporting excerpts for each theme and the analysis offers valuable insights into the specific stressors faced by nursing students during their first clinical practicum. These insights will form the basis for the development of targeted interventions and supportive mechanisms within the clinical training curriculum to better support students’ adjustment and well-being during clinical practice.

Our study identified the stressors students encounter in their first clinical practicum and the coping strategies, both positive and negative, that they employed. Although this study emphasizes the importance of clinical training to prepare nursing students to practice as nurses, it also demonstrates the correlation between stressors and coping strategies.The content analysis of the first theme, managing expectations, paves the way for clinical agencies to realize that the students of today will be the nurses of tomorrow. It is important to provide a welcoming environment where students can develop their identities and learn effectively. Additionally, clinical staff should foster an environment of individualized learning while also assisting students in gaining confidence and competence in their repertoire of nursing skills, including critical thinking, problem solving and communication skills [ 8 , 15 , 19 , 30 ]. Another challenge encountered by the students in our study was that they were prevented from participating in clinical procedures by some nurses or patients. This finding is consistent with previous studies reporting that key challenges for students in clinical learning include a lack of clinical support and poor attitudes among clinical staff and instructors [ 31 ]. Clinical staff with positive attitudes have a positive impact on students’ learning in clinical settings [ 32 ]. The presence, supervision, and guidance of clinical instructors and the assistance of clinical staff are essential motivating components in the clinical learning process and offer positive reinforcement [ 30 , 33 , 34 ]. Conversely, an unsupportive learning environment combined with unwelcoming clinical staff and a lack of sense of belonging negatively impact students’ clinical learning [ 35 ].

The sources of stress identified in this study were consistent with common sources of stress in clinical training reported in previous studies, including the attitudes of some staff, students’ status in their clinical placement and educational factors. Nursing students’ inexperience in the clinical setting and lack of social and emotional experience also resulted in stress and psychological difficulties [ 36 ]. Bhurtun et al. [ 33 ] noted that nursing staff are a major source of stress for students because the students feel like they are constantly being watched and evaluated.

We also found that students were concerned about potential failure when working with patients during their clinical training. Their fear of failure when performing clinical procedures may be attributable to low self-confidence. Previous studies have noted that students were concerned about injuring patients, being blamed or chastised, and failing examinations [ 37 , 38 ]. This was described as feeling “powerless” in a previous study [ 7 , 12 ]. In addition, patients’ attitudes towards “rejecting” nursing students or patients’ refusal of their help were sources of stress among the students in our study and affected their self-confidence. Self-confidence and a sense of belonging are important for nurses’ personal and professional identity, and low self-confidence is a problem for nursing students in clinical learning [ 8 , 39 , 40 ]. Our findings are consistent with a previous study that reported that a lack of self-confidence was a primary source of worry and anxiety for nursing students and affected their communication and intention to leave nursing [ 41 ].

In the second theme, our study suggests that students encounter a theory-practice gap in clinical settings, which creates confusion and presents an additional stressors. Theoretical and clinical training are complementary elements of nursing education [ 40 ], and this combination enables students to gain the knowledge, skills, and attitudes necessary to provide nursing care. This is consistent with the findings of a previous study that reported that inconsistencies between theoretical knowledge and practical experience presented a primary obstacle to the learning process in the clinical context [ 42 ], causing students to lose confidence and become anxious [ 43 ]. Additionally, the second theme, the theory-practice gap, authenticates Safian et al.’s [ 5 ] study of the theory-practice gap that exists United Arab Emirates among nursing students as well as the need for more supportive clinical faculty and the extension of clinical hours. The need for better time availability and time management to complete clinical tasks were also reported by the students in the study. Students indicated that they had insufficient time to complete clinical activities because of the volume of coursework and assignments. Our findings support those of Chaabane et al. [ 15 ]. A study conducted in Saudi Arabia [ 44 ] found that assignments and workload were among the greatest sources of stress for students in clinical settings. Effective time management skills have been linked to academic achievement, stress reduction, increased creativity [ 45 ], and student satisfaction [ 46 ]. Our findings are also consistent with previous studies that reported that a common source of stress among first-year students was the increased classroom workload [ 19 , 47 ]. As clinical assignments and workloads are major stressors for nursing students, it is important to promote activities to help them manage these assignments [ 48 ].

Another major challenge reported by the participants was related to communicating and interacting with other nurses and patients. The UAE nursing workforce and population are largely expatriate and diverse and have different cultural and linguistic backgrounds. Therefore, student nurses encounter difficulty in communication [ 49 ]. This cultural diversity that students encounter in communication with patients during clinical training needs to be addressed by curriculum planners through the offering of language courses and courses on cultural diversity [ 50 ].

Regarding the third and final theme, nursing students in clinical training are unable to avoid stressors and must learn to cope with or adapt to them. Previous research has reported a link between stressors and the coping mechanisms used by nursing students [ 51 , 52 , 53 ]. In particular, the inability to manage stress influences nurses’ performance, physical and mental health, attitude, and role satisfaction [ 54 ]. One such study suggested that nursing students commonly use problem-focused (dealing with the problem), emotion-focused (regulating emotion), and dysfunctional (e.g., venting emotions) stress coping mechanisms to alleviate stress during clinical training [ 15 ]. Labrague et al. [ 51 ] highlighted that nursing students use both active and passive coping techniques to manage stress. The pattern of clinical stress has been observed in several countries worldwide. The current study found that first-year students experienced stress during their first clinical training [ 35 , 41 , 55 ]. The stressors they encountered impacted their overall health and disrupted their clinical learning. Chaabane et al. [ 15 ] reported moderate and high stress levels among nursing students in Bahrain, Egypt, Iraq, Jordan, Oman, Pakistan, Palestine, Saudi Arabia, and Sudan. Another study from Bahrain reported that all nursing students experienced moderate to severe stress in their first clinical placement [ 56 ]. Similarly, nursing students in Spain experienced a moderate level of stress, and this stress was significantly correlated with anxiety [ 30 ]. Therefore, it is imperative that pastoral systems at the university address students’ stress and mental health so that it does not affect their clinical performance. Faculty need to utilize evidence-based interventions to support students so that anxiety-producing situations and attrition are minimized.

In our study, students reported a variety of positive and negative coping mechanisms and strategies they used when they experienced stress during their clinical practice. Positive coping strategies included time management, positive thinking, self-support/motivation, breathing, taking breaks, talking with friends, and physical activity. These findings are consistent with those of a previous study in which healthy coping mechanisms used by students included effective time management, social support, positive reappraisal, and participation in leisure activities [ 57 ]. Our study found that relaxing and talking with friends were stress management strategies commonly used by students. Communication with friends to cope with stress may be considered social support. A previous study also reported that people seek social support to cope with stress [ 58 ]. Some students in our study used physical activity to cope with stress, consistent with the findings of previous research. Stretching exercises can be used to counteract the poor posture and positioning associated with stress and to assist in reducing physical tension. Promoting such exercise among nursing students may assist them in coping with stress in their clinical training [ 59 ].

Our study also showed that when students felt stressed, some adopted negative coping strategies, such as showing anger/irritability, engaging in unhealthy eating habits (e.g., consumption of too much food or coffee), or smoking cigarettes. Previous studies have reported that high levels of perceived stress affect eating habits [ 60 ] and are linked to poor diet quality, increased snacking, and low fruit intake [ 61 ]. Stress in clinical settings has also been linked to sleep problems, substance misuse, and high-risk behaviors’ and plays a major role in student’s decision to continue in their programme.

Implications of the study

The implications of the study results can be grouped at multiple levels including; clinical, educational, and organizational level. A comprehensive approach to addressing the stressors encountered by nursing students during their clinical practicum can be overcome by offering some practical strategies to address the stressors faced by nursing students during their clinical practicum. By integrating study findings into curriculum planning, mentorship programs, and organizational support structures, a supportive and nurturing environment that enhances students’ learning, resilience, and overall success can be envisioned.

Clinical level

Introducing simulation in the skills lab with standardized patients and the use of moulage to demonstrate wounds, ostomies, and purulent dressings enhances students’ practical skills and prepares them for real-world clinical scenarios. Organizing orientation days at clinical facilities helps familiarize students with the clinical environment, identify potential stressors, and introduce interventions to enhance professionalism, social skills, and coping abilities Furthermore, creating a WhatsApp group facilitates communication and collaboration among hospital staff, clinical tutors, nursing faculty, and students, enabling immediate support and problem-solving for clinical situations as they arise, Moreover, involving chief nursing officers of clinical facilities in the Nursing Advisory Group at the Department of Nursing promotes collaboration between academia and clinical practice, ensuring alignment between educational objectives and the needs of the clinical setting [ 62 ].

Educational level

Sharing study findings at conferences (we presented the results of this study at Sigma Theta Tau International in July 2023 in Abu Dhabi, UAE) and journal clubs disseminates knowledge and best practices among educators and clinicians, promoting awareness and implementation of measures to improve students’ learning experiences. Additionally we hold mentorship training sessions annually in January and so we shared with the clinical mentors and preceptors the findings of this study so that they proactively they are equipped with strategies to support students’ coping with stressors during clinical placements.

Organizational level

At the organizational we relooked at the available student support structures, including counseling, faculty advising, and career advice, throughout the nursing program emphasizing the importance of holistic support for students’ well-being and academic success as well as retention in the nursing program. Also, offering language courses as electives recognizes the value of communication skills in nursing practice and provides opportunities for personal and professional development.

For first-year nursing students, clinical stressors are inevitable and must be given proper attention. Recognizing nursing students’ perspectives on the challenges and stressors experienced in clinical training is the first step in overcoming these challenges. In nursing schools, providing an optimal clinical environment as well as increasing supervision and evaluation of students’ practices should be emphasized. Our findings demonstrate that first-year nursing students are exposed to a variety of different stressors. Identifying the stressors, pressures, and obstacles that first-year students encounter in the clinical setting can assist nursing educators in resolving these issues and can contribute to students’ professional development and survival to allow them to remain in the profession. To overcome stressors, students frequently employ problem-solving approaches or coping mechanisms. The majority of nursing students report stress at different levels and use a variety of positive and negative coping techniques to manage stress.

The present results may not be generalizable to other nursing institutions because this study used a purposive sample along with a qualitative approach and was limited to one university in the Middle East. Furthermore, the students self-reported their stress and its causes, which may have introduced reporting bias. The students may also have over or underreported stress or coping mechanisms because of fear of repercussions or personal reasons, even though the confidentiality of their data was ensured. Further studies are needed to evaluate student stressors and coping now that measures have been introduced to support students. Time will tell if these strategies are being used effectively by both students and clinical personnel or if they need to be readdressed. Finally, we need to explore the perceptions of clinical faculty towards supervising students in their first clinical practicum so that clinical stressors can be handled effectively.

Data availability

The data sets are available with the corresponding author upon reasonable request.

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Acknowledgements

The authors are grateful to all second year nursing students who voluntarily participated in the study.

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Jacqueline Maria Dias, Muhammad Arsyad Subu, Nabeel Al-Yateem, Fatma Refaat Ahmed, Syed Azizur Rahman, Mini Sara Abraham, Sareh Mirza Forootan, Farzaneh Ahmad Sarkhosh & Fatemeh Javanbakh

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JMD conceptualized the idea and designed the methodology, formal analysis, writing original draft and project supervision and mentoring. MAS prepared the methodology and conducted the qualitative interviews and analyzed the methodology and writing of original draft and project supervision. NY, FRA, SAR, MSA writing review and revising the draft. SMF, FAS, FJ worked with MAS on the formal analysis and prepared the first draft.All authors reviewed the final manuscipt of the article.

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Dias, J.M., Subu, M.A., Al-Yateem, N. et al. Nursing students’ stressors and coping strategies during their first clinical training: a qualitative study in the United Arab Emirates. BMC Nurs 23 , 322 (2024). https://doi.org/10.1186/s12912-024-01962-5

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• Volume 14, Issue 5
• Interdisciplinary research approach based on a mixed-methods design to explore patient altruism at the end of life: a study protocol
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• http://orcid.org/0000-0003-2823-8806 Mathieu Bernard 1 ,
• Claudia Gamondi 2 ,
• Anca-Cristina Sterie 3 ,
• Philip J Larkin 4 ,
• Ralf Jox 5 ,
• Gian Domenico Borasio 2
• 1 Palliative and Supportive Care Service, Chair of Palliative Psychology , Lausanne University Hospital and University of Lausanne , Lausanne , Vaud , Switzerland
• 2 Palliative and Supportive Care Service , Lausanne University Hospital and University of Lausanne , Lausanne , Vaud , Switzerland
• 3 Palliative and Supportive Care Service and Service of Geriatric Medicine and Geriatric Rehabilitation, Chair of Geriatric Palliative Care and Chair of Palliative Psychology , Lausanne University Hospital and University of Lausanne , Lausanne , Vaud , Switzerland
• 4 Palliative and Supportive Care Service, Chair of Palliative Care Nursing , Lausanne University Hospital and University of Lausanne , Lausanne , Vaud , Switzerland
• 5 Palliative and Supportive Care Service and Service of Geriatric Medicine and Geriatric Rehabilitation, Chair of Geriatric Palliative Care , Lausanne University Hospital and University of Lausanne , Lausanne , Vaud , Switzerland
• Correspondence to Dr Mathieu Bernard; mathieu.bernard{at}chuv.ch

Introduction In the end of life context, patients are often seen as somewhat passive recipients of care provided by health professionals and relatives, with little opportunity to be perceived as autonomous and active agents. Since studies show a very high prevalence of altruistic dispositions in palliative care patients, we strive to investigate the concept of patient altruism in a set of six interdisciplinary studies by considering three settings: (1) in the general palliative context—by studying to what extent patient altruism is associated with essential psychological outcomes of palliative care (subproject 1a), how altruism is understood by patients (subproject 1b) and how altruism expressed by patients is experienced by palliative care nurses (subproject 1c); (2) in two concrete decision-making contexts—advance care planning (subproject 2a) and assisted suicide (subproject 2b); and (3) through verbal and non-verbal patient communication in palliative care settings (subproject 3).

Methods and analysis Subproject 1a: a cross-sectional study using validated and standardised questionnaires. Subprojects 1b and 1c: a constructivist grounded theory method aiming at developing a novel theory from semistructured interviews in both patients and nurses. Subproject 2a: a thematic analysis based on (1) audio-recordings of advance care planning encounters and (2) follow-up semidirective interviews with patients and their relatives. Subproject 2b: a qualitative study based on thematic analysis of interviews with patients actively pursuing assisted suicide and one of their relatives.Subproject 3: a conversation analysis based on audio and video-recorded interactions in two settings: (1) palliative inpatient unit and (2) advance care planning discussions.

Ethics and dissemination The study project was approved by the Ethics Committees of the Canton of Vaud, Bern and Ticino (no: 2023-00088). In addition to participation in national and international conferences, each project will be the subject of two scientific publications in peer-reviewed journals. Additional publications will be realised according to result triangulation between projects. A symposium opened to professionals, patients and the public will be organised in Switzerland at the end of the project.

• PALLIATIVE CARE
• Adult palliative care
• SOCIAL MEDICINE

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

https://doi.org/10.1136/bmjopen-2024-085632

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STRENGTHS AND LIMITATIONS OF THIS STUDY

We propose a set of multidisciplinary, complementary and interlinked studies to explore altruism in palliative care in three different settings.

A complex concept such as patient altruism can only be addressed if several disciplines and methods are used.

Each subproject is conceived to explore a specific facet of patient altruism at the end of life and relies on a specific methodology of analysis corresponding to their research questions.

A joint phase of data and results triangulation between the subprojects will allow exchanges between teams on results and new interpretations of phenomena.

As a limitation, patients and the public were not involved in the design of the study.

Introduction

Palliative care challenges.

In palliative care, the psychological domain is an essential component of patient care. Previous research in the field has mostly focused on improving the pharmacological and psychological treatments for the most frequent psychopathologies, that is, anxiety, depression and adjustment disorders. 1 2 Less is known concerning the factors that foster psychological well-being, autonomy and self-determination, thus improving quality of life. This approach, which has been termed ‘positive psychology’, 3 parallels the resource-oriented, health-promoting approach known as salutogenesis. In recent years, palliative care patients have been considered as active participants in their own dying, but only concerning specific and well-defined aspects of the end of life, namely, the so-called decisions concerning end of life (ie, advance directives, withholding and withdrawing life-sustaining treatment, and requests for hastened death/assisted suicide where legally possible). In all other aspects concerning the last phase of life, patients are rather regarded as passive recipients of care, with only little opportunity to be perceived as ‘agents’ who act, give and contribute something by and of themselves. One possible way of fostering patient autonomy and well-being at the end of life is to consider the patient in line with the concept of ‘patient empowerment’. While this paradigm is trending in many medical disciplines, 4 it has had little impact in the field of palliative care so far, with the exception of those situations where decisions need to be made. It is precisely for this reason that we place the concept of patient altruism, as a form of patient agency, at the centre of this project.

Nowadays, the concept of altruism is used in various disciplines such as psychology, philosophy, economics, sociology and evolutionary biology. 5 6 Numerous authors tend to apply this concept to any prosocial behaviour or action carried out on a voluntary basis and aiming to benefit the society at large, specific individuals or a group of individuals. 5 7–9 While altruistic behaviour is primarily explained as an individual constitutive characteristic, 10–13 this behaviour has to be understood by considering its sources of motivation (benevolence, 11 empathy, 14 reward, 15 norms 16 and anger 5 17 ). Social norms and interaction rules (social responsibility, group gain, reciprocity, negotiated rules) have also been identified as determinants of altruistic behaviours. 18 To adequately address this multilevel concept (personality, motivations, social norms), an interdisciplinary approach appears necessary, which is also underscored by the different disciplines involved in this project (humanities, social sciences, medical sciences and nursing).

Although palliative care addresses all people suffering from a life-limiting illness, most palliative care patients who benefit from it are close to end of their life and are of older age. It is well established that older people report higher altruism levels than younger people. 19 This is in agreement with life span developmental theories that have shown a change in motivation orientation during the last phase of existence, which promotes a sense of realisation and meaning in life. 20 While meaning in life tends to increase with age, 21 22 the sources of meaning change: Sparrow and Spaniol showed that, with increasing age, intrinsic values (such as authenticity, intimacy, spirituality but also altruism) are prioritised over extrinsic goals, such as achievement, competence and power. 23 Other authors mention a shift towards meaningful social goals focusing on others, especially close ones, after the recognition that time is becoming more limited as age increases. 24 Vollhardt suggests that altruism may also be a consequence of suffering after adverse life events, such as a life-threatening illness. 25 26 In line with these findings, Fegg et al showed that palliative care patients consistently reported higher self-transcendent and altruistic values as compared with healthy adults. 27 In addition, palliative care patients cite the social dimension as a source of meaning in life more often than the general population. 28

Since the fragility of patients at the end of life often reduces their capacity to undertake concrete altruistic actions by themselves, we need to broaden our understanding of altruism by also taking into account the attitudes and values at the origin of altruistic behaviours. In the theoretical model of basic human values developed by Schwartz and Cieciuch, the values of ‘benevolence’ and ‘universalism’ (‘self-transcendence’) refer to concern for others’ welfare and represent an internal motivation promoting social relations. 29 30 Since there is currently no clear definition or conceptual framework of altruism that has been applied to palliative care patients, we propose defining altruism in this context as: ‘a personal and intentional interest in improving the well-being and welfare of others—at an individual, group or societal level’. By emphasising the notion of ‘interest’, we aim to include the different levels of manifestations of altruism that might be relevant to palliative care, including the (advance) decisions made by patients and the interactions upon which these decisions are based.

We therefore propose a set of multidisciplinary, complementary and interlinked studies to explore altruism in palliative care in three different settings:

The first level refers to patient altruism in the general context of palliative care:

We first aim to study to what extent altruism, considered in terms of prosocial behaviour and self-transcendent value, is associated with important outcomes and indicators of palliative care (subproject 1a).

We then aim to explore (1) how altruism is defined and understood by the palliative care patients themselves (subproject 1b) and (2) how altruism from patients is experienced by palliative care nurses, the professionals who are closest to patients in clinical practice, and how the expression of altruism by patients and families towards nurses influences professional meaning and fulfilment (subproject 1c).

The second level considers how altruism might be expressed and realised through specific decisions between patients and their social environment by considering two specific decision-making contexts of high importance for palliative care: advance care planning (ACP, subproject 2a) and assisted suicide (subproject 2b). Both represent profound existential expressions of autonomy, which are closely related to the patients’ values and attitudes.

The third level concerns how altruism might be expressed in social interactions (both verbal or non-verbal), and how the interaction itself might have an altruistic dimension. We consider moments in which patients are involved in interaction by their own volition, and in which such interaction might bring a potential benefit to the other (subproject 3).

This project is anchored in an interdisciplinary effort bringing together the expertise of several researchers in palliative healthcare. They are therefore representative of the interdisciplinary nature of palliative care, as defined by the WHO. 31 Mathieu Bernard, head of subprojects 1a and 1b, is a psychologist; Phil J Larkin, head of subproject 1c, is a nurse; Ralf Jox, head of subproject 2a, and Claudia Gamondi, head of subproject 2b, are physicians, as Gian Domenico Borasio, project coordinator. Finally, Anca-Cristina Sterie, head of subproject 3, is a sociologist specialised in interactions in the medical setting.

The repercussions of this project could be manifold: first, it would allow designing and testing an altruism-based intervention for palliative care patients that could represent an important new step in the development of efficient, resource-oriented palliative care. Second, such interventions would have the potential to restore dignity and autonomy for patients in the last phase of life by allowing them, if they so wish, to assume a more active role. Third, the expression of patient altruism towards family members and healthcare professionals could also profoundly affect the latter two: it could diminish their distress and ease their grieving, improve relationships and may be a role model for themselves to become more altruistic.

Subproject 1a

A cross-sectional study using validated and standardised questionnaires will be conducted in both the French-speaking and German-speaking parts of Switzerland (two university hospitals and five palliative care centres), and two palliative care centres in the Italian-speaking part of Switzerland.

Inclusion criteria

18 years or older.

Treated by one of the palliative care teams.

<6 months’ life expectancy according to the treating physician.

Medically stable state or when their state has improved.

Exclusion criteria

Evidence of psychiatric and cognitive symptoms that might significantly alter the decision-making capacity.

Insufficient knowledge of the local language.

Questionnaires and procedure

For the purpose of the study, we will use:

The Prosocialness Scale for Adults. 32

The benevolence (four items) and universalism (six items) subscales of the 40-item Portrait Values Questionnaire. 30

Quality of life will be measured with the McGill Quality of Life Scale Revised version. 33

Psychological distress will be measured with the Hospital Anxiety and Depression Scale. 34

Patients’ feeling of being a burden to their caregivers will be assessed with the Self-Perceived Burden Scale. 35

Meaning in life will be assessed with the Meaning in Life Questionnaire. 36

The will to live intensity will be measured with a single-item Numerical Rating Scale. 37

These questionnaires were chosen because they measure dimensions that have been identified as psychological determinants of quality of life in palliative care. All new patients admitted in the palliative care centres participating in the study and who fulfil the inclusion and exclusion criteria as assessed by the referring physician will be asked by a research assistant to participate in the study as soon as an appropriate acute symptom control has been reached. Written informed consent will be obtained.

Validated translations or cross-cultural adaptations of the questionnaires will be used in face-to-face interviews. In addition, sociodemographic variables and medical data (principal diagnosis, comorbidities, performance status) will be obtained. Finally, questions using Numerical Rating Scales (0–10) will assess the level of stress and the potential for personal development induced by the questionnaires. Such Numerical Rating Scales will also be used to assess (1) to what extent altruism is an important concept in the end of life context, and (2) to what extent patients feel frustration not to be able to express altruism towards others.

Data analysis strategy

Rates will be reported for the recruitment information. Descriptive statistics will be calculated for sociodemographic variables and all outcomes. Missing outcome data will be treated as mentioned in the scoring manuals. Distribution of each outcome measure will be analysed using normality tests and other indicators of distribution (box-plots, skewness and kurtosis estimations). Associations between outcome variables will be assessed using Pearson or Spearman correlations according to distributions. Univariate and multiple linear regressions will be performed in order to determine whether altruism can be considered as a significant explanatory variable (in addition to psychological distress, desire to live, feeling of being a burden and meaning in life) for quality of life. We will use an alpha threshold of <0.05 as a criterion for rejecting the null hypothesis. All models will be controlled for sociodemographic characteristics.

Sample size

Multiple linear regressions represent the crucial elements for assessing the number of participants to be included to ensure sufficient power. According to Howell, 38 we aim to recruit 15 patients per explanatory variable, that is, 120 patients with complete data in this study (50 in the French-speaking and German-speaking parts and 20 in the Italian-speaking part, according to population representativeness). Estimating an exclusion rate of 60% and a refusal rate of 50% based on previous studies in the same context, 39–41 600 patients in total will need to be screened for study eligibility (250 in the French-speaking and German-speaking parts and 100 in the Italian-speaking part).

Subproject 1b

Procedure and sample size.

A subsample of participants from project 1a will be invited to participate in subproject 1b. Agreement to participate will be sought at the end of project 1a data collection. We estimate a maximum sample of 45 participants (approximately 15 per linguistic region), depending on data saturation (REF) and the need to explore items in greater or lesser depth. Therefore, the final sample may not be determined until the end of the study. We will aim to maximise the sample variation by ensuring diversity across gender, age, setting of care, illness type (eg, cancer vs non-cancer) and also by considering the score on the two questionnaires assessing altruism.

A constructivist grounded theory method will be adopted for projects 1b and 1c. 42 In this qualitative method, the researcher inductively analyses individual and collective actions as well as social and psychological processes, approaching the data with no preconceived ideas or hypotheses, accepting that there may be multiple perspectives and acknowledging the importance of their own place in constructing those perspectives with participants. Data collection and analysis are undertaken in parallel and decisions on sampling are revised as the project develops, a process referred to as ‘theoretical sampling’.

An initial interview guide will be developed based on topics derived from data collected in subproject 1a and from research questions of subproject 1b. Semistructured interviews will be conducted by a researcher trained in qualitative methodology and grounded theory data analysis, supported by qualitative research experts. The semistructured approach enables the interviewer to vary the wording and sequence of the questions and pursue leads provided by the participants, while being respectful of the burden of interviewing a frail and potentially vulnerable population.

The interview guide will be developed by the research team, comprising native speakers in French, German, Italian and English. The team will meet after the first five interviews in each region to discuss emerging themes and agree if new directions in terms of revised questions are needed. Theoretical saturation will be determined first in each region and later agreed through consensus with the wider research team.

Data analysis

All interviews will be digitally recorded and transcribed in the language of origin. To account for language and cultural differences, interpretation and analysis of the data will be carried out by research collaborators in each region, trained in qualitative methodology and supported by the local research partners. Data will be entered into MAXQDA software to assist analysis.

In accordance with constructivist grounded theory methods, a broad pool of codes will be obtained during an open (initial) coding using interview data, notes and memos. In a second phase of axial (focused) coding, all individual codes will be sorted and resorted as concepts and common themes are developed. 42 In the final step (theoretical coding), overarching themes will be grouped into more refined categories and central concepts, again referring to wider data sources (notes, memos, etc). Each coding step will be conducted in the individual language for the region and data shared through regular collaborative meetings to ensure accuracy and quality. An iterative discussion process will be engaged throughout the study, in order to reach a substantial agreement between researchers in terms of major themes and any cultural or regional difference identified. The final themes will be translated into English as the common language for the presentation of data and subjected to a second-level inductive analysis and comparison with the host language for accuracy in terms of conceptual equivalence. The emerging theory will be co-constructed by the research team.

Subproject 1c

We first begin with a conceptual analysis of altruism to determine its antecedents, attributes and relationships with palliative care nursing. Conceptual analyses are of particular benefit where a concept requires refinement within a specific discipline or context. 43 This will also inform the development of the interview guide and the outcome can be refined during interviews with the nursing participants.

Following the constructivist grounded theory principles outlined in subproject 1b, 30 semistructured in-depth interviews with nurses working in palliative care nursing practice will be undertaken. Participants will be accessed through the same university hospitals and palliative care centres collaborating for subprojects 1a and 1b (French, German and Italian). Interviews will provide concrete examples of the nurses’ experience of altruism in practice and address the meaning and impact of altruism for the palliative care nurse practitioner.

Inclusion criteria for nurses

Working at specialist or generalist level within an agreed palliative care setting.

Having worked in a full-time or part-time capacity for at least 6 months to be able to reflect and discuss their professional experience and offer concrete examples from practice.

Willing to be interviewed and recorded.

Able to converse in either French, German, Italian or English.

Since the division between specialist and generalist palliative care nursing roles is ill-defined, interviews with a broader nursing sample will help to understand the broader facilitators and barriers to altruism and to seek ulterior expressions and meanings of altruism within a wider professional nursing cohort. 10 interviews per linguistic region are planned.

The process of data analysis described in subproject 1b will also be applied to subproject 1c for symmetry and completeness of data across subprojects 1b and 1c. It will then afford opportunity to consider both datasets for similarities and disparities in the understanding and expression of altruism.

Subproject 2a

In order to address the aims of subproject 2a, a qualitative design will be used with three types of data: (1) audio or video-recorded routine ACP discussions between a facilitator, a patient and their relative(s) if applicable; (2) semistructured follow-up interviews of the persons having participated in these discussions.

Inclusion criteria for patients

Receiving general or specialised palliative care.

Inclusion criteria for relatives

Being nominated and recruited by the patient.

Capable to participate in an interview in French or German.

Inclusion criteria for ACP facilitators

Acting as a facilitator of ACP discussions with the patient (and his or her relatives).

Being trained as an ACP facilitator.

Exclusion criteria for patients and relatives

Evidence of psychiatric or cognitive symptoms significantly altering the decision-making capacity.

We will follow a sampling strategy combining cluster sampling and convenience sampling. The cluster sampling will be oriented towards variation regarding gender, age groups and health status of the patient participants (oncological, neurological and cardiorespiratory illnesses). The convenience part of the sampling relates to the fact that we will recruit in structured and professionally facilitated ACP activities in the university hospitals of both the French and German parts of Switzerland, and in two palliative care centres of the Italian part of Switzerland. It is planned to conduct 9–12 qualitative interviews with ACP facilitators (3–4 per language region), and to register 24 audio-recorded routine ACP discussions (8 in each language area), as well as 24 follow-up interviews with patients and 24 follow-up interviews with relatives having participated in the ACP discussions.

Data collection

The ACP discussions will be audio or video-recorded. Audio-recordings will be transcribed verbatim. The transcripts will then be coded by the investigator and analysed by the researcher.

The semistructured interviews will be conducted face-to-face with the patients, their relatives and the ACP facilitators in the participants’ native language, audio-taped and integrally transcribed anonymising all personal details. The interview grid will be constructed following both an inductive and a deductive approach. The initial grid will be deducted from the research team’s experience in the topic and the literature. Five pilot interviews will be carried out to test the interview design. Whether the pilot interviews will be included in the dataset will be decided depending on the evaluation of their transcripts.

Video and audio data will serve for further analysis in subproject 3.

For data analysis, please see below at subproject 2b.

Subproject 2b

To address the aims of subproject 2b, a qualitative study will be used based on semistructured interviews with patients and one of their relatives regarding the patient’s expression of their wish to die by assisted suicide. Participants will be recruited in the French, German and Italian-speaking parts of Switzerland.

Expression of wish to die by assisted suicide.

Being registered to a right to die association in Switzerland.

Capable of participating in an interview in French or Italian or German.

Having been informed by the patient of their intention to obtain assistance in suicide.

Evidence of psychiatric symptoms or cognitive impairment that might significantly alter the decision-making capacity.

Recruitment will take place through different sources: right to die associations and providers operating in the field of specialised palliative care. Snowball sampling will be also used. 10 patients and 10 relatives from the French-speaking part of Switzerland, 10 patients and 10 relatives from the German-speaking part of Switzerland, and 5 patients and 5 relatives from the Italian-speaking part of Switzerland will be recruited.

We intend to disseminate information about the study through two main channels:

Specialised palliative care centres of the university hospitals in the French and German parts of Switzerland, and two palliative care centres of the Italian part of Switzerland. Recruitment will be non-systematic: health professionals within these services will inform the study investigator when a patient meets the criteria.

Right to die societies will inform their members actively pursuing assisted suicide decision about the study.

Interviews will be conducted face-to-face with both the patients and their relatives. The interview grid will be constructed following the same procedure as described for subproject 2a.

Data analysis for subprojects 2a and 2b

The approach for data analysis is the same for subprojects 2a and 2b. To account for language and cultural differences, each coding step will be conducted in the regional language in which data were collected and data will then be shared through regular collaborative meetings. To ensure accuracy and quality in data generated, results will be translated into English and merged for a final transversal analysis.

The analysis will follow an inductive paradigm derived from thematic analysis. 44 The interviews will be fragmented into significant text units, to which codes, or designations able to synthetically account for their content, will be assigned. The identified codes will be linked and grouped into larger categories to define more abstract concepts around which to organise the various arguments. 25% of the material will be double-coded independently by another researcher affiliated to the project, to allow for parallel coding. For subproject 2a, each data subset (ACP encounters and follow-up interviews) will be analysed individually as well as jointly. These operations will be made with the support of the specialised software for qualitative data analysis MAXQDA.

Our analysis will also account for the fact that the decisions involved in these subsets of data (ACP and assisted suicide) have important ethical implications. We will therefore undertake further conceptual analysis inspired by methods from analytical philosophy and the frameworks of the principles of biomedical ethics 45 and of care ethics. 46 Normative criteria will be identified to ethically evaluate altruistic acts at the end of life, based on the principles of biomedical ethics. 45 Finally, we will present practical recommendations that promote the coexistence of patient autonomy and patient altruism.

Subproject 3

This subproject relies on natural data: audio and/or video-recorded naturally occurring interactions, taking place spontaneously, that is, not generated for the purpose of this study. Data will be collected in two settings in the French part of Switzerland.

1. ACP encounters

We will use data recorded for the subproject 2a.

2. Hospital palliative care units

We will record interactions taking place during 40 patient hospital admissions in three palliative centres in French Switzerland. This concerns activities taking place in the patient’s room, involving the patient, their visitors and palliative care professionals participating in the study. The term ‘activity’ will be used in the broad sense, comprising verbal and non-verbal exchanges and acts of care. Participants will be offered the option to decide, in advance, what type of activities they agree to be recorded in; consent will be reconfirmed prior to each recording. Participants will be offered the option of consenting to audio and video, or just to audio-recording.

Hospitalised in one of three palliative care centres.

Medically stable or when their state has improved.

Exclusion criteria for patients

Imminence of death according to the referent physician.

Impaired decision-making capacity.

Presence of psychological/psychiatric problems due to which participating (being recorded) might harm the patient.

Inclusion criteria for healthcare professionals

All health and allied health professionals affiliated to the palliative care unit.

Inclusion criteria for visitors and relatives

⁃Participation is open to all visitors of patients participating in the study.

Analysis will be guided by the conversation analysis (CA) approach. CA resides in a finely grained analysis of recorded data, focusing on how participants interact in order to accomplish ordinary as well as interactionally challenging tasks. 47 While CA is an inductive approach, its use is regulated by a well-defined and stepwise process:

The first-stage analysis is done as an ‘initial noticing’, in order to identify details of talk (‘phenomena’) that are interesting from a research point of view but also recurrent throughout the data. 48

Second, the researcher starts an exhaustive search throughout all the instances in which the phenomena occur and gathers them in datasets. Sequences of talk in which the phenomena are identified are transcribed according to a CA convention system designed for linguistic and multimodal transcriptions, which takes into account aspects of speech delivery and representation of activities parallel to talk (eye gaze, laughing, motions). 49–51

Third, the essential part of the analysis involves describing the phenomena in terms of sequential location (where it appears, why, what it generates) and content. The analysis will particularly draw on concepts of ‘affiliation’, 52 ‘benefactors and beneficiaries’ 53 and empathic communication 54 developed in CA and in relation to the field of palliative care. 55–57

Data collected in the first setting (ACP conversations) will be monitored for how patients participate in the discussion of medical decisions, especially how patients may be ‘prosocial’ by orienting themselves towards others when talking, for example, about death-related topics, without being required to do so. This is in keeping with our definition of altruism.

Data collected in the second setting (hospital palliative care) will be monitored for when and how patients might interact (verbally or non-verbally) without being prompted, and about what. The focus will be on localising and analysing sequences of interaction in which palliative patients interact by their own volition. These instances will be investigated focusing on whether the patient’s involvement might be identified as being done for the benefit of the other person (eg, make a compliment, participate in an act of care or an exchange without being asked/required to).

Patient and public involvement

No patients or members of the public were involved in the design of the study for any of the subprojects.

Ethics and dissemination

The study project was approved by the Ethics Committees of the Canton of Vaud, Bern and Ticino (no: 2023-00088). Each project will be the subject of two scientific publications in peer-reviewed journals. Additional publications will be realised according to result triangulation between projects. The results will also be presented at international and national conferences. Finally, a symposium opened to professionals, patients and the public will be organised in Switzerland at the end of the project to present all the results.

Ethics statements

Patient consent for publication.

Not applicable.

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Contributors MB and GDB designed the study protocol. MB developed the study design and method of subproject 1a. MB and PJL developed the study design and method of subproject 1b. PJL developed the study design and method of subproject 1c. RJ developed the study design and method of subproject 2a. CG developed the study design and method of subproject 2b. A-CS developed the study design and method of subproject 3.

Funding This work is supported by the Swiss National Science Foundation (grant number 10001G_207814/1). The study is funded for a 3-year period from April 2023 to March 2026.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; peer reviewed for ethical and funding approval prior to submission.

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• Open access
• Published: 02 May 2024

Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology

• Katie L. Kowalski 1 ,
• Heather Gillis 1 ,
• Katherine Henning 1 ,
• Paul Parikh 1 ,
• Jackie Sadi 1 &
• Alison Rushton 1  

BMC Medical Education volume  24 , Article number:  486 ( 2024 ) Cite this article

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Metrics details

Vascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs.

To explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students.

Qualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein’s diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes).

For all participants ( n  = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant’s clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection).

Conclusions

Findings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.

Peer Review reports

Introduction

Musculoskeletal neck pain and headache are highly prevalent and among the most disabling conditions globally that require effective rehabilitation [ 1 , 2 , 3 , 4 ]. A range of rehabilitation professionals, including physiotherapists, assess and manage musculoskeletal neck pain and headache. Assessment of the cervical spine can be a complex process. Patients can present to physiotherapy with vascular pathology masquerading as musculoskeletal pain and dysfunction, as neck pain and/or headache as a common first symptom [ 5 ]. While vascular pathologies of the head and neck are rare [ 6 ], they are important considerations within a cervical spine assessment to facilitate the best possible patient outcomes [ 7 ]. The International IFOMPT (International Federation of Orthopedic Manipulative Physical Therapists) Cervical Framework (Framework) provides guidance in the assessment and management of the cervical spine region, considering the potential for vascular pathologies of the neck and head [ 8 ]. Two separate, but related, risks are considered: risk of misdiagnosis of an existing vascular pathology and risk of serious adverse event following musculoskeletal interventions [ 8 ].

The Framework is a consensus document iteratively developed through rigorous methods and the best contemporary evidence [ 8 ], and is also published as a Position Statement [ 7 ]. Central to the Framework are clinical reasoning and evidence-based practice, providing guidance in the assessment of the cervical spine region, considering the potential for vascular pathologies in advance of planned interventions [ 7 , 8 ]. The Framework was developed and published to be a resource for practicing musculoskeletal clinicians and educators. It has been implemented widely within IFOMPT postgraduate (post-licensure) educational programs, influencing curricula by enabling a comprehensive and systemic approach when considering the potential for vascular pathology [ 9 ]. Frequently reported curricula changes include an emphasis on the patient history and incorporating Framework recommended physical examination tests to evaluate a vascular hypothesis [ 9 ]. The Framework aims to assist musculoskeletal clinicians in their clinical reasoning processes, however no study has investigated students’ use of the Framework to inform their clinical reasoning.

Clinical reasoning is a critical component to physiotherapy practice as it is fundamental to assessment and diagnosis, enabling physiotherapists to provide safe and effective patient-centered care [ 10 ]. This is particularly important for postgraduate physiotherapy educational programs, where developing a high level of clinical reasoning is a priority for educational curricula [ 11 ] and critical for achieving advanced practice physiotherapy competency [ 12 , 13 , 14 , 15 ]. At this level of physiotherapy, diagnostic reasoning is emphasized as an important component of a high level of clinical reasoning, informed by advanced use of domain-specific knowledge (e.g., propositional, experiential) and supported by a range of personal characteristics (e.g., adaptability, reflective) [ 12 ]. Facilitating the development of clinical reasoning improves physiotherapist’s performance and patient outcomes [ 16 ], underscoring the importance of clinical reasoning to physiotherapy practice. Understanding students’ use of the Framework to inform their clinical reasoning can support optimal implementation of the Framework within educational programs to facilitate safe and effective assessment and management of the cervical spine for patients.

To explore the influence of the Framework on the clinical reasoning processes in postgraduate level physiotherapy students.

Using a qualitative case study design, think aloud case analyses enabled exploration of clinical reasoning processes in postgraduate physiotherapy students. Case study design allows evaluation of experiences in practice, providing knowledge and accounts of practical actions in a specific context [ 17 ]. Case studies offer opportunity to generate situationally dependent understandings of accounts of clinical practice, highlighting the action and interaction that underscore the complexity of clinical decision-making in practice [ 17 ]. This study was informed by an interpretive description methodological approach with thematic analysis [ 18 , 19 ]. Interpretive description is coherent with mixed methods research and pragmatic orientations [ 20 , 21 ], and enables generation of evidence-based disciplinary knowledge and clinical understanding to inform practice [ 18 , 19 , 22 ]. Interpretive description has evolved for use in educational research to generate knowledge of educational experiences and the complexities of health care education to support achievement of educational objectives and professional practice standards [ 23 ]. The COnsolidated criteria for REporting Qualitative research (COREQ) informed the design and reporting of this study [ 24 ].

Research team

All research team members hold physiotherapy qualifications, and most hold advanced qualifications specializing in musculoskeletal physiotherapy. The research team is based in Canada and has varying levels of academic credentials (ranging from Clinical Masters to PhD or equivalent) and occupations (ranging from PhD student to Director of Physical Therapy). The final author (AR) is also an author of the Framework, which represents international and multiprofessional consensus. Authors HG and JS are lecturers on one of the postgraduate programs which students were recruited from. The primary researcher and first author (KK) is a US-trained Physical Therapist and Postdoctoral Research Associate investigating spinal pain and clinical reasoning in the School of Physical Therapy at Western University. Authors KK, KH and PP had no prior relationship with the postgraduate educational programs, students, or the Framework.

Study setting

Western University in London, Ontario, Canada offers a one-year Advanced Health Care Practice (AHCP) postgraduate IFOMPT-approved Comprehensive Musculoskeletal Physiotherapy program (CMP) and a postgraduate Sport and Exercise Medicine (SEM) program. Think aloud case analyses interviews were conducted using Zoom, a viable option for qualitative data collection and audio-video recording of interviews that enables participation for students who live in geographically dispersed areas across Canada [ 25 ]. Interviews with individual participants were conducted by one researcher (KK or KH) in a calm and quiet environment to minimize disruption to the process of thinking aloud [ 26 ].

Participants

AHCP postgraduate musculoskeletal physiotherapy students ≥ 18 years of age in the CMP and SEM programs were recruited via email and an introduction to the research study during class by KK, using purposive sampling to ensure theoretical representation. The purposive sample ensured key characteristics of participants were included, specifically gender, ethnicity, and physiotherapy experience (years, type). AHCP students must have attended standardized teaching about the Framework to be eligible to participate. Exclusion criteria included inability to communicate fluently in English. As think-aloud methodology seeks rich, in-depth data from a small sample [ 27 ], this study sought to recruit 8–10 AHCP students. This range was informed by prior think aloud literature and anticipated to balance diversity of participant characteristics, similarities in musculoskeletal physiotherapy domain knowledge and rich data supporting individual clinical reasoning processes [ 27 , 28 ].

Learning about the IFOMPT Cervical Framework

CMP and SEM programs included standardized teaching of the Framework to inform AHCP students’ clinical reasoning in practice. Delivery included a presentation explaining the Framework, access to the full Framework document [ 8 ], and discussion of its role to inform practice, including a case analysis of a cervical spine clinical presentation, by research team members AR and JS. The full Framework document that is publicly available through IFOMPT [ 8 ] was provided to AHCP students as the Framework Position Statement [ 7 ] was not yet published. Discussion and case analysis was led by AHCP program leads in November 2021 (CMP, including research team member JS) and January 2022 (SEM).

Think aloud case analyses data collection

Using think aloud methodology, the analytical processes of how participants use the Framework to inform clinical reasoning were explored in an interview with one research team member not involved in AHCP educational programs (KK or KH). The think aloud method enables description and explanation of complex information paralleling the clinical reasoning process and has been used previously in musculoskeletal physiotherapy [ 29 , 30 ]. It facilitates the generation of rich verbal [ 27 ]as participants verbalize their clinical reasoning protocols [ 27 , 31 ]. Participants were aware of the aim of the research study and the research team’s clinical and research backgrounds, supporting an open environment for depth of data collection [ 32 ]. There was no prior relationship between participants and research team members conducting interviews.

Participants were instructed to think aloud their analysis of two clinical cases, presented in random order (Supplementary  1 ). Case information was provided in stages to reflect the chronology of assessment of patients in practice (patient history, planning the physical examination, physical examination, treatment). Use of the Framework to inform clinical reasoning was discussed at each stage. The cases enabled participants to identify and discuss features of possible vascular pathology, treatment indications and contraindications/precautions, etc. Two research study team members (HG, PP) developed cases designed to facilitate and elicit clinical reasoning processes in neck and head pain presentations. Cases were tested against the research team to ensure face validity. Cases and think aloud prompts were piloted prior to use with three physiotherapists at varying levels of practice to ensure they were fit for purpose.

Data collection took place from March 30-August 15, 2022, during the final terms of the AHCP programs and an average of 5 months after standardized teaching about the Framework. During case analysis interviews, participants were instructed to constantly think aloud, and if a pause in verbalizations was sustained, they were reminded to “keep thinking aloud” [ 27 ]. As needed, prompts were given to elicit verbalization of participants’ reasoning processes, including use of the Framework to inform their clinical reasoning at each stage of case analysis (Supplementary  2 ). Aside from this, all interactions between participants and researchers minimized to not interfere with the participant’s thought processes [ 27 , 31 ]. When analysis of the first case was complete, the researcher provided the second case, each lasting 35–45 min. A break between cases was offered. During and after interviews, field notes were recorded about initial impressions of the data collection session and potential patterns appearing to emerge [ 33 ].

Data analysis

Data from think aloud interviews were analyzed using thematic analysis [ 30 , 34 ], facilitating identification and analysis of patterns in data and key steps in the clinical reasoning process, including use of the Framework to enable its characterization (Fig.  1 ). As established models of clinical reasoning exist, a hybrid approach to thematic analysis was employed, incorporating inductive and deductive processes [ 35 ], which proceeded according to 5 iterative steps: [ 34 ]

Data analysis steps

Familiarize with data: Audio-visual recordings were transcribed verbatim by a physiotherapist external to the research team. All transcripts were read and re-read several times by one researcher (KK), checking for accuracy by reviewing recordings as required. Field notes supported depth of familiarization with data.

Generate initial codes: Line-by-line coding of transcripts by one researcher (KK) supported generation of initial codes that represented components, patterns and meaning in clinical reasoning processes and use of the Framework. Established preliminary coding models were used as a guide. Elstein’s diagnostic reasoning model [ 36 ] guided generating initial codes of key steps in clinical reasoning processes (Table  1 a) [ 29 , 36 ]. Leveraging richness of data, further codes were generated guided by the Postgraduate Musculoskeletal Physiotherapy Practice model, which describes masters level clinical practice (Table  1 b) [ 12 ]. Codes were refined as data analysis proceeded. All codes were collated within participants along with supporting data.

Generate initial themes within participants: Coded data was inductively grouped into initial themes within each participant, reflecting individual clinical reasoning processes and use of the Framework. This inductive stage enabled a systematic, flexible approach to describe each participant’s unique thinking path, offering insight into the complexities of their clinical reasoning processes. It also provided a comprehensive understanding of the Framework informing clinical reasoning and a rich characterization of its components, aiding the development of robust, nuanced insights [ 35 , 37 , 38 ]. Initial themes were repeatedly revised to ensure they were grounded in and reflected raw data.

Develop, review and refine themes across participants: Initial themes were synthesized across participants to develop themes that represented all participants. Themes were reviewed and refined, returning to initial themes and codes at the individual participant level as needed.

Organize themes into established models: Themes were deductively organized into established clinical reasoning models; first into Elstein’s diagnostic reasoning model, second into the Postgraduate Musculoskeletal Physiotherapy Practice model to characterize themes within each diagnostic reasoning component [ 12 , 36 ].

Trustworthiness of findings

The research study was conducted according to an a priori protocol and additional steps were taken to establish trustworthiness of findings [ 39 ]. Field notes supported deep familiarization with data and served as a means of data source triangulation during analysis [ 40 ]. One researcher coded transcripts and a second researcher challenged codes, with codes and themes rigorously and iteratively reviewed and refined. Frequent debriefing sessions with the research team, reflexive discussions with other researchers and peer scrutiny of initial findings enabled wider perspectives and experiences to shape analysis and interpretation of findings. Several strategies were implemented to minimize the influence of prior relationships between participants and researchers, including author KK recruiting participants, KK and KH collecting/analyzing data, and AR, JS, HG and PP providing input on de-identified data at the stage of synthesis and interpretation.

Nine AHCP postgraduate level students were recruited and participated in data collection. One participant was withdrawn because of unfamiliarity with the standardized teaching session about use of the Framework (no recall of session), despite confirmation of attendance. Data from eight participants were used for analysis (CMP: n  = 6; SEM: n  = 2; Table  2 ), which achieved sample size requirements for think aloud methodology of rich and in-depth data [ 27 , 28 ].

Diagnostic reasoning components

Informed by the Framework, all components of Elstein’s diagnostic reasoning processes [ 36 ] were used by participants, including use of treatment with physiotherapy interventions to aid diagnostic reasoning. An illustrative example is presented in Supplement  3 . Clinical reasoning used primarily hypothetico-deductive processes reflecting a continuum of proficiency, was informed by deep Framework knowledge and breadth of prior knowledge (e.g., experiential), and supported by a range of personal characteristics (e.g., justification for decisions).

Cue acquisition

All participants sought to acquire additional cues early in the patient history, and for some this persisted into the medical history and physical examination. Cue acquisition enabled depth and breadth of understanding patient history information to generate hypotheses and factors contributing to the patient’s pain experience (Table  3 ). All participants asked further questions to understand details of the patients’ pain and their presentation, while some also explored the impact of pain on patient functioning and treatments received to date. There was a high degree of specificity to questions for most participants. Ongoing clinical reasoning processes through a thorough and complete assessment, even if the patient had previously received treatment for similar symptoms, was important for some participants. Cue acquisition was supported by personal characteristics including a patient-centered approach (e.g., understanding the patient’s beliefs about pain) and one participant reflected on their approach to acquiring patient history cues.

Hypothesis generation

Participants generated an average of 4.5 hypotheses per case (range: 2–8) and most hypotheses (77%) were generated rapidly early in the patient history. Knowledge from the Framework about patient history features of vascular pathology informed vascular hypothesis generation in the patient history for all participants in both cases (Table  4 ). Vascular hypotheses were also generated during the past medical history, where risk factors for vascular pathology were identified and interpreted by some participants who had high levels of suspicion for cervical articular involvement. Non-vascular hypotheses were generated during the physical examination by some participants to explain individual physical examination or patient history cues. Deep knowledge of the patient history section in the Framework supported high level of cue identification and interpretation for generating vascular hypotheses. Initial hypotheses were prioritized by some participants, however the level of specificity of hypotheses varied.

Cue evaluation

All participants evaluated cues throughout the patient history and physical examination in relationship to hypotheses generated, indicating use of hypothetico-deductive reasoning processes (Table  5 ). Framework knowledge of patient history features of vascular pathology was used to test vascular hypotheses and aid differential diagnosis. The patient history section supported high level of cue identification and interpretation of patient history features for all but one participant, and generation of further patient history questions for all participants. The level of specificity of these questions was high for all but one participant. Framework knowledge of recommended physical examination tests, including removal of positional testing, supported planning a focused and prioritized physical examination to further test vascular hypotheses for all participants. No participant indicated intention to use positional testing as part of their physical examination. Treatment with physiotherapy interventions served as a form of cue evaluation, and cues were evaluated to inform prognosis for some participants. At times during the physical examination, some participants demonstrated occasional errors or difficulty with cue evaluation by omitting key physical exam tests (e.g., no cranial nerve assessment despite concerns for trigeminal nerve involvement), selecting physical exam tests in advance of hypothesis generation (e.g., cervical spine instability testing), difficulty interpreting cues, or late selection of a physical examination test. Cue acquisition was supported by a range of personal characteristics. Most participants justified selection of physical examination tests, and some self-reflected on their ability to collect useful physical examination information to inform selection of tests. Precaution to the physical examination was identified by all participants but one, which contributed to an adaptable approach, prioritizing patient safety and comfort. Critical analysis of physical examination information aided interpretation within the context of the patient for most participants.

Hypothesis evaluation

All participants used the Framework to evaluate their hypotheses throughout the patient history and physical examination, continuously shifting their level of support for hypotheses (Table  6 , Supplement  4 ). This informed clarity in the overall level of suspicion for vascular pathology or musculoskeletal diagnoses, which were specific for most participants. Response to treatment with physiotherapy interventions served as a form of hypothesis evaluation for most participants who had low level suspicion for vascular pathology, highlighting ongoing reasoning processes. Hypotheses evaluated were prioritized by ranking according to level of suspicion by some participants. Difficulties weighing patient history and physical examination cues to inform judgement on overall level of suspicion for vascular pathology was demonstrated by some participants who reported that incomplete physical examination data and not being able to see the patient contributed to difficulties. Hypothesis evaluation was supported by the personal characteristic of reflection, where some students reflected on the Framework’s emphasis on the patient history to evaluate a vascular hypothesis.

The Framework supported all participants in clinical reasoning related to treatment (Table  7 ). Treatment decisions were always linked to the participant’s overall level of suspicion for vascular pathology or musculoskeletal diagnosis. Framework knowledge supported participants with high level of suspicion for vascular pathology to refer for further investigations. Participants with a musculoskeletal diagnosis kept the patient for physiotherapy interventions. The Framework patient history section supported patient education about symptoms of vascular pathology and safety netting for some participants. Framework knowledge influenced informed consent processes and risk-benefit analysis to support the selection of musculoskeletal physiotherapy interventions, which were specific and prioritized for some participants. Less Framework knowledge related to treatment was demonstrated by some students, generating unclear recommendations regarding the urgency of referral and use of the Framework to inform musculoskeletal physiotherapy interventions. Treatment was supported by a range of personal characteristics. An adaptable approach that prioritized patient safety and was supported by justification was demonstrated in all participants except one. Shared decision-making enabled the selection of physiotherapy interventions, which were patient-centered (individualized, considered whole person, identified future risk for vascular pathology). Communication with the patient’s family doctor facilitated collaborative patient-centered care for most participants.

This is the first study to explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students. The Framework supported clinical reasoning that used primarily hypothetico-deductive processes. The Framework informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests to inform clarity and support for diagnosis and management. Most postgraduate students’ clinical reasoning processes were characterized by high-level features (e.g. specificity, prioritization). However, some demonstrated occasional difficulties or errors, reflecting a continuum of clinical reasoning proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., justification for decisions, reflection).

Use of the Framework to inform clinical reasoning processes

The Framework provided a structured and comprehensive approach to support postgraduate students’ clinical reasoning processes in assessment and management of the cervical spine region, considering the potential for vascular pathology. Patient history and physical examination information was evaluated to inform clarity and support the decision to refer for further vascular investigations or proceed with musculoskeletal physiotherapy diagnosis/interventions. The Framework is not intended to lead to a vascular pathology diagnosis [ 7 , 8 ], and following the Framework does not guarantee vascular pathologies will be identified [ 41 ]. Rather, it aims to support a process of clinical reasoning to elicit and interpret appropriate patient history and physical examination information to estimate the probability of vascular pathology and inform judgement about the need to refer for further investigations [ 7 , 8 , 42 ]. Results of this study suggest the Framework has achieved this aim for postgraduate physiotherapy students.

The Framework supported postgraduate students in using primarily hypothetico-deductive diagnostic reasoning processes. This is expected given the diversity of vascular pathology clinical presentations precluding a definite clinical pattern and inherent complexity as a potential masquerader of a musculoskeletal problem [ 7 ]. It is also consistent with prior research investigating clinical reasoning processes in musculoskeletal physiotherapy postgraduate students [ 12 ] and clinical experts [ 29 ] where hypothetico-deductive and pattern recognition diagnostic reasoning are employed according to the demands of the clinical situation [ 10 ]. Diagnostic reasoning of most postgraduate students in this study demonstrated features suggestive of high-level clinical reasoning in musculoskeletal physiotherapy [ 12 ], including ongoing reasoning with high-level cue identification and interpretation, specificity and prioritization during assessment and treatment, use of physiotherapy interventions to aid diagnostic reasoning, and prognosis determination [ 12 , 29 , 43 ]. Expert physiotherapy practice has been further described as using a dialectical model of clinical reasoning with seamless transitions between clinical reasoning strategies [ 44 ]. While diagnostic reasoning was a focus in this study, postgraduate students considered a breadth of information as important to their reasoning (e.g., patient’s perspectives of the reason for their pain). This suggests wider reasoning strategies (e.g., narrative, collaborative) were employed to enable shared decision-making within the context of patient-centered care.

Study findings also highlighted a continuum of proficiency in use of the Framework to inform clinical reasoning processes. Not all students demonstrated all characteristics of high-level clinical reasoning and there are suggestions of incomplete reasoning processes, for example occasional errors in evaluating cues. Some students offered explanations such as incomplete case information as factors contributing to difficulties with clinical reasoning processes. However, the ability to critically evaluate incomplete and potentially conflicting clinical information is consistently identified as an advanced clinical practice competency [ 14 , 43 ]. A continuum of proficiency in clinical reasoning in musculoskeletal physiotherapy is supported by wider healthcare professions describing acquisition and application of clinical knowledge and skills as a developmental continuum of clinical competence progressing from novice to expert [ 45 , 46 ]. The range of years of clinical practice experience in this cohort of students (3–14 years) or prior completed postgraduate education may have contributed to the continuum of proficiency, as high-quality and diverse experiential learning is essential for the development of high-level clinical reasoning [ 14 , 47 ].

Deep knowledge of the Framework informs clinical reasoning processes

Postgraduate students demonstrated deep Framework knowledge to inform clinical reasoning processes. All students demonstrated knowledge of patient history features of vascular pathology, recommended physical examination tests to test a vascular hypothesis, and the need to refer if there is a high level of suspicion for vascular pathology. A key development in the recent Framework update is the removal of the recommendation to perform positional testing [ 8 ]. All students demonstrated knowledge of this development, and none wanted to test a vascular hypothesis with positional testing. Most also demonstrated Framework knowledge about considerations for planning treatment with physiotherapy interventions (e.g., risk-benefit analysis, informed consent), though not all, which underscores the continuum of proficiency in postgraduate students. Rich organization of multidimensional knowledge is a required component for high level clinical reasoning and is characteristic of expert physiotherapy practice [ 10 , 48 , 49 ]. Most postgraduate physiotherapy students displayed this expert practice characteristic through integration of deep Framework knowledge with a breadth of prior knowledge (e.g., experiential, propositional) to inform clinical reasoning processes. This highlights the utility of the Framework in postgraduate physiotherapy education to develop advanced level evidence-based knowledge informing clinical reasoning processes for safe assessment and management of the cervical spine, considering the potential for vascular pathology [ 9 , 8 , 50 , 51 , 52 ].

Framework supports personal characteristics to facilitate integration of knowledge and clinical reasoning

The Framework supported personal characteristics of postgraduate students, which are key drivers for the complex integration of advanced knowledge and high-level clinical reasoning [ 10 , 12 , 48 ]. For all students, the Framework supported justification for decisions and patient-centered care, emphasizing a whole-person approach and shared decision-making. Further demonstrating a continuum of proficiency, the Framework supported a wider breadth of personal characteristics for some students, including critical analysis, reflection, self-analysis, and adaptability. These personal characteristics illustrate the interwoven cognitive and metacognitive skills that influence and support a high level of clinical reasoning [ 10 , 12 ] and the development of clinical expertise [ 48 , 53 ]. For example [ 54 ], reflection is critical to developing high-level clinical reasoning and advanced level practice [ 12 , 55 ]. Postgraduate students reflected on prior knowledge, experiences, and action within the context of current Framework knowledge, emphasizing active engagement in cognitive processes to inform clinical reasoning processes. Reflection-in-action is highlighted by self-analysis and adaptability. These characteristics require continuous cognitive processing to consider personal strengths and limitations in the context of the patient and evidence-based practice, adapting the clinical encounter as required [ 53 , 55 ]. These findings highlight use of the Framework in postgraduate education to support development of personal characteristics that are indicative of an advanced level of clinical practice [ 12 ].

Synthesis of findings

Derived from synthesis of research study findings and informed by the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ], use of the Framework to inform clinical reasoning processes in postgraduate students is illustrated in Fig.  2 . Overlapping clinical reasoning, knowledge and personal characteristic components emphasize the complex interaction of factors contributing to clinical reasoning processes. Personal characteristics of postgraduate students underpin clinical reasoning and knowledge, highlighting their role in facilitating the integration of these two components. Bolded subcomponents indicate convergence of results reflecting all postgraduate students and underscores the variability among postgraduate students contributing to a continuum of clinical reasoning proficiency. The relative weighting of the components is approximately equal to balance the breadth and convergence of subcomponents. Synthesis of findings align with the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ], though some differences exist. Limited personal characteristics were identified in this study with little convergence across students, which may be due to the objective of this study and the case analysis approach.

Use of the Framework to inform clinical reasoning in postgraduate level musculoskeletal physiotherapy students. Adapted from the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ].

Strengths and limitations

Think aloud case analyses enabled situationally dependent understanding of the Framework to inform clinical reasoning processes in postgraduate level students [ 17 ], considering the rare potential for vascular pathology. A limitation of this approach was the standardized nature of case information provided to students, which may have influenced clinical reasoning processes. Future research studies may consider patient case simulation to address this limitation [ 30 ]. Interviews were conducted during the second half of the postgraduate educational program, and this timing could have influenced clinical reasoning processes compared to if interviews were conducted at the end of the program. Future research can explore use of the Framework to inform clinical reasoning processes in established advanced practice physiotherapists. The sample size of this study aligns with recommendations for think aloud methodology [ 27 , 28 ], achieved rich data, and purposive sampling enabled wide representation of key characteristics (e.g., gender, ethnicity, country of training, physiotherapy experiences), which enhances transferability of findings. Students were aware of the study objective in advance of interviews which may have contributed to a heightened level of awareness of vascular pathology. The prior relationship between students and researchers may have also influenced results, however several strategies were implemented to minimize this influence.

Implications

The Framework is widely implemented within IFOMPT postgraduate educational programs and has led to important shifts in educational curricula [ 9 ]. Findings of this study support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering the potential for vascular pathology. Individualized approaches may be required to support each student, owing to a continuum of clinical reasoning proficiency. As the Framework was written for practicing musculoskeletal clinicians, future research is required to explore use of the Framework to inform clinical reasoning in learners at different levels, for example entry-level physiotherapy students.

The Framework supported clinical reasoning that used primarily hypothetico-deductive processes in postgraduate physiotherapy students. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most postgraduate students clinical reasoning processes were characterized as high-level, informed by deep Framework knowledge integrated with a breadth of wider knowledge, and supported by a range of personal characteristics to facilitate the integration of advanced knowledge and high-level clinical reasoning. Future research is required to explore use of the Framework to inform clinical reasoning in learners at different levels.

Data availability

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

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Acknowledgements

The authors would like to acknowledge study participants and the transcriptionist for their time in completing and transcribing think aloud interviews.

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Katie L. Kowalski, Heather Gillis, Katherine Henning, Paul Parikh, Jackie Sadi & Alison Rushton

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Katie Kowalski: Conceptualization, methodology, validation, formal analysis, investigation, data curation, writing– original draft, visualization, project administration. Heather Gillis: Validation, resources, writing– review & editing. Katherine Henning: Investigation, formal analysis, writing– review & editing. Paul Parikh: Validation, resources, writing– review & editing. Jackie Sadi: Validation, resources, writing– review & editing. Alison Rushton: Conceptualization, methodology, validation, writing– review & editing, supervision.

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Author AR is an author of the IFOMPT Cervical Framework. Authors JS and HG are lecturers on the AHCP CMP program. AR and JS led standardized teaching of the Framework. Measures to reduce the influence of potential competing interests on the conduct and results of this study included: the Framework representing international and multiprofessional consensus, recruitment of participants by author KK, data collection and analysis completed by KK with input from AR, JS and HG at the stage of data synthesis and interpretation, and wider peer scrutiny of initial findings. KK, KH and PP have no potential competing interests.

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Kowalski, K.L., Gillis, H., Henning, K. et al. Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology. BMC Med Educ 24 , 486 (2024). https://doi.org/10.1186/s12909-024-05399-x

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QAnon casualties: Conspiracy theory’s devastating impact highlighted in new research

R ecent research provides insight into how belief in the QAnon conspiracy theory can strain interpersonal relationships. The qualitative study, published in the Journal of Social and Personal Relationships , reveals how followers’ deep entrenchment in QAnon can alienate their loved ones, leading to reduced communication and often the breakdown of relationships.

QAnon emerged in late 2017 and quickly gained attention for its extensive, if not outlandish, set of beliefs. Central to QAnon is the notion that a secretive government insider known as “Q” is revealing vital secrets about a supposed global cabal of satanic pedophiles that includes prominent liberal figures and that former President Donald Trump is waging a clandestine war against these forces.

The belief system not only demonizes perceived enemies but also encourages followers to decipher cryptic online postings to unveil supposed truths. This shared mission fosters a strong sense of community among followers, who use slogans like “Where we go one, we go all” to promote unity and resilience against opposing views.

The new study was motivated by the surprising prevalence of QAnon beliefs and their potential to strain interpersonal relationships, as evidenced by anecdotal reports and growing membership in online support groups like /r/QAnonCasualties. Given the radical and polarizing nature of QAnon, the researchers aimed to gain a deeper understanding of how these beliefs impact relationships.

“I have been a long-time reader of the r/QAnonCasualties subreddit. I found it both fascinating and heartbreaking to read the stories people shared there,” explained study author Lauren Mastroni of the University of Derby. “When I started my master’s degree I knew I wanted to write a paper on QAnon’s impact on relationships. Then, when I started doing background research I was surprised to find that there was a dearth of research on the topic, which made me even more motivated to do this study.”

The researchers conducted semi-structured interviews with 15 participants from the r/QAnonCasualties subreddit, which included 10 females, four males, and one nonbinary individual, aged between 21 to 54 years from five different countries (the United States, Australia, Canada, the UK, and the Netherlands).

Participants were asked a series of open-ended questions designed to elicit detailed accounts of how their loved one’s belief in QAnon affected their personal relationships. The questions covered topics such as changes in the relationship dynamic, emotional responses to their loved one’s beliefs, and strategies employed to manage or resolve conflicts arising from these beliefs. The interviews were recorded and transcribed.

The analysis of the interview transcripts was conducted using thematic analysis, a method that involves identifying, analyzing, and reporting patterns or themes within qualitative data. This approach was inductive, meaning the themes were strongly linked to the data itself without trying to fit it into a pre-existing coding frame.

The researchers identified four primary themes that encapsulate the effects of QAnon on relationships: Malignant Q, Distance, Conflict, and Attempts at Healing.

Malignant Q was a theme that described the transformation of participants’ loved ones into individuals with radical and extremist beliefs. Participants reported a profound change in the behavior and ideology of their QAnon-affiliated loved ones, noting an increase in anger, paranoia, and intolerance. This radicalization often led to expressions of xenophobic, homophobic, and anti-Semitic sentiments, which participants found shocking and deeply disturbing.

“It’s mindblowing to hear what she says and really believes,” one participant remarked.

Loved ones were perceived as becoming consumed by the conspiracy, affecting their personality and worsening their social interactions. This theme highlighted the deep emotional impact on participants, who struggled with the realization that someone they cared about had adopted such extreme views.

Distance emerged as another significant theme, illustrating how QAnon beliefs led to both emotional and physical separation between participants and their loved ones. Communication breakdown was common, with participants often choosing to avoid conversations to escape conflicts or feeling unable to engage in meaningful dialogue due to the pervasive nature of QAnon rhetoric. The strain was exacerbated by a sense of loss over the closeness they once shared, with many relationships becoming superficial or strained to the point of minimal contact.

The theme of Conflict encapsulated the direct confrontations and disagreements sparked by the entrenched QAnon beliefs. Participants described frequent arguments that were not only stressful but often fruitless, leading to cycles of defense and accusation.

Loved ones entrenched in QAnon displayed extreme defensiveness when faced with opposing views, rejecting any information that contradicted their beliefs. This defensiveness was often accompanied by a dismissal of credible sources and an adherence to conspiracy narratives, making rational discussion nearly impossible and emotionally taxing for participants.

Attempts at Healing reflected the efforts made by participants to salvage their relationships. Despite the challenges, many held a strong desire to understand and reconnect with their loved ones. Strategies varied from engaging in deep conversations to trying to debunk QAnon claims gently, or setting boundaries about discussion topics.

However, the effectiveness of these strategies was mixed, with some participants finding temporary success in avoiding sensitive topics, while others ultimately resigned to the deterioration or end of the relationship. As one participant explained: “QAnon is like drug addiction, and, you know the whole cliche, the first step is them admitting they have a problem and then you can do the deprogramming and all that. But until they recognize they need help you can’t do a damn thing.”

Overall, the study’s findings highlighted the pervasive and often destructive impact of QAnon on personal relationships. The conspiracy theory not only influenced the believers’ perceptions and behaviors but also had profound emotional and relational consequences for those close to them.

“While additional quantitative research is necessary to determine the scale of QAnon’s impact on relationships, this study has highlighted how deeply QAnon belief can harm relationships,” Mastroni told PsyPost. “Participants found that their QAnon-believing loved ones often act on their beliefs in ways that damage their relationships, either by proselytizing, arguing, saying things that aren’t grounded in reality, or spouting increasingly hateful rhetoric.”

“Participants were highly motivated to understand their loved ones and tried many different strategies to heal their relationships, with varying degrees of success. I believe that QAnon is unprecedented in its impact on relationships compared to other, more benign (for lack of a better term) conspiracy beliefs and that further research into possible interventions to repair these damaged relationships is badly needed.”

Many participants reported being blindsided because their loved ones’ embrace of QAnon emerged without a clear link to their prior political stances.

“I was surprised that roughly half of participants said that their loved one was either more left-wing, less political, or apolitical before adopting QAnon beliefs,” Mastroni explained. “I thought that for most, their loved ones’ beliefs would have been a natural progression or continuation of previously-held beliefs, but that wasn’t the case for many participants. The fact that some participants’ loved ones started believing in QAnon seemingly out of nowhere certainly added to the shock these participants felt at their loved ones’ radicalization.”

While the study provides valuable insights, it is based on a small sample drawn from a single online community, possibly limiting the scope. Further research could expand on this by quantitatively measuring the prevalence of QAnon-related relationship issues or comparing its impact to other conspiracy beliefs.

“This is a qualitative study and therefore not generalizable,” Mastroni noted. “While this study aimed to highlight the existence of this phenomenon and explore QAnon’s impact on close relationships, more quantitative research is needed to measure the scale of the issue. I would like to see (and possibly conduct) further research into what interventions may be effective for repairing relationships damaged by QAnon.”

The study, “ “I one-hundred thousand percent blame it on QAnon”: The impact of QAnon belief on interpersonal relationships ,” was authored by Lauren Mastroni and Robyn Mooney.