qualitative research strategy advantages

23 Advantages and Disadvantages of Qualitative Research

Investigating methodologies. Taking a closer look at ethnographic, anthropological, or naturalistic techniques. Data mining through observer recordings. This is what the world of qualitative research is all about. It is the comprehensive and complete data that is collected by having the courage to ask an open-ended question.

Print media has used the principles of qualitative research for generations. Now more industries are seeing the advantages that come from the extra data that is received by asking more than a “yes” or “no” question.

The advantages and disadvantages of qualitative research are quite unique. On one hand, you have the perspective of the data that is being collected. On the other hand, you have the techniques of the data collector and their own unique observations that can alter the information in subtle ways.

That’s why these key points are so important to consider.

What Are the Advantages of Qualitative Research?

1. Subject materials can be evaluated with greater detail. There are many time restrictions that are placed on research methods. The goal of a time restriction is to create a measurable outcome so that metrics can be in place. Qualitative research focuses less on the metrics of the data that is being collected and more on the subtleties of what can be found in that information. This allows for the data to have an enhanced level of detail to it, which can provide more opportunities to glean insights from it during examination.

2. Research frameworks can be fluid and based on incoming or available data. Many research opportunities must follow a specific pattern of questioning, data collection, and information reporting. Qualitative research offers a different approach. It can adapt to the quality of information that is being gathered. If the available data does not seem to be providing any results, the research can immediately shift gears and seek to gather data in a new direction. This offers more opportunities to gather important clues about any subject instead of being confined to a limited and often self-fulfilling perspective.

3. Qualitative research data is based on human experiences and observations. Humans have two very different operating systems. One is a subconscious method of operation, which is the fast and instinctual observations that are made when data is present. The other operating system is slower and more methodical, wanting to evaluate all sources of data before deciding. Many forms of research rely on the second operating system while ignoring the instinctual nature of the human mind. Qualitative research doesn’t ignore the gut instinct. It embraces it and the data that can be collected is often better for it.

4. Gathered data has a predictive quality to it. One of the common mistakes that occurs with qualitative research is an assumption that a personal perspective can be extrapolated into a group perspective. This is only possible when individuals grow up in similar circumstances, have similar perspectives about the world, and operate with similar goals. When these groups can be identified, however, the gathered individualistic data can have a predictive quality for those who are in a like-minded group. At the very least, the data has a predictive quality for the individual from whom it was gathered.

5. Qualitative research operates within structures that are fluid. Because the data being gathered through this type of research is based on observations and experiences, an experienced researcher can follow-up interesting answers with additional questions. Unlike other forms of research that require a specific framework with zero deviation, researchers can follow any data tangent which makes itself known and enhance the overall database of information that is being collected.

6. Data complexities can be incorporated into generated conclusions. Although our modern world tends to prefer statistics and verifiable facts, we cannot simply remove the human experience from the equation. Different people will have remarkably different perceptions about any statistic, fact, or event. This is because our unique experiences generate a different perspective of the data that we see. These complexities, when gathered into a singular database, can generate conclusions with more depth and accuracy, which benefits everyone.

7. Qualitative research is an open-ended process. When a researcher is properly prepared, the open-ended structures of qualitative research make it possible to get underneath superficial responses and rational thoughts to gather information from an individual’s emotional response. This is critically important to this form of researcher because it is an emotional response which often drives a person’s decisions or influences their behavior.

8. Creativity becomes a desirable quality within qualitative research. It can be difficult to analyze data that is obtained from individual sources because many people subconsciously answer in a way that they think someone wants. This desire to “please” another reduces the accuracy of the data and suppresses individual creativity. By embracing the qualitative research method, it becomes possible to encourage respondent creativity, allowing people to express themselves with authenticity. In return, the data collected becomes more accurate and can lead to predictable outcomes.

9. Qualitative research can create industry-specific insights. Brands and businesses today need to build relationships with their core demographics to survive. The terminology, vocabulary, and jargon that consumers use when looking at products or services is just as important as the reputation of the brand that is offering them. If consumers are receiving one context, but the intention of the brand is a different context, then the miscommunication can artificially restrict sales opportunities. Qualitative research gives brands access to these insights so they can accurately communicate their value propositions.

10. Smaller sample sizes are used in qualitative research, which can save on costs. Many qualitative research projects can be completed quickly and on a limited budget because they typically use smaller sample sizes that other research methods. This allows for faster results to be obtained so that projects can move forward with confidence that only good data is able to provide.

11. Qualitative research provides more content for creatives and marketing teams. When your job involves marketing, or creating new campaigns that target a specific demographic, then knowing what makes those people can be quite challenging. By going through the qualitative research approach, it becomes possible to congregate authentic ideas that can be used for marketing and other creative purposes. This makes communication between the two parties to be handled with more accuracy, leading to greater level of happiness for all parties involved.

12. Attitude explanations become possible with qualitative research. Consumer patterns can change on a dime sometimes, leaving a brand out in the cold as to what just happened. Qualitative research allows for a greater understanding of consumer attitudes, providing an explanation for events that occur outside of the predictive matrix that was developed through previous research. This allows the optimal brand/consumer relationship to be maintained.

What Are the Disadvantages of Qualitative Research?

1. The quality of the data gathered in qualitative research is highly subjective. This is where the personal nature of data gathering in qualitative research can also be a negative component of the process. What one researcher might feel is important and necessary to gather can be data that another researcher feels is pointless and won’t spend time pursuing it. Having individual perspectives and including instinctual decisions can lead to incredibly detailed data. It can also lead to data that is generalized or even inaccurate because of its reliance on researcher subjectivisms.

2. Data rigidity is more difficult to assess and demonstrate. Because individual perspectives are often the foundation of the data that is gathered in qualitative research, it is more difficult to prove that there is rigidity in the information that is collective. The human mind tends to remember things in the way it wants to remember them. That is why memories are often looked at fondly, even if the actual events that occurred may have been somewhat disturbing at the time. This innate desire to look at the good in things makes it difficult for researchers to demonstrate data validity.

3. Mining data gathered by qualitative research can be time consuming. The number of details that are often collected while performing qualitative research are often overwhelming. Sorting through that data to pull out the key points can be a time-consuming effort. It is also a subjective effort because what one researcher feels is important may not be pulled out by another researcher. Unless there are some standards in place that cannot be overridden, data mining through a massive number of details can almost be more trouble than it is worth in some instances.

4. Qualitative research creates findings that are valuable, but difficult to present. Presenting the findings which come out of qualitative research is a bit like listening to an interview on CNN. The interviewer will ask a question to the interviewee, but the goal is to receive an answer that will help present a database which presents a specific outcome to the viewer. The goal might be to have a viewer watch an interview and think, “That’s terrible. We need to pass a law to change that.” The subjective nature of the information, however, can cause the viewer to think, “That’s wonderful. Let’s keep things the way they are right now.” That is why findings from qualitative research are difficult to present. What a research gleans from the data can be very different from what an outside observer gleans from the data.

5. Data created through qualitative research is not always accepted. Because of the subjective nature of the data that is collected in qualitative research, findings are not always accepted by the scientific community. A second independent qualitative research effort which can produce similar findings is often necessary to begin the process of community acceptance.

6. Researcher influence can have a negative effect on the collected data. The quality of the data that is collected through qualitative research is highly dependent on the skills and observation of the researcher. If a researcher has a biased point of view, then their perspective will be included with the data collected and influence the outcome. There must be controls in place to help remove the potential for bias so the data collected can be reviewed with integrity. Otherwise, it would be possible for a researcher to make any claim and then use their bias through qualitative research to prove their point.

7. Replicating results can be very difficult with qualitative research. The scientific community wants to see results that can be verified and duplicated to accept research as factual. In the world of qualitative research, this can be very difficult to accomplish. Not only do you have the variability of researcher bias for which to account within the data, but there is also the informational bias that is built into the data itself from the provider. This means the scope of data gathering can be extremely limited, even if the structure of gathering information is fluid, because of each unique perspective.

8. Difficult decisions may require repetitive qualitative research periods. The smaller sample sizes of qualitative research may be an advantage, but they can also be a disadvantage for brands and businesses which are facing a difficult or potentially controversial decision. A small sample is not always representative of a larger population demographic, even if there are deep similarities with the individuals involve. This means a follow-up with a larger quantitative sample may be necessary so that data points can be tracked with more accuracy, allowing for a better overall decision to be made.

9. Unseen data can disappear during the qualitative research process. The amount of trust that is placed on the researcher to gather, and then draw together, the unseen data that is offered by a provider is enormous. The research is dependent upon the skill of the researcher being able to connect all the dots. If the researcher can do this, then the data can be meaningful and help brands and progress forward with their mission. If not, there is no way to alter course until after the first results are received. Then a new qualitative process must begin.

10. Researchers must have industry-related expertise. You can have an excellent researcher on-board for a project, but if they are not familiar with the subject matter, they will have a difficult time gathering accurate data. For qualitative research to be accurate, the interviewer involved must have specific skills, experiences, and expertise in the subject matter being studied. They must also be familiar with the material being evaluated and have the knowledge to interpret responses that are received. If any piece of this skill set is missing, the quality of the data being gathered can be open to interpretation.

11. Qualitative research is not statistically representative. The one disadvantage of qualitative research which is always present is its lack of statistical representation. It is a perspective-based method of research only, which means the responses given are not measured. Comparisons can be made and this can lead toward the duplication which may be required, but for the most part, quantitative data is required for circumstances which need statistical representation and that is not part of the qualitative research process.

The advantages and disadvantages of qualitative research make it possible to gather and analyze individualistic data on deeper levels. This makes it possible to gain new insights into consumer thoughts, demographic behavioral patterns, and emotional reasoning processes. When a research can connect the dots of each information point that is gathered, the information can lead to personalized experiences, better value in products and services, and ongoing brand development.

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10 Advantages and Disadvantages of Qualitative Research

  — August 5th, 2021

Research is about gathering data so that it can inform meaningful decisions. In the workplace, this can be invaluable in allowing informed decision-making that will meet with wider strategic organizational goals.

However, research comes in a variety of guises and, depending on the methodologies applied, can achieve different ends. There are broadly two key approaches to research -- qualitative and quantitative.

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Qualitative v quantitative – what’s the difference.

Qualitative Research is at the touchy-feely end of the spectrum. It’s not so much about bean-counting and much more about capturing people’s opinions and emotions.

“Research following a qualitative approach is exploratory and seeks to explain ‘how’ and ‘why’ a particular phenomenon, or behavior, operates as it does in a particular context.” (simplypsychology.org)

Examples of the way qualitative research is often gathered includes:

Interviews are a conversation based inquiry where questions are used to obtain information from participants. Interviews are typically structured to meet the researcher’s objectives.

Focus Groups

Focus group discussions are a common qualitative research strategy . In a focus group discussion, the interviewer talks to a group of people about their thoughts, opinions, beliefs, and attitudes towards a topic. Participants are typically a group who are similar in some way, such as income, education, or career. In the context of a company, the group dynamic is likely their common experience of the workplace.

Observation

Observation is a systematic research method in which researchers look at the activity of their subjects in their typical environment. Observation gives direct information about your research. Using observation can capture information that participants may not think to reveal or see as important during interviews/focus groups.

Existing Documents

This is also called secondary data. A qualitative data collection method entails extracting relevant data from existing documents. This data can then be analyzed using a qualitative data analysis method called content analysis. Existing documents might be work documents, work email , or any other material relevant to the organization.

Quantitative Research is the ‘bean-counting’ bit of the research spectrum. This isn’t to demean its value. Now encompassed by the term ‘ People Analytics ’, it plays an equally important role as a tool for business decision-making.

Organizations can use a variety of quantitative data-gathering methods to track productivity. In turn, this can help:

• To rank employees and work units
• To award raises or promotions.
• To measure and justify termination or disciplining of staff
• To measure productivity
• To measure group/individual targets

Examples might include measuring workforce productivity. If Widget Makers Inc., has two production lines and Line A is producing 25% more per day than Line B, capturing this data immediately informs management/HR of potential issues. Is the slower production on Line B due to human factors or is there a production process issue?

Quantitative Research can help capture real-time activities in the workplace and point towards what needs management attention.

The Pros & Cons of the Qualitative approach

By its nature, qualitative research is far more experiential and focused on capturing people’s feelings and views. This undoubtedly has value, but it can also bring many more challenges than simply capturing quantitative data. Here are a few challenges and benefits to consider.

• Qualitative Research can capture changing attitudes within a target group such as consumers of a product or service, or attitudes in the workplace.
• Qualitative approaches to research are not bound by the limitations of quantitative methods. If responses don’t fit the researcher’s expectation that’s equally useful qualitative data to add context and perhaps explain something that numbers alone are unable to reveal .
• Qualitative Research provides a much more flexible approach . If useful insights are not being captured researchers can quickly adapt questions, change the setting or any other variable to improve responses.
• Qualitative data capture allows researchers to be far more speculative about what areas they choose to investigate and how to do so. It allows data capture to be prompted by a researcher’s instinctive or ‘gut feel’ for where good information will be found.

Qualitative research can be more targeted . If you want to compare productivity across an entire organization, all parts, process, and participants need to be accounted for. Qualitative research can be far more concentrated, sampling specific groups and key points in a company to gather meaningful data. This can both speed the process of data capture and keep the costs of data-gathering down.

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• Sample size can be a big issue. If you seek to infer from a sample of, for example, 200 employees, based upon a sample of 5 employees, this raises the question of whether sampling will provide a true reflection of the views of the remaining 97.5% of the company?
• Sample bias - HR departments will have competing agendas. One argument against qualitative methods alone is that HR tasked with finding the views of the workforce may be influenced both consciously or unconsciously, to select a sample that favors an anticipated outcome .
• Self-selection bias may arise where companies ask staff to volunteer their views . Whether in a paper, online survey , or focus group, if an HR department calls for participants there will be the issue of staff putting themselves forward. The argument goes that this group, in self-selecting itself, rather than being a randomly selected snapshot of a department, will inevitably have narrowed its relevance to those that typically are willing to come forward with their views. Quantitative data is gathered whether someone volunteered or not.
• The artificiality of qualitative data capture. The act of bringing together a group is inevitably outside of the typical ‘norms ’ of everyday work life and culture and may influence the participants in unforeseen ways.
• Are the right questions being posed to participants? You can only get answers to questions you think to ask . In qualitative approaches, asking about “how” and “why” can be hugely informative, but if researchers don’t ask, that insight may be missed.

The reality is that any research approach has both pros and cons. The art of effective and meaningful data gathering is thus to be aware of the limitations and strengths of each method.

In the case of Qualitative research, its value is inextricably linked to the number-crunching that is Quantitative data. One is the Ying to the other’s Yang. Each can only provide half of the picture, but together, you get a more complete view of what’s occurring within an organization.

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• What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on 4 April 2022 by Pritha Bhandari . Revised on 30 January 2023.

Qualitative research involves collecting and analysing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analysing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, and history.

• How does social media shape body image in teenagers?
• How do children and adults interpret healthy eating in the UK?
• What factors influence employee retention in a large organisation?
• How is anxiety experienced around the world?
• How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography, action research, phenomenological research, and narrative research. They share some similarities, but emphasise different aims and perspectives.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

• Observations: recording what you have seen, heard, or encountered in detailed field notes.
• Interviews:  personally asking people questions in one-on-one conversations.
• Focus groups: asking questions and generating discussion among a group of people.
• Surveys : distributing questionnaires with open-ended questions.
• Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
• You take field notes with observations and reflect on your own experiences of the company culture.
• You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
• You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves ‘instruments’ in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analysing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

• Prepare and organise your data. This may mean transcribing interviews or typing up fieldnotes.
• Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
• Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorise your data.
• Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
• Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analysing qualitative data. Although these methods share similar processes, they emphasise different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

• Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

• Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

• Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

• Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

Researchers must consider practical and theoretical limitations in analysing and interpreting their data. Qualitative research suffers from:

• Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

• Subjectivity

Due to the researcher’s primary role in analysing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

• Limited generalisability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalisable conclusions because the data may be biased and unrepresentative of the wider population .

• Labour-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to test a hypothesis by systematically collecting and analysing data, while qualitative methods allow you to explore ideas and experiences in depth.

There are five common approaches to qualitative research :

• Grounded theory involves collecting data in order to develop new theories.
• Ethnography involves immersing yourself in a group or organisation to understand its culture.
• Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
• Phenomenological research involves investigating phenomena through people’s lived experiences.
• Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organisations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organise your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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Pritha Bhandari

Criteria for Good Qualitative Research: A Comprehensive Review

• Regular Article
• Open access
• Published: 18 September 2021
• Volume 31 , pages 679–689, ( 2022 )

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This review aims to synthesize a published set of evaluative criteria for good qualitative research. The aim is to shed light on existing standards for assessing the rigor of qualitative research encompassing a range of epistemological and ontological standpoints. Using a systematic search strategy, published journal articles that deliberate criteria for rigorous research were identified. Then, references of relevant articles were surveyed to find noteworthy, distinct, and well-defined pointers to good qualitative research. This review presents an investigative assessment of the pivotal features in qualitative research that can permit the readers to pass judgment on its quality and to condemn it as good research when objectively and adequately utilized. Overall, this review underlines the crux of qualitative research and accentuates the necessity to evaluate such research by the very tenets of its being. It also offers some prospects and recommendations to improve the quality of qualitative research. Based on the findings of this review, it is concluded that quality criteria are the aftereffect of socio-institutional procedures and existing paradigmatic conducts. Owing to the paradigmatic diversity of qualitative research, a single and specific set of quality criteria is neither feasible nor anticipated. Since qualitative research is not a cohesive discipline, researchers need to educate and familiarize themselves with applicable norms and decisive factors to evaluate qualitative research from within its theoretical and methodological framework of origin.

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Good Qualitative Research: Opening up the Debate

Beyond qualitative/quantitative structuralism: the positivist qualitative research and the paradigmatic disclaimer.

What is Qualitative in Research

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Introduction

“… It is important to regularly dialogue about what makes for good qualitative research” (Tracy, 2010 , p. 837)

To decide what represents good qualitative research is highly debatable. There are numerous methods that are contained within qualitative research and that are established on diverse philosophical perspectives. Bryman et al., ( 2008 , p. 262) suggest that “It is widely assumed that whereas quality criteria for quantitative research are well‐known and widely agreed, this is not the case for qualitative research.” Hence, the question “how to evaluate the quality of qualitative research” has been continuously debated. There are many areas of science and technology wherein these debates on the assessment of qualitative research have taken place. Examples include various areas of psychology: general psychology (Madill et al., 2000 ); counseling psychology (Morrow, 2005 ); and clinical psychology (Barker & Pistrang, 2005 ), and other disciplines of social sciences: social policy (Bryman et al., 2008 ); health research (Sparkes, 2001 ); business and management research (Johnson et al., 2006 ); information systems (Klein & Myers, 1999 ); and environmental studies (Reid & Gough, 2000 ). In the literature, these debates are enthused by the impression that the blanket application of criteria for good qualitative research developed around the positivist paradigm is improper. Such debates are based on the wide range of philosophical backgrounds within which qualitative research is conducted (e.g., Sandberg, 2000 ; Schwandt, 1996 ). The existence of methodological diversity led to the formulation of different sets of criteria applicable to qualitative research.

Among qualitative researchers, the dilemma of governing the measures to assess the quality of research is not a new phenomenon, especially when the virtuous triad of objectivity, reliability, and validity (Spencer et al., 2004 ) are not adequate. Occasionally, the criteria of quantitative research are used to evaluate qualitative research (Cohen & Crabtree, 2008 ; Lather, 2004 ). Indeed, Howe ( 2004 ) claims that the prevailing paradigm in educational research is scientifically based experimental research. Hypotheses and conjectures about the preeminence of quantitative research can weaken the worth and usefulness of qualitative research by neglecting the prominence of harmonizing match for purpose on research paradigm, the epistemological stance of the researcher, and the choice of methodology. Researchers have been reprimanded concerning this in “paradigmatic controversies, contradictions, and emerging confluences” (Lincoln & Guba, 2000 ).

In general, qualitative research tends to come from a very different paradigmatic stance and intrinsically demands distinctive and out-of-the-ordinary criteria for evaluating good research and varieties of research contributions that can be made. This review attempts to present a series of evaluative criteria for qualitative researchers, arguing that their choice of criteria needs to be compatible with the unique nature of the research in question (its methodology, aims, and assumptions). This review aims to assist researchers in identifying some of the indispensable features or markers of high-quality qualitative research. In a nutshell, the purpose of this systematic literature review is to analyze the existing knowledge on high-quality qualitative research and to verify the existence of research studies dealing with the critical assessment of qualitative research based on the concept of diverse paradigmatic stances. Contrary to the existing reviews, this review also suggests some critical directions to follow to improve the quality of qualitative research in different epistemological and ontological perspectives. This review is also intended to provide guidelines for the acceleration of future developments and dialogues among qualitative researchers in the context of assessing the qualitative research.

The rest of this review article is structured in the following fashion: Sect.  Methods describes the method followed for performing this review. Section Criteria for Evaluating Qualitative Studies provides a comprehensive description of the criteria for evaluating qualitative studies. This section is followed by a summary of the strategies to improve the quality of qualitative research in Sect.  Improving Quality: Strategies . Section  How to Assess the Quality of the Research Findings? provides details on how to assess the quality of the research findings. After that, some of the quality checklists (as tools to evaluate quality) are discussed in Sect.  Quality Checklists: Tools for Assessing the Quality . At last, the review ends with the concluding remarks presented in Sect.  Conclusions, Future Directions and Outlook . Some prospects in qualitative research for enhancing its quality and usefulness in the social and techno-scientific research community are also presented in Sect.  Conclusions, Future Directions and Outlook .

For this review, a comprehensive literature search was performed from many databases using generic search terms such as Qualitative Research , Criteria , etc . The following databases were chosen for the literature search based on the high number of results: IEEE Explore, ScienceDirect, PubMed, Google Scholar, and Web of Science. The following keywords (and their combinations using Boolean connectives OR/AND) were adopted for the literature search: qualitative research, criteria, quality, assessment, and validity. The synonyms for these keywords were collected and arranged in a logical structure (see Table 1 ). All publications in journals and conference proceedings later than 1950 till 2021 were considered for the search. Other articles extracted from the references of the papers identified in the electronic search were also included. A large number of publications on qualitative research were retrieved during the initial screening. Hence, to include the searches with the main focus on criteria for good qualitative research, an inclusion criterion was utilized in the search string.

From the selected databases, the search retrieved a total of 765 publications. Then, the duplicate records were removed. After that, based on the title and abstract, the remaining 426 publications were screened for their relevance by using the following inclusion and exclusion criteria (see Table 2 ). Publications focusing on evaluation criteria for good qualitative research were included, whereas those works which delivered theoretical concepts on qualitative research were excluded. Based on the screening and eligibility, 45 research articles were identified that offered explicit criteria for evaluating the quality of qualitative research and were found to be relevant to this review.

Figure  1 illustrates the complete review process in the form of PRISMA flow diagram. PRISMA, i.e., “preferred reporting items for systematic reviews and meta-analyses” is employed in systematic reviews to refine the quality of reporting.

PRISMA flow diagram illustrating the search and inclusion process. N represents the number of records

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

Various researchers have put forward criteria for evaluating qualitative research, which have been summarized in Table 3 . Also, the criteria outlined in Table 4 effectively deliver the various approaches to evaluate and assess the quality of qualitative work. The entries in Table 4 are based on Tracy’s “Eight big‐tent criteria for excellent qualitative research” (Tracy, 2010 ). Tracy argues that high-quality qualitative work should formulate criteria focusing on the worthiness, relevance, timeliness, significance, morality, and practicality of the research topic, and the ethical stance of the research itself. Researchers have also suggested a series of questions as guiding principles to assess the quality of a qualitative study (Mays & Pope, 2020 ). Nassaji ( 2020 ) argues that good qualitative research should be robust, well informed, and thoroughly documented.

Qualitative Research: Interpretive Paradigms

All qualitative researchers follow highly abstract principles which bring together beliefs about ontology, epistemology, and methodology. These beliefs govern how the researcher perceives and acts. The net, which encompasses the researcher’s epistemological, ontological, and methodological premises, is referred to as a paradigm, or an interpretive structure, a “Basic set of beliefs that guides action” (Guba, 1990 ). Four major interpretive paradigms structure the qualitative research: positivist and postpositivist, constructivist interpretive, critical (Marxist, emancipatory), and feminist poststructural. The complexity of these four abstract paradigms increases at the level of concrete, specific interpretive communities. Table 5 presents these paradigms and their assumptions, including their criteria for evaluating research, and the typical form that an interpretive or theoretical statement assumes in each paradigm. Moreover, for evaluating qualitative research, quantitative conceptualizations of reliability and validity are proven to be incompatible (Horsburgh, 2003 ). In addition, a series of questions have been put forward in the literature to assist a reviewer (who is proficient in qualitative methods) for meticulous assessment and endorsement of qualitative research (Morse, 2003 ). Hammersley ( 2007 ) also suggests that guiding principles for qualitative research are advantageous, but methodological pluralism should not be simply acknowledged for all qualitative approaches. Seale ( 1999 ) also points out the significance of methodological cognizance in research studies.

Table 5 reflects that criteria for assessing the quality of qualitative research are the aftermath of socio-institutional practices and existing paradigmatic standpoints. Owing to the paradigmatic diversity of qualitative research, a single set of quality criteria is neither possible nor desirable. Hence, the researchers must be reflexive about the criteria they use in the various roles they play within their research community.

Improving Quality: Strategies

Another critical question is “How can the qualitative researchers ensure that the abovementioned quality criteria can be met?” Lincoln and Guba ( 1986 ) delineated several strategies to intensify each criteria of trustworthiness. Other researchers (Merriam & Tisdell, 2016 ; Shenton, 2004 ) also presented such strategies. A brief description of these strategies is shown in Table 6 .

It is worth mentioning that generalizability is also an integral part of qualitative research (Hays & McKibben, 2021 ). In general, the guiding principle pertaining to generalizability speaks about inducing and comprehending knowledge to synthesize interpretive components of an underlying context. Table 7 summarizes the main metasynthesis steps required to ascertain generalizability in qualitative research.

Figure  2 reflects the crucial components of a conceptual framework and their contribution to decisions regarding research design, implementation, and applications of results to future thinking, study, and practice (Johnson et al., 2020 ). The synergy and interrelationship of these components signifies their role to different stances of a qualitative research study.

Essential elements of a conceptual framework

In a nutshell, to assess the rationale of a study, its conceptual framework and research question(s), quality criteria must take account of the following: lucid context for the problem statement in the introduction; well-articulated research problems and questions; precise conceptual framework; distinct research purpose; and clear presentation and investigation of the paradigms. These criteria would expedite the quality of qualitative research.

How to Assess the Quality of the Research Findings?

The inclusion of quotes or similar research data enhances the confirmability in the write-up of the findings. The use of expressions (for instance, “80% of all respondents agreed that” or “only one of the interviewees mentioned that”) may also quantify qualitative findings (Stenfors et al., 2020 ). On the other hand, the persuasive reason for “why this may not help in intensifying the research” has also been provided (Monrouxe & Rees, 2020 ). Further, the Discussion and Conclusion sections of an article also prove robust markers of high-quality qualitative research, as elucidated in Table 8 .

Quality Checklists: Tools for Assessing the Quality

Numerous checklists are available to speed up the assessment of the quality of qualitative research. However, if used uncritically and recklessly concerning the research context, these checklists may be counterproductive. I recommend that such lists and guiding principles may assist in pinpointing the markers of high-quality qualitative research. However, considering enormous variations in the authors’ theoretical and philosophical contexts, I would emphasize that high dependability on such checklists may say little about whether the findings can be applied in your setting. A combination of such checklists might be appropriate for novice researchers. Some of these checklists are listed below:

The most commonly used framework is Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007 ). This framework is recommended by some journals to be followed by the authors during article submission.

Standards for Reporting Qualitative Research (SRQR) is another checklist that has been created particularly for medical education (O’Brien et al., 2014 ).

Also, Tracy ( 2010 ) and Critical Appraisal Skills Programme (CASP, 2021 ) offer criteria for qualitative research relevant across methods and approaches.

Further, researchers have also outlined different criteria as hallmarks of high-quality qualitative research. For instance, the “Road Trip Checklist” (Epp & Otnes, 2021 ) provides a quick reference to specific questions to address different elements of high-quality qualitative research.

Conclusions, Future Directions, and Outlook

This work presents a broad review of the criteria for good qualitative research. In addition, this article presents an exploratory analysis of the essential elements in qualitative research that can enable the readers of qualitative work to judge it as good research when objectively and adequately utilized. In this review, some of the essential markers that indicate high-quality qualitative research have been highlighted. I scope them narrowly to achieve rigor in qualitative research and note that they do not completely cover the broader considerations necessary for high-quality research. This review points out that a universal and versatile one-size-fits-all guideline for evaluating the quality of qualitative research does not exist. In other words, this review also emphasizes the non-existence of a set of common guidelines among qualitative researchers. In unison, this review reinforces that each qualitative approach should be treated uniquely on account of its own distinctive features for different epistemological and disciplinary positions. Owing to the sensitivity of the worth of qualitative research towards the specific context and the type of paradigmatic stance, researchers should themselves analyze what approaches can be and must be tailored to ensemble the distinct characteristics of the phenomenon under investigation. Although this article does not assert to put forward a magic bullet and to provide a one-stop solution for dealing with dilemmas about how, why, or whether to evaluate the “goodness” of qualitative research, it offers a platform to assist the researchers in improving their qualitative studies. This work provides an assembly of concerns to reflect on, a series of questions to ask, and multiple sets of criteria to look at, when attempting to determine the quality of qualitative research. Overall, this review underlines the crux of qualitative research and accentuates the need to evaluate such research by the very tenets of its being. Bringing together the vital arguments and delineating the requirements that good qualitative research should satisfy, this review strives to equip the researchers as well as reviewers to make well-versed judgment about the worth and significance of the qualitative research under scrutiny. In a nutshell, a comprehensive portrayal of the research process (from the context of research to the research objectives, research questions and design, speculative foundations, and from approaches of collecting data to analyzing the results, to deriving inferences) frequently proliferates the quality of a qualitative research.

Prospects : A Road Ahead for Qualitative Research

Irrefutably, qualitative research is a vivacious and evolving discipline wherein different epistemological and disciplinary positions have their own characteristics and importance. In addition, not surprisingly, owing to the sprouting and varied features of qualitative research, no consensus has been pulled off till date. Researchers have reflected various concerns and proposed several recommendations for editors and reviewers on conducting reviews of critical qualitative research (Levitt et al., 2021 ; McGinley et al., 2021 ). Following are some prospects and a few recommendations put forward towards the maturation of qualitative research and its quality evaluation:

In general, most of the manuscript and grant reviewers are not qualitative experts. Hence, it is more likely that they would prefer to adopt a broad set of criteria. However, researchers and reviewers need to keep in mind that it is inappropriate to utilize the same approaches and conducts among all qualitative research. Therefore, future work needs to focus on educating researchers and reviewers about the criteria to evaluate qualitative research from within the suitable theoretical and methodological context.

There is an urgent need to refurbish and augment critical assessment of some well-known and widely accepted tools (including checklists such as COREQ, SRQR) to interrogate their applicability on different aspects (along with their epistemological ramifications).

Efforts should be made towards creating more space for creativity, experimentation, and a dialogue between the diverse traditions of qualitative research. This would potentially help to avoid the enforcement of one's own set of quality criteria on the work carried out by others.

Moreover, journal reviewers need to be aware of various methodological practices and philosophical debates.

It is pivotal to highlight the expressions and considerations of qualitative researchers and bring them into a more open and transparent dialogue about assessing qualitative research in techno-scientific, academic, sociocultural, and political rooms.

Frequent debates on the use of evaluative criteria are required to solve some potentially resolved issues (including the applicability of a single set of criteria in multi-disciplinary aspects). Such debates would not only benefit the group of qualitative researchers themselves, but primarily assist in augmenting the well-being and vivacity of the entire discipline.

To conclude, I speculate that the criteria, and my perspective, may transfer to other methods, approaches, and contexts. I hope that they spark dialog and debate – about criteria for excellent qualitative research and the underpinnings of the discipline more broadly – and, therefore, help improve the quality of a qualitative study. Further, I anticipate that this review will assist the researchers to contemplate on the quality of their own research, to substantiate research design and help the reviewers to review qualitative research for journals. On a final note, I pinpoint the need to formulate a framework (encompassing the prerequisites of a qualitative study) by the cohesive efforts of qualitative researchers of different disciplines with different theoretic-paradigmatic origins. I believe that tailoring such a framework (of guiding principles) paves the way for qualitative researchers to consolidate the status of qualitative research in the wide-ranging open science debate. Dialogue on this issue across different approaches is crucial for the impending prospects of socio-techno-educational research.

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Home » Qualitative Research – Methods, Analysis Types and Guide

Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

Qualitative research is a type of research methodology that focuses on exploring and understanding people’s beliefs, attitudes, behaviors, and experiences through the collection and analysis of non-numerical data. It seeks to answer research questions through the examination of subjective data, such as interviews, focus groups, observations, and textual analysis.

Qualitative research aims to uncover the meaning and significance of social phenomena, and it typically involves a more flexible and iterative approach to data collection and analysis compared to quantitative research. Qualitative research is often used in fields such as sociology, anthropology, psychology, and education.

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

This method involves conducting an interview with a single participant to gain a detailed understanding of their experiences, attitudes, and beliefs. One-to-one interviews can be conducted in-person, over the phone, or through video conferencing. The interviewer typically uses open-ended questions to encourage the participant to share their thoughts and feelings. One-to-one interviews are useful for gaining detailed insights into individual experiences.

Focus Groups

This method involves bringing together a group of people to discuss a specific topic in a structured setting. The focus group is led by a moderator who guides the discussion and encourages participants to share their thoughts and opinions. Focus groups are useful for generating ideas and insights, exploring social norms and attitudes, and understanding group dynamics.

Ethnographic Studies

This method involves immersing oneself in a culture or community to gain a deep understanding of its norms, beliefs, and practices. Ethnographic studies typically involve long-term fieldwork and observation, as well as interviews and document analysis. Ethnographic studies are useful for understanding the cultural context of social phenomena and for gaining a holistic understanding of complex social processes.

Text Analysis

This method involves analyzing written or spoken language to identify patterns and themes. Text analysis can be quantitative or qualitative. Qualitative text analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Text analysis is useful for understanding media messages, public discourse, and cultural trends.

This method involves an in-depth examination of a single person, group, or event to gain an understanding of complex phenomena. Case studies typically involve a combination of data collection methods, such as interviews, observations, and document analysis, to provide a comprehensive understanding of the case. Case studies are useful for exploring unique or rare cases, and for generating hypotheses for further research.

Process of Observation

This method involves systematically observing and recording behaviors and interactions in natural settings. The observer may take notes, use audio or video recordings, or use other methods to document what they see. Process of observation is useful for understanding social interactions, cultural practices, and the context in which behaviors occur.

Record Keeping

This method involves keeping detailed records of observations, interviews, and other data collected during the research process. Record keeping is essential for ensuring the accuracy and reliability of the data, and for providing a basis for analysis and interpretation.

This method involves collecting data from a large sample of participants through a structured questionnaire. Surveys can be conducted in person, over the phone, through mail, or online. Surveys are useful for collecting data on attitudes, beliefs, and behaviors, and for identifying patterns and trends in a population.

Qualitative data analysis is a process of turning unstructured data into meaningful insights. It involves extracting and organizing information from sources like interviews, focus groups, and surveys. The goal is to understand people’s attitudes, behaviors, and motivations

Qualitative Research Analysis Methods

Qualitative Research analysis methods involve a systematic approach to interpreting and making sense of the data collected in qualitative research. Here are some common qualitative data analysis methods:

Thematic Analysis

This method involves identifying patterns or themes in the data that are relevant to the research question. The researcher reviews the data, identifies keywords or phrases, and groups them into categories or themes. Thematic analysis is useful for identifying patterns across multiple data sources and for generating new insights into the research topic.

Content Analysis

This method involves analyzing the content of written or spoken language to identify key themes or concepts. Content analysis can be quantitative or qualitative. Qualitative content analysis involves close reading and interpretation of texts to identify recurring themes, concepts, and patterns. Content analysis is useful for identifying patterns in media messages, public discourse, and cultural trends.

Discourse Analysis

This method involves analyzing language to understand how it constructs meaning and shapes social interactions. Discourse analysis can involve a variety of methods, such as conversation analysis, critical discourse analysis, and narrative analysis. Discourse analysis is useful for understanding how language shapes social interactions, cultural norms, and power relationships.

Grounded Theory Analysis

This method involves developing a theory or explanation based on the data collected. Grounded theory analysis starts with the data and uses an iterative process of coding and analysis to identify patterns and themes in the data. The theory or explanation that emerges is grounded in the data, rather than preconceived hypotheses. Grounded theory analysis is useful for understanding complex social phenomena and for generating new theoretical insights.

Narrative Analysis

This method involves analyzing the stories or narratives that participants share to gain insights into their experiences, attitudes, and beliefs. Narrative analysis can involve a variety of methods, such as structural analysis, thematic analysis, and discourse analysis. Narrative analysis is useful for understanding how individuals construct their identities, make sense of their experiences, and communicate their values and beliefs.

Phenomenological Analysis

This method involves analyzing how individuals make sense of their experiences and the meanings they attach to them. Phenomenological analysis typically involves in-depth interviews with participants to explore their experiences in detail. Phenomenological analysis is useful for understanding subjective experiences and for developing a rich understanding of human consciousness.

Comparative Analysis

This method involves comparing and contrasting data across different cases or groups to identify similarities and differences. Comparative analysis can be used to identify patterns or themes that are common across multiple cases, as well as to identify unique or distinctive features of individual cases. Comparative analysis is useful for understanding how social phenomena vary across different contexts and groups.

Applications of Qualitative Research

Qualitative research has many applications across different fields and industries. Here are some examples of how qualitative research is used:

• Market Research: Qualitative research is often used in market research to understand consumer attitudes, behaviors, and preferences. Researchers conduct focus groups and one-on-one interviews with consumers to gather insights into their experiences and perceptions of products and services.
• Health Care: Qualitative research is used in health care to explore patient experiences and perspectives on health and illness. Researchers conduct in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education: Qualitative research is used in education to understand student experiences and to develop effective teaching strategies. Researchers conduct classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work : Qualitative research is used in social work to explore social problems and to develop interventions to address them. Researchers conduct in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : Qualitative research is used in anthropology to understand different cultures and societies. Researchers conduct ethnographic studies and observe and interview members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : Qualitative research is used in psychology to understand human behavior and mental processes. Researchers conduct in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy : Qualitative research is used in public policy to explore public attitudes and to inform policy decisions. Researchers conduct focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

• Identify your research question: Qualitative research starts with a research question or set of questions that you want to explore. This question should be focused and specific, but also broad enough to allow for exploration and discovery.
• Select your research design: There are different types of qualitative research designs, including ethnography, case study, grounded theory, and phenomenology. You should select a design that aligns with your research question and that will allow you to gather the data you need to answer your research question.
• Recruit participants: Once you have your research question and design, you need to recruit participants. The number of participants you need will depend on your research design and the scope of your research. You can recruit participants through advertisements, social media, or through personal networks.
• Collect data: There are different methods for collecting qualitative data, including interviews, focus groups, observation, and document analysis. You should select the method or methods that align with your research design and that will allow you to gather the data you need to answer your research question.
• Analyze data: Once you have collected your data, you need to analyze it. This involves reviewing your data, identifying patterns and themes, and developing codes to organize your data. You can use different software programs to help you analyze your data, or you can do it manually.
• Interpret data: Once you have analyzed your data, you need to interpret it. This involves making sense of the patterns and themes you have identified, and developing insights and conclusions that answer your research question. You should be guided by your research question and use your data to support your conclusions.
• Communicate results: Once you have interpreted your data, you need to communicate your results. This can be done through academic papers, presentations, or reports. You should be clear and concise in your communication, and use examples and quotes from your data to support your findings.

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

• Customer Feedback: A company may conduct qualitative research to understand the feedback and experiences of its customers. This may involve conducting focus groups or one-on-one interviews with customers to gather insights into their attitudes, behaviors, and preferences.
• Healthcare : A healthcare provider may conduct qualitative research to explore patient experiences and perspectives on health and illness. This may involve conducting in-depth interviews with patients and their families to gather information on their experiences with different health care providers and treatments.
• Education : An educational institution may conduct qualitative research to understand student experiences and to develop effective teaching strategies. This may involve conducting classroom observations and interviews with students and teachers to gather insights into classroom dynamics and instructional practices.
• Social Work: A social worker may conduct qualitative research to explore social problems and to develop interventions to address them. This may involve conducting in-depth interviews with individuals and families to understand their experiences with poverty, discrimination, and other social problems.
• Anthropology : An anthropologist may conduct qualitative research to understand different cultures and societies. This may involve conducting ethnographic studies and observing and interviewing members of different cultural groups to gain insights into their beliefs, practices, and social structures.
• Psychology : A psychologist may conduct qualitative research to understand human behavior and mental processes. This may involve conducting in-depth interviews with individuals to explore their thoughts, feelings, and experiences.
• Public Policy: A government agency or non-profit organization may conduct qualitative research to explore public attitudes and to inform policy decisions. This may involve conducting focus groups and one-on-one interviews with members of the public to gather insights into their perspectives on different policy issues.

Purpose of Qualitative Research

The purpose of qualitative research is to explore and understand the subjective experiences, behaviors, and perspectives of individuals or groups in a particular context. Unlike quantitative research, which focuses on numerical data and statistical analysis, qualitative research aims to provide in-depth, descriptive information that can help researchers develop insights and theories about complex social phenomena.

Qualitative research can serve multiple purposes, including:

• Exploring new or emerging phenomena : Qualitative research can be useful for exploring new or emerging phenomena, such as new technologies or social trends. This type of research can help researchers develop a deeper understanding of these phenomena and identify potential areas for further study.
• Understanding complex social phenomena : Qualitative research can be useful for exploring complex social phenomena, such as cultural beliefs, social norms, or political processes. This type of research can help researchers develop a more nuanced understanding of these phenomena and identify factors that may influence them.
• Generating new theories or hypotheses: Qualitative research can be useful for generating new theories or hypotheses about social phenomena. By gathering rich, detailed data about individuals’ experiences and perspectives, researchers can develop insights that may challenge existing theories or lead to new lines of inquiry.
• Providing context for quantitative data: Qualitative research can be useful for providing context for quantitative data. By gathering qualitative data alongside quantitative data, researchers can develop a more complete understanding of complex social phenomena and identify potential explanations for quantitative findings.

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

• Exploring a new area: If little is known about a particular topic, qualitative research can help to identify key issues, generate hypotheses, and develop new theories.
• Understanding complex phenomena: Qualitative research can be used to investigate complex social, cultural, or organizational phenomena that are difficult to measure quantitatively.
• Investigating subjective experiences: Qualitative research is particularly useful for investigating the subjective experiences of individuals or groups, such as their attitudes, beliefs, values, or emotions.
• Conducting formative research: Qualitative research can be used in the early stages of a research project to develop research questions, identify potential research participants, and refine research methods.
• Evaluating interventions or programs: Qualitative research can be used to evaluate the effectiveness of interventions or programs by collecting data on participants’ experiences, attitudes, and behaviors.

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

• Focus on subjective experience: Qualitative research is concerned with understanding the subjective experiences, beliefs, and perspectives of individuals or groups in a particular context. Researchers aim to explore the meanings that people attach to their experiences and to understand the social and cultural factors that shape these meanings.
• Use of open-ended questions: Qualitative research relies on open-ended questions that allow participants to provide detailed, in-depth responses. Researchers seek to elicit rich, descriptive data that can provide insights into participants’ experiences and perspectives.
• Sampling-based on purpose and diversity: Qualitative research often involves purposive sampling, in which participants are selected based on specific criteria related to the research question. Researchers may also seek to include participants with diverse experiences and perspectives to capture a range of viewpoints.
• Data collection through multiple methods: Qualitative research typically involves the use of multiple data collection methods, such as in-depth interviews, focus groups, and observation. This allows researchers to gather rich, detailed data from multiple sources, which can provide a more complete picture of participants’ experiences and perspectives.
• Inductive data analysis: Qualitative research relies on inductive data analysis, in which researchers develop theories and insights based on the data rather than testing pre-existing hypotheses. Researchers use coding and thematic analysis to identify patterns and themes in the data and to develop theories and explanations based on these patterns.
• Emphasis on researcher reflexivity: Qualitative research recognizes the importance of the researcher’s role in shaping the research process and outcomes. Researchers are encouraged to reflect on their own biases and assumptions and to be transparent about their role in the research process.

Advantages of Qualitative Research

Qualitative research offers several advantages over other research methods, including:

• Depth and detail: Qualitative research allows researchers to gather rich, detailed data that provides a deeper understanding of complex social phenomena. Through in-depth interviews, focus groups, and observation, researchers can gather detailed information about participants’ experiences and perspectives that may be missed by other research methods.
• Flexibility : Qualitative research is a flexible approach that allows researchers to adapt their methods to the research question and context. Researchers can adjust their research methods in real-time to gather more information or explore unexpected findings.
• Contextual understanding: Qualitative research is well-suited to exploring the social and cultural context in which individuals or groups are situated. Researchers can gather information about cultural norms, social structures, and historical events that may influence participants’ experiences and perspectives.
• Participant perspective : Qualitative research prioritizes the perspective of participants, allowing researchers to explore subjective experiences and understand the meanings that participants attach to their experiences.
• Theory development: Qualitative research can contribute to the development of new theories and insights about complex social phenomena. By gathering rich, detailed data and using inductive data analysis, researchers can develop new theories and explanations that may challenge existing understandings.
• Validity : Qualitative research can offer high validity by using multiple data collection methods, purposive and diverse sampling, and researcher reflexivity. This can help ensure that findings are credible and trustworthy.

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

• Subjectivity : Qualitative research relies on the subjective interpretation of researchers, which can introduce bias into the research process. The researcher’s perspective, beliefs, and experiences can influence the way data is collected, analyzed, and interpreted.
• Limited generalizability: Qualitative research typically involves small, purposive samples that may not be representative of larger populations. This limits the generalizability of findings to other contexts or populations.
• Time-consuming: Qualitative research can be a time-consuming process, requiring significant resources for data collection, analysis, and interpretation.
• Resource-intensive: Qualitative research may require more resources than other research methods, including specialized training for researchers, specialized software for data analysis, and transcription services.
• Limited reliability: Qualitative research may be less reliable than quantitative research, as it relies on the subjective interpretation of researchers. This can make it difficult to replicate findings or compare results across different studies.
• Ethics and confidentiality: Qualitative research involves collecting sensitive information from participants, which raises ethical concerns about confidentiality and informed consent. Researchers must take care to protect the privacy and confidentiality of participants and obtain informed consent.

Also see Research Methods

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• Open access
• Published: 27 May 2020

How to use and assess qualitative research methods

• Loraine Busetto   ORCID: orcid.org/0000-0002-9228-7875 1 ,
• Wolfgang Wick 1 , 2 &
• Christoph Gumbinger 1  

Neurological Research and Practice volume  2 , Article number:  14 ( 2020 ) Cite this article

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

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

What is qualitative research?

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

Why conduct qualitative research?

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

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

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 , 10 , 11 , 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

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

Iterative research process

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

Data collection

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

Document study

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

Observations

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

Semi-structured interviews

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

Focus groups

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

Choosing the “right” method

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

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

Possible combination of data collection methods

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

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

Data analysis

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

From data collection to data analysis

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

How to report qualitative research?

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

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 , 25 , 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

Three common mixed methods designs

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

How to assess qualitative research?

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

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

Reflexivity

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

Sampling and saturation

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

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

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

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

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

Member checking

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

Stakeholder involvement

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

How not to assess qualitative research

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

Protocol adherence

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

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 , 38 , 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

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

Interrater reliability, variability and other “objectivity checks”

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

Not being quantitative research

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

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

Availability of data and materials

Not applicable.

Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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Busetto, L., Wick, W. & Gumbinger, C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2 , 14 (2020). https://doi.org/10.1186/s42466-020-00059-z

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

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

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

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

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Background/aims

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

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

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

Conclusions

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

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

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

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

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

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

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

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

Background to the integration of qualitative research within CTR

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

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

Understanding implementation—Normalisation Process Theory (NPT)

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

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

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

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

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

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

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

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

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

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

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

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

Coherence—making sense of qualitative research

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

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

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

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

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

Cognitive participation—legitimising qualitative research

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

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

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

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

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

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

Collective action—operationalising qualitative research

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

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

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

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

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

Reflexive monitoring—evaluating the impact of qualitative research

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

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

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

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

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

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

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

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

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

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

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

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

Availability of data and materials

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Acknowledgements

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

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

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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

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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.

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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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Towards inclusive learning environments in post-graduate medical education: stakeholder-driven strategies in Dutch GP-specialty training

• N.M. van Moppes   ORCID: orcid.org/0000-0003-3457-7724 1 ,
• M. Nasori   ORCID: orcid.org/0000-0001-8559-1791 1 ,
• J. Bont   ORCID: orcid.org/0000-0002-5358-0235 1 ,
• J.M. van Es 1 ,
• M.R.M. Visser 1 &
• M.E.T.C. van den Muijsenbergh   ORCID: orcid.org/0000-0002-4994-4008 2 , 3  

BMC Medical Education volume  24 , Article number:  550 ( 2024 ) Cite this article

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A recent study found that ethnic minority General Practice (GP)-trainees receive more negative assessments than their majority peers. Previous qualitative research suggested that learning climate-related factors play a pivotal role in unequal opportunities for trainees in post-graduate medical settings, indicating that insufficient inclusivity had put minority students at risk of failure and dropout.

Study objectives

We aimed to develop broadly supported strategies for an inclusive learning climate in Dutch GP-specialty training.

We employed Participatory Action Research (PAR)-methods, incorporating Participatory Learning and Action (PLA)-techniques to ensure equal voices for all stakeholders in shaping Diversity, Equity, and Inclusion (DEI)-strategies for GP-specialty training. Our approach engaged stakeholders within two pilot GP-specialty training institutes across diverse roles, including management, support staff, in-faculty teachers, in-clinic supervisors, and trainees, representing ethnic minorities and the majority population. Purposeful convenience sampling formed stakeholder- and co-reader groups in two Dutch GP-specialty training institutes. Stakeholder discussion sessions were based on experiences and literature, including two relevant frameworks, and explored perspectives on the dynamics of potential ethnic minority trainees’ disadvantages and opportunities for inclusive strategies. A co-reader group commented on discussion outcomes. Consequently, a management group prioritized suggested strategies based on expected feasibility and compatibility.

Input from twelve stakeholder group sessions and thirteen co-readers led to implementation guidance for seven inclusive learning environment strategies, of which the management group prioritized three:

• Provide DEI-relevant training programs to all GP-specialty training stakeholders;

• Appoint DEI ambassadors in all layers of GP-specialty training;

• Give a significant voice to minority GP-trainees in their education.

The study’s participatory approach engaged representatives of all GP-specialty training stakeholders and identified seven inclusive learning climate strategies, of which three were prioritized for implementation in two training institutions.

Peer Review reports

Introduction

Following international migration trends [ 1 , 2 ], diversity among students and trainees is growing [ 3 , 4 ], with each of them bringing their specific cultural values, family- and migration histories [ 5 ]. However, postgraduate medical ethnic minority GP-trainees still face underrepresentation [ 3 , 4 ] and may encounter unequal opportunities for success compared to their majority peers [ 6 , 7 , 8 , 9 ]. Learning climate-related factors, notably those related to lacking inclusiveness, likely play a pivotal role in this discrepancy [ 10 , 11 , 12 ].

Educational opportunities in GP-specialty training primarily rely on in-clinic learning, encompassing formal and informal contexts. Formal learning, characterized by structured, planned, and accredited activities within educational institutions, coexists with less structured informal learning, which is self-directed and arises from in-clinic everyday experiences and interactions, often susceptible to unspoken norms. While both approaches complement each other in providing a well-rounded education, the informal context might inadvertently reflect dominant cultural values and attitudes, potentially affecting in-classroom learning [ 13 , 14 , 15 ]. Particularly for ethnic minority GP-trainees, this lacking transparency may contribute to an increased risk of facing underperformance assessments, as these unspoken norms and values may not be self-evidently familiar to them [ 10 , 11 , 12 ].

Learning environments are subject to complex dynamics. Understanding the interconnected constructs of these dynamics is crucial for implementing transformative changes [ 16 ]. Accordingly, changes for inclusive learning opportunities require input from all organizational layers [ 17 ].

With this study, we aimed to develop broadly supported recommendations for an inclusive learning climate in Dutch GP-specialty training.

We used a qualitative Participatory Action Research (PAR) approach [ 18 , 19 ], applying Participatory Learning and Action (PLA) techniques in stakeholder groups combined with insights from literature (Appendix) along with GP-trainees’ experiences related to inclusive education, to actively engage stakeholders in an inclusive dialogue [ 20 , 21 , 22 ]. This approach supported co-ownership, promoted compatibility with the organization’s actual needs, and facilitated successful implementation [ 23 ].

We employed two conceptual frameworks to shape the topic lists for stakeholder groups and guide result analysis.

The Building Equity Taxonomy (BET) framework for Diversity, Equity, and Inclusion (DEI), addressing students’ needs for equal educational opportunities, and covering the areas of physical integration, social-emotional engagement, equal learning opportunities, instructional excellence, and fostering inspired learners [ 24 , 25 ] (Fig.  1 ). This framework is relevant to various educational settings, including GP-specialty training [ 12 , 26 , 27 , 28 , 29 ].

Building Equity Taxonomy [ 24 ] compared to Maslow’s hierarchy of needs [ 25 ]

The Wensing & Grol framework implementation guidance, equivalent to the internationally recognized Consolidated Framework for Implementation Research (CFIR) [ 30 ]. It provides implementation guidance for complex organizations, including clinical healthcare and educational settings [ 30 , 31 ] (Fig.  2 ). This framework underpinned our implementation guidance, which the management team used for prioritization.

The Wensing & Groll model for implementation guidance [ 30 ]

This study took place at Amsterdam UMC’s two GP-specialty training institutes (AMC and VUmc). These institutes have demonstrated commitment to inclusiveness in their 2020–2022 annual reports, and they collaborate with the six other Dutch GP-specialty training institutes under GP-specialty Training Netherlands (HN).

One in three medical graduates in the Netherlands aims to enter GP-specialty training. In response to national medical demands, HN annually expands its acceptance of new trainees, projecting 921 in 2023 and an anticipated 1,190 in 2024, distributed across eight training institutes. About 17% of these trainees belong to ethnic minority groups, with most having completed pre-training at Dutch Medical Schools and a smaller group having graduated abroad [ 7 ]. Due to General Data Protection Regulation (GDPR) restrictions, the precise distribution of minority trainees across the eight national institutes remains undisclosed. However, a prior quantitative study indicated that by 2023, our pilot institutes showed a relatively proportional representation of Dutch GP-specialty training [ 7 ]. However, it is essential to note that qualitative research emphasizes a thorough description of the setting to enrich readers’ contextual understanding rather than strict representativeness.

The Dutch GP-specialty training program is a three-year dual-track program, supporting professional growth by combining in-clinic experience learning with one-day-a-week in-faculty education. Entry assessments aspire to guarantee the applicants’ knowledge, motivation, and Dutch proficiency. The program includes protocolled assessments, such as practical observations, systematic testing, and reviews of learning objectives.

Study population

Acknowledging the essential need of broad support for inclusive organizational changes, we engaged participants from all backgrounds represented within the organization. Our study population encompassed the ethnic majority background as well as diverse ethnic backgrounds across all organizational layers (ranging from support personnel, management, educational staff (comprising both faculty and clinical educators), and trainees themselves), divided into two stakeholder groups, one co-reader group, and a management team group (Fig.  3 ).

Participant groups

Aiming to prevent eligible participants from experiencing researchers’ pressure, researchers sent information letters to team leaders, requesting them to forward in-faculty teachers, in-clinic supervisors, supporting bureau and management personnel, and trainees. From those interested, we purposefully selected twelve participants (six in each stakeholder group), striving for diversity regarding the position in the institute, age, gender, and ethnicity [ 32 ]. Stakeholders ranged from supporting bureau and management personnel (further in this text referred to as ‘staff’) to trainees, in-faculty teachers, and in-clinic supervisors representing diverse minority backgrounds as well as the majority background.

Stakeholder groups, each representing one GP-specialty training institute, provided input for inclusive strategies. Additionally, a co-reader group comprising interested individuals not in the stakeholder groups provided further insights through written comments. These groups represented diverse organizational layers, cultural backgrounds, ages, and gender. Representatives from management teams then evaluated and prioritized the suggested strategies.

Data collection

Data collection and analysis took place from January 2021 to December 2022. Two researchers (MN, NvM) familiar with PLA-techniques facilitated six 90-minute PLA-based sessions for each stakeholder group. The sessions focused on inclusive learning environments and GP-specialty training’s inclusivity. In a cyclical process [ 33 ](Fig.  4 ), participants engaged in PLA techniques such as ice-breaking, flexible brainstorming, free-associating, direct ranking, mind-mapping, and visual evaluation. These methods facilitated sharing experiences and opinions and aligning these with relevant literature (Appendix, Table  1 ) to identify suitable inclusive strategies. After each stakeholder group session, the facilitator-researchers held debriefing sessions to reflect on their roles and identify areas for improvement. Independently, they summarized the key findings from each session and reached consensus through discussions. They presented these summaries in subsequent sessions for a member check and made adjustments based on participants’ feedback. To ensure a broader perspective, the co-reader group commented anonymously on these approved summaries, allowing them to contribute their personal perspectives, opinions, and experiences freely. Stakeholder groups then discussed and implemented these comments in their final session (Fig.  3 ).

Cyclic phases until consensus of stakeholder groups’ processes [ 33 ]

The stakeholder group topic list focused on:

Exploring :

The initial educational context;

Potential learning climate-related disparities;

Out-of-the-box wishes and key elements for an inclusive learning climate;

Strategy developing and preparing for implementation:

Recommendations for inclusive GP-specialty training;

Mapping onto the BET framework’s hierarchical levels of DEI [ 24 ](Fig.  1 );

Translating recommendations into actionable strategies.

Identifying Wensing & Grol conditions and requirements for implementation [ 30 ](Fig.  2 ).

Due to the Covid-19 pandemic, we adapted the study’s in-person design to online methods for creative brainstorming. In these virtual sessions, physical distance and potential distractions of personal environments challenged trust and commitment, especially for GP-trainees who felt vulnerable sharing ideas with in-faculty teachers, in-clinic supervisors, and staff, who might also be their assessors in daily educational contexts [ 34 ]. To address this risk, we dedicated extra time, and utilized online tools: Zoom 5.13.11 for breakout rooms, Padlet 200.0.0 for visualizing PLA techniques, and concise PowerPoint presentations for member check summaries and goal-setting [ 35 ].

The facilitator-researchers (NvM, MN) collected audio recordings and written co-reader comments. An external bureau transcribed audio-recordings verbatim.

One researcher (NvM) regularly presented our findings during periodic staff meetings. These presentations not only aimed to keep the entire team informed but also played a crucial role in garnering broader support and incorporating diverse opinions for our project.

Data analysis

Within three days after each session, we (NvM, MN, and MV) analyzed the transcribed audio recordings and written co-readers’ comments, and discussed our analyses until consensus.

To provide actionable qualitative insights while responding to ongoing participant feedback, we adopted an inductive rapid qualitative data analysis approach inspired by Hamilton’s model [ 36 , 37 , 38 , 39 ]. This method prioritizes identifying key elements and mechanisms over extensive theoretical insights. Through structured data collection using topic lists and Participatory Learning and Action (PLA) techniques, along with expedited transcription, we efficiently analyzed ideas and condensed findings into concise formats like post-interview notes and matrix summaries. Although not a traditional thematic or framework analysis, we employed theme-informed and framework-informed codes to organize data, considering context and group dynamics, which allowed us to explore interactional group dynamics and communication styles in the participants’ discourse and its points of consensus or contention within specific statements [ 40 ]. We anticipated this method, aligned with the literature, to yield qualitative outcomes as consistent and rich as traditional in-depth transcription coding while facilitating the analysis of interconnected sessions [ 36 , 41 , 42 ].

We analyzed the stakeholders’ ideas, recommendations, and their identifyed Wensing & Grol conditions and requirements for implementation to create implementation guidance [ 30 ]. This guidance encompassed analyzing organizational structure, identifying change potential and barriers, defining the target population, describing tailored DEI-strategies, estimating timelines for internalization processes and implementation, and designing evaluation methods (Fig.  2 ). Subsequently, we invited management group participants for hybrid (online and in-person) meetings, where they engaged in substantive discussions to evaluate this guidance and prioritize recommended strategies, based on the expected feasibility and compatibility with their setting.

Reflexivity and ethics

Two authors, NM and MN, identify as minority females. While their unique backgrounds enhance sensitivity towards minority peers’ experiences, a potential challenge arises where these experiences resonating with them might be more salient. To mitigate this, we organized reflective debriefing sessions addressing diverse viewpoints and emphasizing the researchers’ roles as instruments in data collection and analysis. During these sessions, we engaged in candid discussions probing our experiences, expectations, preoccupations, and opinions that could have influenced our approach to data collection and analysis.

Also, the roles of participating stakeholders may have influenced views they shared in this research process. They spanned all organizational positions, ranging from department heads to trainees, in-faculty teachers, and in-clinic supervisors, representing both, majority and minority backgrounds. While deliberately seeking these varied insights, we remained mindful of potential power dynamics influenced by different positions or ethnic backgrounds. To foster a safe space and address these dynamics, facilitators employed PLA-techniques, such as ice-breakers. Also, they established clear agreements with all stakeholder group members regarding privacy, openness to differing views, and ensuring safety. Should any commitments be breached, facilitators were trained to address them promptly. In fact, stakeholders demonstrated remarkable respect and curiosity towards understanding each other’s perspectives throughout the process.

Participant characteristics

Table  1 presents participant characteristics for the stakeholder, co-reader, and management groups. In total, 31 stakeholders participated, aged 24 to 60, including eight males, 24 staff members from diverse organizational positions, seven trainees, and 12 ethnic minority participants.

The stakeholder group sessions had an attendance rate of 97%. All co-readers responded to the request for comments. During the hybrid management group session, 40% of participants attended in-person, while 60% joined online.

Stakeholder group sessions

In line with the topic list, we organized the results into two sections: [ 1 ]Exploring and [ 2 ] Strategy developing and preparing for implementation. In Sect. 2, the stakeholders aligned their results with the BET framework and structured them according to the Wensing & Grol framework.

The initial educational context

Stakeholders defined inclusiveness in the GP-specialty training as collective curiosity and support for trainees’ unique professional identities, regardless of their characteristics or backgrounds. As preconditions for in-faculty teachers, in-clinic supervisors, and staff, participants mentioned [ 1 ] willingness to encounter emotional discomfort [ 2 ], embracing failures in order to learn, and [ 3 ] acknowledgement of unconscious bias.

‘… we will not always succeed to be without prejudice, that is allowed as long as we will put the effort in gaining awareness’ (participant 2, group 1).

Participants emphasized creating a safe learning environment where all voices, including minority voices, can be heard. They suggested reflective questions starting with:

‘ Could you imagine that…’.

Participants highlighted parallel processes whereby educators foster trainees’ personal and professional development, and GPs support patients’ individual coping styles. Such an inclusive and safe learning environment would act as a flywheel, enhancing the institute’s inclusive image and attracting prospective minority trainees, teachers, and in-clinic supervisors.

Co-readers confirmed these view points and they added their concerns regarding prioritization by some staff members:

‘I have nothing to add. I think it is essential that diversity is given a priority, that we as staff all agree that this is important. The pitfall is that some of them might not see the importance’. (co-reader 2)

Potential learning climate-related disparities

Stakeholders from ethnic minority groups expressed distress experiences in a dominant white world:

‘The GP-specialty training population is predominantly white and female; trainees, in-faculty teachers, and in-clinic supervisors even seem to resemble one another. Without them saying or acting, I continuously feel the stress of having to adapt to them, which I will never be able to’ (participant 2, group 1).

Stakeholders discussed the majority’s naivety in understanding the experience of belonging to a minority and expressed concerns about some DEI programs potentially leading to paradoxical stigmatization. They noted instances where in-faculty teachers appointed minority trainees as representatives for their cultural groups, ignoring the vast diversity within these groups. Also, participants reported stereotyping case reports:

‘They always use the example of the non-Dutch speaking overweight Moroccan mother of seven children, not engaged in any sports, who favors sweet and fatty food, and suffers from diabetes’ (participant 3, group 2).

Co-readers added that this one-sided picture made minority trainees uneasy, feeling discussed rather than equal partners in GP-training. Additionally, they emphasized that presenting DEI programs as non-mandatory, implied that diversity and inclusiveness were not necessarily integral to GP-skills requirements.

‘Mandatory inclusive training for mentors, staff, and teachers holds significant importance, signifying our commitment. Participation in these courses should be integrated into evaluations and annual interviews’. (co-reader 4)

Out-of-the-box wishes and key elements for an inclusive learning climate

Upon the invitation to make a wish:

‘Wouldn’t it be wonderful if….‘ ,

stakeholders wished for diverse staff as role models, willing to learn from each other, normalizing various meaningful insights, and embracing diverse worldviews:

‘By using these differences, we keep each other awake and open-minded in exploring possibilities; thus, we allow ourselves to grow without assuming that our paved path is always the best way at the time’ (participant 3, group 1).

Stakeholders indicated the institute’s responsibility to educate GP-trainees for a diverse patient population as an essential component of an inclusive learning environment. Key elements related to such inclusiveness were:

The GP-specialty training should represent society in all its diversity:

‘It’s been a few years since I started GP-specialty training, of course, but… I’m just digging whether I had a feeling of: “I fit in there” or: “I recognize my roots there”. These are important feelings to me to feel safe at my work- and study place’ (participant 7, group 1);

A diverse GP workforce meets patients’ appreciation for GPs they can identify with:

‘Regarding this cultural background or ethnicity, I have the impression that patients from ethnic minorities often liked that I obviously am not Dutch, they said, “oh, you are not Dutch, are you?“, it led to recognition, a little laugh, and connected us. Having a doctor just like them helped my patients to share their concerns.’ (participant 2, group 2);

GP-trainees need identifiable and diverse educational role models:

‘The moment you sit down together and see that diversity, …brings different working styles, learning styles, or communication styles… that you realize we have to do it together, the greater the diversity, the more we learn from one another, the higher we rise, the more fun and creative ideas…’ (participant 4, group 2);

Diverse GP-trainee cohorts improve mutual learning processes:

‘To me, utilizing diversity means that there’s always someone in the classroom who says, “Okay, so what if we look at it from that perspective or through those glasses?’ (participant 1, group 1).

Co-readers agreed and added that GP-specialty training already utilized diversity among in-faculty teachers to some extent:

‘Great idea! Diversity among teachers is already being leveraged to some extent. Trainees can synthesize a blend of styles and insights from different teachers and mentors. Expanding on this concept could help cultivate a more inclusive learning environment’ . (co-reader 1)

Strategy developing and preparing for implementation

Recommendations for an inclusive gp-specialty training.

Participants (stakeholders in collaboration with co-readers) made six fundamental recommendations and mapped these onto the BET framework levels to ensure all aspects of inclusive education would be covered [ 24 ] (Table  2 ).

Actionable strategies

From these recommendations, participants derived seven actionable strategies for promoting inclusive GP-specialty training (Table  3 ).

Provide a clear message of inclusiveness in all internal and external communications .

Participants explored various means and media platforms for promoting the GP-specialty training’s DEI core values (websites, ads, social media, podcasts), focusing on design, content, and appeal to the target group. They recommended involving trainees with media experience rather than exclusively hiring specialized communication consultants.

Appoint DEI ambassadors in all layers of the organization .

Participants suggested involving employees as DEI ambassadors to effectively spread DEI core values in the organization. Ambassadors would undergo comprehensive training in DEI, reflective skills, leadership, and change management. They would also attend conferences, masterclasses, join knowledge networks, and contribute to think tank initiatives as part of their preparation.

Facilitate procedures for secure incident reporting .

Participants highlighting the significant impact of unintentional discriminatory behavior, often resulting in experiencing barriers to reporting such incidents. They proposed implementing low-threshold and secure reporting procedures with targeted questions on DEI and (micro)aggression. Regular team sessions would enable open discussions based on anonymous reports, fostering inclusive education, uncovering organizational trends, and providing support for trainees who faced discrimination, microaggression, or exclusion. Confidential advisors would receive training in DEI, reflective skills, and relevant legislation.

Give a significant voice to minority trainees in ongoing program development .

Participants advised inviting minority trainees to round table discussions, fostering insider perspective exchange with mutual respect, critical reflection, and empathy. Including these diverse voices would promote resilience and professional growth and attract eligible trainees and staff from diverse backgrounds.

Assign more than one in-faculty teacher per group / in-clinic training .

GP-trainees - like all individuals - naturally mirror the behavior of significant others, such as teachers, in-clinic supervisors, or peers. Participants believed that trainees with multiple role models would outperform those with single role models. They suggested introducing dual in-faculty teachers and dual in-clinic supervisors as additional role models and an extra pair of eyes during education. To ensure success, participants recommended training programs for optimum role model utilization.

Offer ‘just-in-time’ learning .

Participants agreed that effective learning is closely related to immediate learning needs. For GP-trainees, such learning needs often arise from societal encounters in the consultation room, e.g., guiding Muslims during Ramadan while simultaneously managing diabetes or comprehending increasing PTSD symptoms around Keti Koti (Afro-Surinamese Emancipation Day). Timely incorporating these contextual factors into training programs could provide directly applicable knowledge.

Provide mandatory DEI relevant training programs for professional development .

Participants emphasized the necessity of new knowledge, skills, and attitudes. They considered within-group differences valuable learning tools for diverse personal and professional development paths. Well-trained staff and trainees could drive inclusive knowledge networks, empower the organization, and positively influence external perceptions. Thus, they recommended mandatory and tailored training programs aligned with the anticipated learning needs from the suggested strategies. Where applicable, they advised considering outsourcing.

Conditions and requirements for implementation

Participants indicated the importance of in-faculty teachers, in-clinic supervisors, and staff having the courage to be vulnerable. They emphasized the essence of transparent norms and values and a welcoming learning environment, and they highlighted an attitude of:

‘… genuinely enjoying to support a diverse population in their growth towards their professional identities’ (participant 6, group 2).

‘Implementing these ideas demands courage and vulnerability, particularly as their execution could inadvertently carry stigmatizing effects’. (co-reader 6)

In this context, they mentioned the risk of unconscious bias, which could require external expert trainers at certain stages:

‘Well, you know, I had a trainee of Moroccan descent, and it shocked me that, while I always thought to be very open, diversity-minded, and curious for everything and everyone, I found it way more difficult to connect than I’d admit. I wonder what would have helped me unveil this blind spot in an earlier stage…’ (participant 5, group 1).

‘… allow and embrace the differences, see them as opportunities that actually add learning qualities, and not take them away? So, professionalism will become more colorful, and it can be viewed from different points of view, not just the traditional, established perspectives and routes’ (participant 1, group 1).

Ultimately, we provided the management group with implementation guidance for these seven strategies, along with an analysis of the target group and context, and summaries of relevant literature on DEI best practices in educational settings (Appendix). The management team agreed that enhancing DEI should have priority in Dutch GP-specialty training:

‘We should acknowledge that we are trailing behind societal advancements in diversity. Therefore, maintaining a strong focus on this topic must stay a priority’ (participant 5, management group).

Based on these comprehensive data, the management group prioritized strategies that covered the overarching recommendations and BET-levels (detailed in Table  3 ; Fig.  1 ), which aided in selecting strategies with anticipated effectiveness. To enhance alignment with the organizational requirements and feasibility, they considered implementation requirements, staff feedback from our presentations during periodic meetings, and opportunities for synergy with existing projects in other Amsterdam UMC departments.

‘We can see that literature describes these strategies as effective and we assume that stakeholders meticulously aligned them with the institute’s needs. Let us not repeat that process but rather look into strategies that can be implemented effectively in our setting’ (participant 1, management group).

‘For each suggested strategy, this guidance envisions its coverage and practical implications. Now, it is up to us to consider how far we are willing to commit. This process prompts pertinent questions on specific effective actions’ (participant 2, management group).

The management group prioritized three strategies:

Appoint DEI ambassadors in all organizational levels,

Give a significant voice to minority trainees in ongoing program development,

Provide mandatory DEI-relevant training programs for professional development to all involved in GP-specialty training.

Summary of findings

In twelve PLA-based stakeholder sessions, participants explored perspectives on potential disparities, underlying causes, and aspirations for an inclusive learning climate in the Dutch GP-specialty training. They suggested seven strategies based on six overarching recommendations, which they presented embedded in an implementation guidance to the management group:

Provide a clear message of inclusiveness in all internal and external communications.

Appoint DEI ambassadors Footnote 1 in all layers of the organization

Facilitate procedures for secure incident reporting.

Give a significant voice to minority trainees in ongoing program development.

Assign more than one in-faculty teacher per group / in-clinic supervisor per trainee.

Offer ‘just-in-time’ learning.

Provide mandatory DEI relevant training programs for professional development.

The management team selected strategies 2, 4, and 7, deeming them most effective, feasible, and aligned with the organization’s requirements.

Comparison to existing literature

Worldwide attention to inclusive learning climates in postgraduate medical education revealed the complexity and multidimensionality of educational constructs and institutes [ 29 , 43 ]. Interpretations of formal and informal learning contexts within these environments depend on the perspectives of various stakeholders [ 15 ]. Consequently, unconsciously normalized rules and codes across all layers may implicitly exclude ethnic minority professionals and -trainees in many ways throughout their careers [ 44 ].

This paper extends the literature on inclusive GP-specialty training [ 15 , 43 , 44 ], detailing the efforts to design- and create broad support for inclusive training strategies. Like most organizational changes, implementing inclusive strategies in GP-specialty training posed challenges and demanded a focus on building confidence and trust in novel approaches [ 45 ]. Hence, understanding the values and expectations of target groups and tailoring strategies to meet their needs and aspirations was crucial. Our study involved representatives from all key stakeholders, including ethnic minority trainees, aiming to address critical research gaps and enhance knowledge quality, relevance, and impact [ 46 ]. Collaborative decisions, rooted in an equal and reciprocal partnership, empowered stakeholders, raised management team awareness and inspired the research team [ 47 ]. These effects mirror findings in previous PAR studies on inclusive primary healthcare [ 48 ] and highlight PAR’s role as a catalyst for transformative change in GP-specialty training [ 33 ].

Stakeholder insights, combined with DEI-strategy literature, underscored the need for a gradual, committed cultural shift towards inclusivity in the learning environment. Based on these insights, the management group recognized that this transformation would necessitate a set of strategies addressing inclusiveness at various levels rather than relying on one single intervention [ 26 , 28 , 49 , 50 ]. They employed our Wensing and Grol-based implementation guidance to select the following feasible strategies aligned with the GP-specialty training context as a first step in an ongoing process:

Providing mandatory DEI-relevant training programs to all stakeholders supports cultural responsiveness within all strategies to be implemented. It facilitates understanding how cultural backgrounds and experiences influence teaching and learning [ 49 ]. Ultimately, it fosters engagement and motivation to create collaborative learning environments and accommodate learners’ needs based on their diverse backgrounds [ 26 ].

Appointing DEI ambassadors in all layers of the organization has in other contexts proven to enhance the effectiveness of DEI-related strategic initiatives [ 51 ]. DEI ambassadors engage change agents within their teams, foster collaboration and effective communication, facilitate diversity goals, and involve key stakeholders in sustainable, inclusive changes [ 50 ].

Giving a significant voice to minority trainees empowers and amplifies their agency. Including their experiences and perspectives in staff meetings and brainstorming sessions is a crucial first step toward an open and innovative culture. Prior research indicated that promoting minority trainees’ participation requires supportive supervision, encouraging them to share transformative ideas [ 28 ].

Strengths and limitations

Our participatory approach fostered broad support across all organizational levels. PLA-based stakeholder discussions facilitated open dialogue, refined ideas, and sparked valuable insights. Co-reader feedback prompted stakeholder group participants to reevaluate their interpretation of specific experiences. This approach allowed diverse perspectives and theoretical idea saturation, aiding participants in identifying seven actionable strategies with high potential for effective implementation. In turn, these results allowed the management group to leverage their organizational expertise and prioritize three strategies they considered feasible and compatible with the organization’s requirements.

While most post-graduate medical education settings share similarities, contextual variations, such as educational emphasis and cultural factors, may exist, leading to potential limitations in the transferability of our findings. Nonetheless, the dynamics between informal and formal in-classroom learning remain pertinent across various postgraduate medical contexts, where in-clinic learning, shaped by day-to-day experiences and supervisor-trainee dynamics, inevitably influences formal learning objectives and settings. Also, our study’s confinement to two Dutch GP-specialty training institutes and its relatively modest participant count may require caution in the transferability of our findings to other similar settings. In light of this, it is noteworthy that statistics from a previous quantitative study suggest that by 2023, our pilot institutes closely mirrored Dutch GP-specialty training in terms of minority trainee [ 7 ]. Moreover, we provided meticulous descriptions of our setting to enhance contextual understanding, aiding in assessing transferability to similar settings. Additionally, the explicit commitment to inclusiveness by the participating GP-specialty training institutions, which could be instrumental in promoting successful implementation, could pose challenges when transferring the results to less DEI-focused settings.

Still, employing multiple sources by connecting stakeholder perspectives to relevant literature and two frameworks enabled participants to structure their thoughts and opinions on the organization’s DEI strengths and limitations, along with the opportunities and challenges for implementation. For future researchers, this approach may prove valuable in identifying overarching concepts and theories that transcend specific individuals or contexts and facilitate the assessment of the transferability of our findings to similar educational settings [ 52 , 53 , 54 , 55 ].

Implications for further research and practice

Fostering a DEI-minded culture in post-graduate medical training calls for a multifaceted strategy. As training institutes diversify and curricula address nuanced topics, skills for adeptly navigating complex conversations become increasingly critical for educational staff. The ongoing process of promoting inclusive teaching, assessment, and curriculum design abilities will necessitate the inclusion of a wide range of perspectives. Consequently, we recommend involving stakeholders from the most diverse backgrounds possible. Also, the explicit commitment to inclusiveness by the participating GP-specialty training institutions may pose challenges when transferring the results to less DEI-focused settings. Therefore, we suggest further investigation in such contexts to better understand the transferability of our results.

Ensuring high-quality, inclusive learning environments in postgraduate medical education is crucial for educational opportunities and the overall quality of healthcare [ 56 ]. However, this inclusiveness is not solely shaped by the beliefs and values of teachers; it is also intricately influenced by the complex social and cultural dynamics within educational institutions [ 29 ]. Inclusiveness strategies are catalysts for enduring cultural transformation, demanding the consistent integration of multiple strategies through incremental steps over an extended period [ 43 ]. The three strategies identified in our study, which were prioritized for implementation, represent initial strides toward instigating this cultural transformation. Subsequent phases involving evaluation, adaptation, and implementation of additional strategies are imperative for sustaining engagement in a culture of inclusive postgraduate medical education. All Dutch GP-specialty training institutes closely monitor our findings and have committed to implementing mandatory DEI-relevant training programs for their staff and trainees.

Additional research on the impact of the implemented strategies and the level of stakeholder engagement throughout the implementation phase is needed. This follow-up research should encompass inclusive teaching methods, assessment strategies, curriculum design, attitudes, and the ethnic minority trainees’ experienced inclusion aligned with the BET framework.

Engaging stakeholders in PLA-based sessions at two Dutch GP-specialty training institutes proved instrumental in identifying recommendations for an inclusive learning climate. Stakeholders identified seven tangible DEI-strategies, addressing all five BET aspects:

Provide a clear message of inclusiveness in all internal and external communications: enhances inclusive accessibility and a diverse learning community;

Appoint DEI ambassadors in all layers of the organization: promotes knowledge exchange, reflection on potential biases, and active engagement in DEI networks;

Facilitate secure DEI-incident reporting procedures;

Give a significant voice to minority trainees in ongoing program development: empowers them and creates reciprocal learning;

Assign more than one teacher per group / in-clinic training: creates multiple role models and perspectives;

Offer ‘just-in-time’ learning: fosters social and educational engagement;

Provide mandatory DEI-relevant training programs for professional development: promotes DEI-expertise and awareness among all involved.

Based on anticipated feasibility and effectiveness, the management group prioritized strategy numbers 2, 4, and 7 for implementation.

Our integrative approach supported collaborative, context-specific strategy development and prioritization, effectively balancing anticipated effectiveness and compatibility. As such, this approach will prove valuable in identifying widely supported DEI strategies within varying and complex post-graduate medical educational contexts.

Data availability

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

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We affirm that no individuals other than the listed authors provided professional writing or analysis services. Still, we thank all anonymous participants whose contributions enriched this study.

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All authors have made substantial contributions to the conception OR design of the work; OR the acquisition, analysis, OR interpretation of data; OR have drafted the work or substantively revised it. All authors have approved the submitted version (and any substantially modified version that involves the author’s contribution to the study); and have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Contributions per author: N.M. van Moppes: Conception, Design of the work, Acquisition, Analysis and interpretation of data, Drafted the work and integrated all revisions; M. Nasori: Conception, Design of the work, Acquisition, Analysis and interpretation of data, Substantively revised the work; J. Bont: Substantively revised the work; J.M. van Es: Substantively revised the work; M.R.M. Visser: Conception, Design of the work, Substantively revised the work; M.E.T.C. van den Muijsenbergh: Conception, Design of the work, Substantively revised the work.

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van Moppes, N., Nasori, M., Bont, J. et al. Towards inclusive learning environments in post-graduate medical education: stakeholder-driven strategies in Dutch GP-specialty training. BMC Med Educ 24 , 550 (2024). https://doi.org/10.1186/s12909-024-05521-z

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An investigation into the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companionship in Tehran: a qualitative inquiry on mitigating mistreatment of women during childbirth

• Marjan Mirzania 1 ,
• Elham Shakibazadeh 1 , 2 ,
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BMC Public Health volume  24 , Article number:  1292 ( 2024 ) Cite this article

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A birth companion is a powerful mechanism for preventing mistreatment during childbirth and is a key component of respectful maternity care (RMC). Despite a growing body of evidence supporting the benefits of birth companions in enhancing the quality of care and birth experience, the successful implementation of this practice continues to be a challenge, particularly in developing countries. Our aim was to investigate the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companions to mitigate the mistreatment of women during childbirth in Tehran.

This exploratory descriptive qualitative study was conducted between April and August 2023 at Valiasr Hospital in Tehran, Iran. Fifty-two face-to-face in-depth interviews were conducted with a purposive sample of women, birth companions, and maternity healthcare providers. Interviews were audio-recorded, transcribed verbatim, and analyzed using content analysis, with a deductive approach based on the Implementation Outcomes Framework in the MAXQDA 18.

Participants found the implemented program to be acceptable and beneficial, however the implementation team noticed that some healthcare providers were initially reluctant to support it and perceived it as an additional burden. However, its adoption has increased over time. Healthcare providers felt that the program was appropriate and feasible, and it improved satisfaction with care and the birth experience. Participants, however, highlighted several issues that need to be addressed. These include the need for training birth companions prior to entering the maternity hospital, informing women about the role of birth companions, assigning a dedicated midwife to provide training, and addressing any physical infrastructure concerns.

Despite some issues raised by the participants, the acceptability, adoption, appropriateness, feasibility, and fidelity of the implementation strategies for birth companions to mitigate the mistreatment of women during childbirth were well received. Future research should explore the sustainability of this program. The findings of this study can be used to support the implementation of birth companions in countries with comparable circumstances.

Peer Review reports

Despite every woman’s right to have a positive birth experience, the mistreatment during childbirth has been documented worldwide in health facilities [ 1 , 2 , 3 , 4 ]. Recent studies from Iran have reported a high rate of mistreatment, including verbal abuse, frequent and painful vaginal examinations, neglect and abandonment, lack of supportive care, physical abuse [ 5 ], denial of mobility [ 5 , 6 , 7 ], and pain relief [ 5 , 8 ]. Additionally, women are typically not allowed to choose their labour positions [ 6 ] or have a birth companion [ 7 ].

A powerful mechanism to prevent mistreatment during childbirth, as demonstrated in previous research, is the presence of a birth companion [ 6 , 9 , 10 ]. The World Health Organization (WHO) recommends ensuring the presence of a chosen companion during labour and childbirth, as outlined in three guidelines [ 11 , 12 , 13 ]. This practice is recognized as a significant strategy for enhancing the quality of care and the birthing experience [ 12 ], and is considered a crucial element of respectful maternity care (RMC) [ 14 ]. Evidence shows that having birth companions is associated with reduced pain intensity and duration of labour, increased likelihood of spontaneous vaginal birth, decreased need for analgesia, episiotomy, and cesarean section, improved birth experience, early initiation of breastfeeding, and reduced postpartum depression [ 15 , 16 , 17 ]. Despite recognizing these benefits, the successful implementation of birth companions remains a challenge. Many women in health facilities across the world, particularly in developing countries, are denied this right [ 18 , 19 , 20 , 21 , 22 , 23 ].

Addressing the research-to-practice gap and scaling up evidence-based interventions (EBIs) are key goals of implementation science (IS). IS is a multidisciplinary field defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence, to improve the quality and effectiveness of health services” [ 24 ]. A wide range of implementation frameworks has been published. The implementation outcomes framework, introduced by Proctor et al. (2011), is one of these frameworks. This evaluation framework includes eight outcomes that serve as indicators of successful implementation: acceptability, adoption, appropriateness, feasibility, fidelity, implementation costs, penetration, and sustainability [ 25 ].

In Iran, the Ministry of Health and Medical Education (MOHME) implemented a policy in 2014 to promote maternal and newborn health by encouraging vaginal childbirth in public hospitals. One strategy of this policy to enhance the childbirth experience is the redesign of maternity wards to allow for the presence of birth companions [ 26 ]. However, public hospitals do not always support the implementation of birth companionship. As part of a large implementation research project, we have identified the challenges of implementing a birth companion as a formative research. The results showed that the major challenges include the lack of knowledge of companions, interference of companions in the clinical duties of staff, cultural issues, staff unwillingness, lack of supervision, and structural characteristics such as lack of physical space [ 27 ]. To address these issues, we developed and implemented strategies for birth companions. To the best of our knowledge, no comprehensive study has examined the implementation outcomes of birth companions in Iran. Therefore, this study aimed to investigate the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companions to mitigate the mistreatment of women during childbirth in Tehran.

Study design and setting

This study was part of a larger implementation research project examining the development and implementation of a context-specific intervention to reduce disrespectful maternity care and evaluation of strategies to improve implementation. This project, initiated in October 2021, consists of five phases: (1) needs assessment, (2) identifying the interventions to reduce mistreatment of women during childbirth, (3) identifying the implementation challenges of interventions, (4) designing implementation strategies for the intervention, and (5) testing implementation strategies in a real-life setting. The results of phases 1 and 3 of the project are presented in detail elsewhere [ 5 , 27 , 28 ]. This study used an exploratory descriptive qualitative design. It employed face-to-face in-depth interviews as data collection methods. Data was analyzed according to content analysis with a deductive approach.

Study context

This study was conducted between April and August 2023 at Valiasr Hospital in Tehran, Iran. We selected this hospital because it is a major, tertiary referral hospital in Tehran that offers a wide range of obstetric services to diverse groups of women. The maternity ward, which supports approximately 200 women giving birth per month, consists of a 12-bed hall for the first stage of labour and a separate room with one bed for the active stage of labour.

Designing implementation strategies of birth companions

In response to the challenges identified for the presence of birth companions in phase 3 of the project, we designed implementation strategies. These strategies include: (1) determining the implementation team, (2) training midwives, (3) conducting orientation sessions for obstetricians and residents, (4) training birth companions, (5) allowing birth companions to accompany women during labour and childbirth, and (6) continuously monitoring the implementation process. The implementation of these strategies spanned an 8-week period from April to June 2023. Our study focused on the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companions during the early implementation phase. These indicators are crucial for the initial stages of implementing health interventions [ 25 ]. According to the implementation outcomes framework of Proctor et al. (2011), acceptability is defined as “the perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory”; adoption as “the intention, initial decision, or action to employ an innovation”; appropriateness as “the degree of compatibility or perceived fit of the innovation”; feasibility as “the degree of successful implementation of the innovation in a setting”; and fidelity as “the degree of implementation of the innovation as intended” [ 25 ]. The details of implementation strategies of birth companions are provided below.

Determining the implementation team

The team consisted of members of the study team, the head of obstetrics, and maternity healthcare providers (MHCPs). The members of the study team (first and second authors) held a meeting with the head of obstetrics and the matron-in-charge to explain the purpose of the study.

Training midwives

All midwives received training from the matron-in-charge ( n  = 30, five midwives in each session). The training focused on the purpose of the study, the benefits of having birth companions during labour and childbirth, and specifically on providing training to birth companions. A member of the study team (the lead researcher) participated in the sessions.

Conducting orientation sessions for obstetricians and residents

The head of obstetrics held a meeting with obstetricians and residents to explain the purpose of the study and the benefits of having birth companions during labour and childbirth.

Training birth companions

Each birth companion received a 10-minute training session from midwives on supportive labour techniques, their roles and responsibilities during labour and childbirth, and the maternity regulations upon arrival at the maternity hospital for birth.

Allowing birth companions to accompany women during labour and childbirth

Any female birth companion that labouring women wanted was allowed to stay with her during labour and childbirth.

Continuously monitoring the implementation process

Supervisory visits to the maternity hospital were conducted by the study team, the matron-in-charge, and a team from the MOHME to oversee the implementation. The first author was present at the maternity hospital every day during both morning and evening shifts. The matron-in-charge visited the maternity hospital daily, and the third author visited the maternity hospital on a weekly basis, specifically on Fridays.

Recruitment and participants

Three groups of participants were identified for this study: (a) women, (b) birth companions, and (c) MHCPs (midwives, residents, and head of obstetrics). The eligibility criteria were as follows: women who had a vaginal birth, regardless of the outcome; female birth companions stayed with women during labour and childbirth; residents who had completed at least one semester (six months) in the maternity hospital; and midwives and head of obstetrics with at least one year of work experience in their role and involvement in the birth companion study. Women who had a labour progress disorder and cesarean section were excluded from this study. A purposive sampling technique with maximum variation was used to recruit participants. This technique aimed to include individuals with diverse characteristics, such as age, education, socioeconomic status for women and birth companions, and age, work experience, and shift for MHCPs.

Following prior coordination and permission from the hospital authorities, the first author (M.M.) invited participants to contribute in person. The purpose and reasons for conducting the study were explained to participants. All participants provided written consent to participate in the study and audio recordings p the interviews. They were also aware that their participation was voluntary, and that they could decline or stop the interviews at any time without facing any consequences.

Data collection

A semi-structured interview guide and face-to-face in-depth interviews were used to collect data. The interview guides were developed based on the framework of Proctor et al. [ 25 ] and then pilot-tested by conducting three initial interviews with participants, but were not analyze (Additional file 1 : Interview guides). For women and birth companions, the study examined the acceptability and adoption of having a birth companion. Meanwhile the MHCPS were asked about the acceptability, adoption, appropriateness, feasibility, and fidelity of having a birth companion. Each interview started with an overarching question such as “Please describe your overall experience with the implementation of the birth companion program at this hospital”. The interview process continued with questions such as “Are you satisfied or dissatisfied with the current implementation of the program or intervention?”, “How appropriate is the implementation of this program or intervention in the hospital?”, “What are your thoughts on integrating this program or intervention into your hospital?”. Probing questions, such as ‘“Can you explain more?”, “Why do you think that is?” and ‘What would need to change?, were used. All interviews were conducted in Persian by the first author (M.M.), a PhD candidate in Health Education and Promotion with experience in conducting qualitative research. No prior relationships existed between her and any of the other participants. Interviews with the women and birth companions were conducted before discharge in a quiet and private place in the postpartum ward. Interviews with MHCPs were conducted in a private room with no one else present at the maternity hospital. The interviews lasted approximately 30–40 minutes, and field notes were taken. Each participant was contacted once during the study. At the end of each interview, demographic information of the participants was collected. Data saturation was achieved through interviews with 22 women, 14 birth companions, and 16 MHCPs, after which, no new major themes emerged.

Data analysis

Data analysis was conducted simultaneously with data collection, using content analysis with a deductive approach [ 29 ]. First, M.M. listened to the recorded interviews repeatedly and transcribed them verbatim in Persian. Anonymity was ensured using numerical labels for each transcript file. The transcripts were checked for accuracy by the second author (E.Sh., a female professor in health education and promotion with experience in qualitative research). They were then independently coded by M.M. and E.Sh. We marked the segments of interest in the text and color-coded them. We then put these color-coded text segments together and assigned codes to them. We grouped the various codes according to their similarities and differences and linked them to pre-determined categorizations in different themes and sub-themes. The differences among coders regarding coding were discussed until a consensus was reached. Data management and analysis were performed using MAXQDA 18 software [ 30 ]. The selected quotations were translated into English to complement the findings of the study.

The trustworthiness of the study was assessed using Lincoln and Guba’s criteria [ 31 ]. Credibility was ensured through the triangulation of participants, including women, birth companions, and MHCPs. Additionally, the initially extracted codes were provided to three participants for approval, further enhancing credibility. Confirmability ensured by utilizing multiple data sources such as field notes, observations, audio recordings, and transcripts. Additionally, the data analysis process was reviewed and confirmed by an expert qualitative researcher who was not involved in the study. To enhance dependability, two authors independently analyzed the interviews. Furthermore, a detailed description of the research process was provided to ensure the transferability of the results. This allows for the evaluation and application of the study in different contexts. The study was reported according to the consolidated criteria for reporting qualitative research (COREQ) checklist [ 32 ] (Additional file 2 : COREQ Checklist).

Review author reflexivity

The authors maintained a reflexive stance throughout the study from study selection to data synthesis. The author team represents diverse international academic and professional backgrounds (health education and promotion, reproductive health, obstetrics and gynecology, and health services management) with a range of research focus areas and expertise. We are mindful that the authors’ perspectives might have affected the manner in which the data were collected, analyzed, and interpreted. The different perspectives of the authors could be related to their subject expertise, professional backgrounds, and knowledge of birth companionship and respectful care. As a multidisciplinary team, the authors challenged and critiqued their preconceived assumptions through reflective dialogue and supported each other to understand how these assumptions affected the analysis or interpretation of the findings. We believe that the diversity in our team helped us to critique and challenge our biases and develop the findings of the study.

Socio-demographic characteristics of participants

A total of 52 interviews were conducted, including 22 with women, 14 with birth companions and 16 with MHCPs. The socio-demographic characteristics of the participants are summarized in Tables  1 and 2 . None potential participants declined to participate in this study. Most of the women in this study were Iranians housewives with secondary education. More than one-third of the birth companions were mothers of women and most of the support was provided only during labour. We reported on the acceptability, adoption, appropriateness, feasibility, and fidelity of birth companions’ implementation strategies, using direct quotations from the participants (Table  3 ).

Acceptability

Participants shared opinions on the acceptability of implementing birth companion strategies in three sub-themes: perceived value of birth companions, relative advantage, and credibility.

Perceived value of birth companions

Women and birth companions had overall positive experiences with the implementation of birth companions. They believed that the implementation of the program was a good idea, which resulted in continuous support from companions, satisfaction with care, and an improved birth experience. As one woman explained:

“It was my first delivery, and I was feeling very stressed. The healthcare providers were busy and unable to give me the attention I needed, but having my sister there made a significant difference. She massaged my back, used a hot water bag, assisted me with walking and exercising, and contacted healthcare providers when I required assistance. If my companion was not there, I would have had a difficult birth.” (Woman 2, 25 years old).

Another person noted that: “It was a positive experience for me, and I am content with how everything went, particularly because my mother was present in the delivery room. For example, when I was in pain, she would hold my hand and say, ‘send blessings’ or during childbirth, she would say, ‘well done, push, it’s great, I can see the baby’s head’, and it was encouraging … Thank you for making it possible for companions to be with us even during childbirth.” (Woman 19, 16 years old)

“The presence of birth companions at this hospital was a good idea; we were satisfied with this program. In the public hospitals of our city, the companions are not allowed to enter the maternity hospital. However, here I had no barrier to my presence …” (Birth companion 7, 26 years old).

Relative advantage

Women were asked if they would be more inclined to choose a hospital for giving birth if it offered birth companions as a standard practice in the maternity ward, and all of them responded affirmatively. One woman stated:

“When I gave birth a few years ago, they did not allow me to have a companion. This hospital was recommended to me by a friend. She said that last week, my sister gave birth there, and she had a companion… I came here only because I could have a companion, and I was satisfied with having a companion by my side.” (Woman 14, 21 years old).

Credibility

Both women and their companions described the quality of program implementation and training provided by midwives as beneficial:

“I think this program is being implemented well… The midwife taught me support techniques. I did them for my daughter and tried not to interfere with the clinical work of the providers… They were effective in relieving her pain.” (Birth companion 14, 50 years old).

“When I was in pain, my companion used a hot water bag, asked me to take deep breaths, or used Entonox gas… They were very helpful.” (Woman 12, 24 years old).

While providers also acknowledged the usefulness of implementing birth companions, the implementation team felt that some were initially reluctant to support the program and perceived it as an added burden. However, this reluctance changed over time due to positive outcomes, such as increasing women’s satisfaction, greater participation of companions, and reducing the workload of providers. Several providers also mentioned concerns about limited physical space, violation of women’s privacy, overcrowding, and the transmission of infection:

“Some of us initially did not support the implementation of this program, because it was perceived as an additional burden. However, after some time of implementation of the program, we observed positive outcomes, such as increased satisfaction among women during childbirth, participation of companions, and a reduction in workload… Now I can confidently say that all the providers have accepted it.” (Midwife 1, 40 years old).

In this study, adoption of implementation of birth companion strategies was discussed in two sub-themes: uptake and actual use.

The providers’ responses to the program were positive. They stated that they allow companions to accompany women during labour and childbirth. Upon entering, they provided explanations about the regulations of the maternity hospital, the role and responsibilities of the companion during labour and childbirth. They also taught emotional support techniques such as praying, using calming verbal expressions, encouraging, and comforting. Additionally, they taught physical support techniques including helping with walking, feeding, massaging, and breathing exercises.

“Upon entering, we ask women if they would like to have a companion. If they wish, we allow their companion to enter the maternity hospital. We teach her (companion)… Finally, we ask her to sign the form to receive training from the midwife.” (Midwife 14, 29 years old).

“We allow the companion to be present. We offer training to birth companions led by midwives. The midwife teaches… Most companions also perform well, according to the training they receive.” (Resident 10, 31 years old).

Providers’ adoption of the program increased over time as they gained a clearer understanding of how the program was intended to work. However, a few providers also raised concerns that the program may not be sustainable after its initial phase ends. These concerns have contributed to doubts about the program’s full adoption.

“This program cannot be expected to be sustainable within a few months of implementation… I believe it requires additional time and ongoing monitoring to be effectively integrated into the work tasks of our providers.” (Head of obstetrics, 49 years old).

Appropriateness

Participants reported three sub-themes related to the appropriateness of implementation of birth companion strategies, including perceived usefulness, integration into existing workflows, and informing women about the possibility of having a birth companion.

Perceived usefulness

Most of the participants agreed that implementation of the program in this maternity hospital was appropriate. One birth companion stated:

“I believe it is necessary to have a companion in this maternity hospital due to the overcrowding and insufficient staff. The healthcare providers do not have enough time to provide back massages of comfort a woman in labour. As companions, we can fulfil this role for them.” (Birth companion 4, 46 years old).

Integration into existing workflows

Some providers agreed that birth companions could be integrated into the existing workflows:

“I think that these implementation strategies for birth companions can be very helpful… they are simple and low cost. If we use these strategies correctly, there will be no problems in our workflow.” (Midwife 3, 41 years old).

Informing women about the possibility of having a birth companion

Some women mentioned that if they had been informed in advance (e.g., in childbirth preparation classes) about the possibility of having a birth companion, they could have chosen a more suitable person to accompany them.

“… If I had known that I could have a companion, I would have brought someone with me who would be more comfortable, trained, or at least had experience with vaginal delivery.” (Woman 1, 43 years old).

Feasibility

The providers felt that the routine use of birth companions was feasible in this maternity hospital and described three sub-themes that would contribute to improving feasibility: training birth companions in prenatal care, recruiting a fixed midwife, and improving the physical infrastructure.

Training birth companions in prenatal care

The providers commented on the importance of training birth companions and preparing them to play a role in prenatal care. Most providers stated that in order for the few minutes of training upon entering the maternity hospital to be more effective, it is important to give attention to the training of birth companions in childbirth preparation classes.

“I think the important thing is to train… It is necessary to provide training for labouring women and their companions before they enter maternity hospitals.” (Midwife 8, 40 years old).

“… Unfortunately, most of the companions were not trained here. Well, how much time do I have to explain to her during labour?” (Midwife 13, 37 years old).

“I believe that training at the maternity hospital can be more effective if the companion is already trained, and our training includes a review component.” (Resident 11, 30 years old).

Recruiting a fixed midwife

Similarly, providers discussed the importance of recruiting a fixed midwife to improve the feasibility of birth companions in maternity hospitals. The majority of providers stated that, in light of the overcrowding and understaffing, successful implementation of the program relied on recruit a fixed midwife who could provide training to labouring women and their companions.

“… I believe it is necessary to have a permanent midwife for training in order to consistently implement this program.” (Head of obstetrics, 49 years old).

Improving the physical infrastructure

Improving the physical infrastructure of maternity hospitals was also suggested by some providers as a factor related to feasibility:

“… Yes, routine use of this program is possible, but it is also important to ensure that the physical environment is suitable. We have limited physical space here. The burden of visiting is also high, and we are concerned about overcrowding and the transmission of infection.” (Resident 2, 30 years old).

Two sub-themes related to the fidelity of implementation of birth companion strategies were identified: adherence and participant responsiveness.

Almost all providers agreed that they had implemented the program as intended by the project developers. However, several of them stated that as the implementation progressed, other women (those who were scheduled for a caesarean section or had an abortion) also requested the presence of their companions, which posed a challenge at times. This is because providers had to spend time explaining and justifying their decisions.

“I believe the providers implemented the program according to the original protocol. I noticed a significant improvement in the conditions at the maternity hospital after the implementation of this program.” (Midwife 15, 34 years old).

“… The women who were scheduled for a caesarean section or had an abortion also requested the presence of their companions. If there are also companions, the maternity hospital will become very crowded, which will hinder the provision of proper care.” (Resident 16, 28 years old).

“Anyway, when a program starts to reach the ideal, it faces challenges. However, I believe that the providers who were directly involved in the implementation process adhered to the plan…” (Head of obstetrics, 49 years old).

Participant responsiveness

The level of participant engagement in the program was reported to be high, as one provider remarked:

“I think almost all providers were involved in this program. We may not have had a good participation at the beginning of the program, but it increased over time …” (Midwife 8, 40 years old).

Furthermore, providers’ statements showed that the reception of women and their companions in the presence of a birth companion was positive:

“Both women and their companions were receptive to this program. When we informed women that they could have a companion, even during their childbirth, they would be happy…” (Midwife 4, 41 years old).

This was the first qualitative study in Iran to examine the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies of birth companions based on the experience of women, birth companions, and MHCPs. In summary, the findings of this study indicated strategies for effectively implementing birth companions in public hospitals in Tehran.

In our study, the sub-themes associated with the acceptability of implementing birth companion strategies from the participants’ perspectives included perceived value, relative advantage, and credibility. We found that the implementation strategies used by the birth companion were acceptable to most participants. Our findings are consistent with those of previous studies [ 33 , 34 ]. Overall, women and their companions greatly appreciated the provision of a birth companion in the hospital, as it improved satisfaction with care and the birth experience [ 22 , 33 , 35 , 36 ]. Similarly, providers have described the benefits of implementing birth companions, such as continuous support and a reduced workload [ 16 , 20 , 34 , 37 ]. Furthermore, in our study, women and their companions mentioned the benefits of the quality of the program implementation and training provided by midwives. Similar findings have been reported by Kabakian-Khasholian et al. [ 34 ].

Our findings showed that although the presence of birth companions was not initially supported by some providers, its acceptance grew over time with an increased understanding of the program as well as the positive outcomes that followed for both women and providers. Another study on birth companions in the labour ward of a center in India showed that providers were initially hesitant to allow birth companions due to overcrowding and the potential disruption of their duties and decision-making [ 20 ]. The experience reported by our providers is not surprising. This is an important finding for implementation, and demonstrates that immediate acceptance of new programs after introduction cannot be expected, as research has shown that the acceptability of any program increases with knowledge of that program [ 25 ]. A possible explanation for the higher acceptability of birth companions in our study could be attributed to the continuous monitoring of the implementation team and the provision of feedback throughout the implementation process.

The uptake and actual use were perceived as important aspects of adoption of implementing birth companion strategies. Despite the fact that providers adopted the program and responded positively to its use, a few expressed doubts about the program’s sustainability beyond the initial phase. Our findings are consistent with those of a previous study conducted in Arab countries, which reported that obstetric residents expressed uncertainty regarding about the long-term viability of the labour companionship model [ 34 ]. Although examining the sustainability of the program was not the goal of our study, it is important to note this issue, which should be explored in the future.

Our study findings showed that the appropriateness of implementation of birth companion strategies refers to the perceived usefulness, integration into existing workflows, and informing women about the possibility of having a birth companion. Providers found that birth companions could be integrated into workflows. Though studies in LIMCs show that providers were reluctant to incorporate birth companions into routine maternity services for reasons such as women’s disobedience to provider instructions, companion interference in care, and the transmission of infections [ 36 , 38 , 39 ]. Some women in our study expressed the desire to be informed about the option of having a birth companion during antenatal care. This finding aligns with a study on birth companionship in Tanzania [ 33 ].

This study suggests that the implementation of birth companion strategies in this maternity hospital is feasible, but several potential factors should be considered. Some of our providers pointed out the importance of training birth companions through childbirth preparation classes for the effectiveness of their support upon entering maternity hospitals, as highlighted by Kabakian-Khasholian et al. [ 34 ]. Providers also emphasized that recruiting fixed midwives to provide training to women and their birth companions in the maternity hospital was important to support the feasibility of the program. Women and companions have also criticized the infrastructure of the maternity hospital. It is important to note that in this study, any strategy for the reconstruction of physical space (such as the lack of suitable space for the accommodation of companions) was considered but opposed by the management of the maternity hospital, despite it being an important component in the implementation of birth companions.

Our study has several practical implications. Despite the recommendations of the WHO regarding the choice of a companion during labour and childbirth, as well as existing policies, there is a need for the presence of a birth companion in Iran. Increased efforts by policy-makers and managers of maternal health programs are necessary to ensure women’s access to this right and to effectively and sustainably implement it in maternity hospitals. This will help to improve the quality of maternity care and enhance positive childbirth experiences. Furthermore, the collaboration of MHCPs in the implementation of birth companions and the establishment of continuous monitoring systems in maternity hospitals is important. It is also necessary to include training for birth companions in childbirth preparation classes, educating them about their expected role in supporting women.

Strengths and limitations

To our knowledge, this is the first study to examine the implementation outcomes of birth companions in Iran. This study encompasses a wide range of perspectives and experiences from women, birth companions, and MHCPs. This study has several limitations. First, due to the sensitive nature of the mistreatment issue, participants may have underreported some of their experiences with the companionship program possibly influenced by social desirability bias. We attempted to reduce this bias by conducting interviews in a private room and ensuring the anonymity of the participants’ identities. Second, this study was conducted solely at a public teaching hospital in Tehran, which restricts the generalizability of the findings to private hospitals in Iran. Nonetheless, this study adds to the literature on implementation strategies for birth companion’s support by incorporating implementation research (IR). The findings of this study will be useful for health policymakers in supporting the implementation of birth companions to reduce mistreatment of women during labour and childbirth. However, we recommend continuous monitoring of the actual collaboration among MHCPs during the program implementation process.

Our study found that the implementation strategies for birth companions in Tehran public hospitals are acceptable, appropriate, and feasible. These strategies improve satisfaction with care and the birth experience, seek continuous support from companions, and reduce provider workloads. However, there are several issues that need to be addressed regarding birth companions in maternity hospitals. These include training birth companions prior to the arrival, informing women about the presence of birth companions, assigning a dedicated midwife to provide training, and improving the physical infrastructure. The findings of this study can be utilized to support the implementation of birth companions in countries with comparable circumstances.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to privacy restrictions of the participants but are available from the corresponding author on reasonable request.

Abbreviations

World Health Organizaion

Respectful Maternity Care

Evidence-Based Interventions

Implementation Science

Ministry of Health and Medical Education

Maternity Healthcare Providers

Consolidated Criteria for Reporting Qualitative Research

Implementation Research

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Acknowledgements

This study was part of a PhD dissertation. The authors would like to thank the officials and maternity healthcare providers of Valiasr Hospital in Tehran as well as all the women and birth companions for their valuable contribution to this study.

This study was funded by the Health Information Management Research Center, Tehran University of Medical Sciences, Iran (grant number 1401-3-208-62407). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Marjan Mirzania & Elham Shakibazadeh

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Elham Shakibazadeh

Department of Obstetrics and Gynecology, School of Medicine, Vali-E-Asr Reproductive Health research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran

Sedigheh Hantoushzadeh

Department of Obstetrics and Gynecology, Maternal-Fetal Neonatal Research Center, Tehran University of Medical Sciences, Valiasr Hospital, Tehran, Iran

Zahra Panahi

Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, VIC, Australia

Meghan A. Bohren

Department of Social Medicine, School of Medicine, Gonabad University of Medical Sciences, Gonabad, Iran

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E.Sh., M.M., S.H., M.B., A.Kh., and Z.P. designed the study. M.M. and E.Sh. developed the interview guide. M.M. conducted the interviews. M.M. and E.Sh. analyzed the data. M.M. drafted the manuscript, and E.Sh. reviewed and edited it. All authors have read and approved the final manuscript. All authors have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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Correspondence to Elham Shakibazadeh .

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This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval for this study was obtained from the Tehran University of Medical Sciences Ethics Committee (code number: IR.TUMS.SPH.REC.1400.169). Participation was voluntary, and all participants provided written informed consent. For any participant under 16 years of age, we obtained informed consent to participate in the study from parents or legal guardians.

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Mirzania, M., Shakibazadeh, E., Hantoushzadeh, S. et al. An investigation into the acceptability, adoption, appropriateness, feasibility, and fidelity of implementation strategies for birth companionship in Tehran: a qualitative inquiry on mitigating mistreatment of women during childbirth. BMC Public Health 24 , 1292 (2024). https://doi.org/10.1186/s12889-024-18751-z

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Not all data are created equal; some are structured, but most of them are unstructured. Structured and unstructured data are sourced, collected and scaled in different ways and each one resides in a different type of database.

In this article, we will take a deep dive into both types so that you can get the most out of your data.

Structured data—typically categorized as quantitative data—is highly organized and easily decipherable by  machine learning algorithms .  Developed by IBM® in 1974 , structured query language (SQL) is the programming language used to manage structured data. By using a  relational (SQL) database , business users can quickly input, search and manipulate structured data.

Examples of structured data include dates, names, addresses, credit card numbers, among others. Their benefits are tied to ease of use and access, while liabilities revolve around data inflexibility:

• Easily used by machine learning (ML) algorithms:  The specific and organized architecture of structured data eases the manipulation and querying of ML data.
• Easily used by business users:  Structured data do not require an in-depth understanding of different types of data and how they function. With a basic understanding of the topic relative to the data, users can easily access and interpret the data.
• Accessible by more tools:  Since structured data predates unstructured data, there are more tools available for using and analyzing structured data.
• Limited usage:  Data with a predefined structure can only be used for its intended purpose, which limits its flexibility and usability.
• Limited storage options:  Structured data are usually stored in data storage systems with rigid schemas (for example, “ data warehouses ”). Therefore, changes in data requirements necessitate an update of all structured data, which leads to a massive expenditure of time and resources.
• OLAP :  Performs high-speed, multidimensional data analysis from unified, centralized data stores.
• SQLite : (link resides outside ibm.com)  Implements a self-contained,  serverless , zero-configuration, transactional relational database engine.
• MySQL :  Embeds data into mass-deployed software, particularly mission-critical, heavy-load production system.
• PostgreSQL :  Supports SQL and JSON querying as well as high-tier programming languages (C/C+, Java,  Python , among others.).
• Customer relationship management (CRM):  CRM software runs structured data through analytical tools to create datasets that reveal customer behavior patterns and trends.
• Online booking:  Hotel and ticket reservation data (for example, dates, prices, destinations, among others.) fits the “rows and columns” format indicative of the pre-defined data model.
• Accounting:  Accounting firms or departments use structured data to process and record financial transactions.

Unstructured data, typically categorized as qualitative data, cannot be processed and analyzed through conventional data tools and methods. Since unstructured data does not have a predefined data model, it is best managed in  non-relational (NoSQL) databases . Another way to manage unstructured data is to use  data lakes  to preserve it in raw form.

The importance of unstructured data is rapidly increasing.  Recent projections  (link resides outside ibm.com) indicate that unstructured data is over 80% of all enterprise data, while 95% of businesses prioritize unstructured data management.

Examples of unstructured data include text, mobile activity, social media posts, Internet of Things (IoT) sensor data, among others. Their benefits involve advantages in format, speed and storage, while liabilities revolve around expertise and available resources:

• Native format:  Unstructured data, stored in its native format, remains undefined until needed. Its adaptability increases file formats in the database, which widens the data pool and enables data scientists to prepare and analyze only the data they need.
• Fast accumulation rates:  Since there is no need to predefine the data, it can be collected quickly and easily.
• Data lake storage:  Allows for massive storage and pay-as-you-use pricing, which cuts costs and eases scalability.
• Requires expertise:  Due to its undefined or non-formatted nature, data science expertise is required to prepare and analyze unstructured data. This is beneficial to data analysts but alienates unspecialized business users who might not fully understand specialized data topics or how to utilize their data.
• Specialized tools:  Specialized tools are required to manipulate unstructured data, which limits product choices for data managers.
• MongoDB :  Uses flexible documents to process data for cross-platform applications and services.
• DynamoDB :  (link resides outside ibm.com) Delivers single-digit millisecond performance at any scale through built-in security, in-memory caching and backup and restore.
• Hadoop :  Provides distributed processing of large data sets using simple programming models and no formatting requirements.
• Azure :  Enables agile cloud computing for creating and managing apps through Microsoft’s data centers.
• Data mining :  Enables businesses to use unstructured data to identify consumer behavior, product sentiment and purchasing patterns to better accommodate their customer base.
• Predictive data analytics :  Alert businesses of important activity ahead of time so they can properly plan and accordingly adjust to significant market shifts.
• Chatbots :  Perform text analysis to route customer questions to the appropriate answer sources.

While structured (quantitative) data gives a “birds-eye view” of customers, unstructured (qualitative) data provides a deeper understanding of customer behavior and intent. Let’s explore some of the key areas of difference and their implications:

• Sources:  Structured data is sourced from GPS sensors, online forms, network logs, web server logs,  OLTP systems , among others; whereas unstructured data sources include email messages, word-processing documents, PDF files, and others.
• Forms:  Structured data consists of numbers and values, whereas unstructured data consists of sensors, text files, audio and video files, among others.
• Models:  Structured data has a predefined data model and is formatted to a set data structure before being placed in data storage (for example, schema-on-write), whereas unstructured data is stored in its native format and not processed until it is used (for example, schema-on-read).
• Storage:  Structured data is stored in tabular formats (for example, excel sheets or SQL databases) that require less storage space. It can be stored in data warehouses, which makes it highly scalable. Unstructured data, on the other hand, is stored as media files or NoSQL databases, which require more space. It can be stored in data lakes, which makes it difficult to scale.
• Uses:  Structured data is used in machine learning (ML) and drives its algorithms, whereas unstructured data is used in  natural language processing  (NLP) and text mining.

Semi-structured data (for example, JSON, CSV, XML) is the “bridge” between structured and unstructured data. It does not have a predefined data model and is more complex than structured data, yet easier to store than unstructured data.

Semi-structured data uses “metadata” (for example, tags and semantic markers) to identify specific data characteristics and scale data into records and preset fields. Metadata ultimately enables semi-structured data to be better cataloged, searched and analyzed than unstructured data.

• Example of metadata usage:  An online article displays a headline, a snippet, a featured image, image alt-text, slug, among others, which helps differentiate one piece of web content from similar pieces.
• Example of semi-structured data vs. structured data:  A tab-delimited file containing customer data versus a database containing CRM tables.
• Example of semi-structured data vs. unstructured data:  A tab-delimited file versus a list of comments from a customer’s Instagram.

Recent developments in  artificial intelligence  (AI) and machine learning (ML) are driving the future wave of data, which is enhancing business intelligence and advancing industrial innovation. In particular, the data formats and models that are covered in this article are helping business users to do the following:

• Analyze digital communications for compliance:  Pattern recognition and email threading analysis software that can search email and chat data for potential noncompliance.
• Track high-volume customer conversations in social media:  Text analytics and sentiment analysis that enables monitoring of marketing campaign results and identifying online threats.
• Gain new marketing intelligence:  ML analytics tools that can quickly cover massive amounts of data to help businesses analyze customer behavior.

Furthermore, smart and efficient usage of data formats and models can help you with the following:

• Understand customer needs at a deeper level to better serve them
• Create more focused and targeted marketing campaigns
• Track current metrics and create new ones
• Create better product opportunities and offerings
• Reduce operational costs

Whether you are a seasoned data expert or a novice business owner, being able to handle all forms of data is conducive to your success. By using structured, semi-structured and unstructured data options, you can perform optimal data management that will ultimately benefit your mission.

Get the latest tech insights and expert thought leadership in your inbox.

To better understand data storage options for whatever kind of data best serves you, check out IBM Cloud Databases

Get our newsletters and topic updates that deliver the latest thought leadership and insights on emerging trends.

• Open access
• Published: 14 May 2024

Health systems challenges, mitigation strategies and adaptations to maintain essential health services during the COVID-19 pandemic: learnings from the six geopolitical regions in Nigeria

• Segun Bello 1 ,
• Rachel Neill 2 ,
• Ayodele S Jegede 1 ,
• Eniola A. Bamgboye 1 ,
• Mobolaji M. Salawu 1 ,
• Rotimi Felix Afolabi 1 ,
• Charles Nzelu 3 ,
• Ngozi Azodo 3 ,
• Anthony Adoghe 3 ,
• Munirat Ogunlayi 2 ,
• Saudatu Umma Yaradua 2 ,
• William Wang 4 ,
• Anne Liu 4 &
• Olufunmilayo I. Fawole 1  

BMC Health Services Research volume  24 , Article number:  625 ( 2024 ) Cite this article

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The COVID-19 pandemic control strategies disrupted the smooth delivery of essential health services (EHS) globally. Limited evidence exists on the health systems lens approach to analyzing the challenges encountered in maintaining EHS during the COVID-19 pandemic. This study aimed to identify the health system challenges encountered and document the mitigation strategies and adaptations made across geopolitical zones (GPZs) in Nigeria.

The national qualitative survey of key actors across the six GPZs in Nigeria involved ten states and the Federal Capital Territory (FCT) which were selected based on resilience, COVID-19 burden and security considerations. A pre-tested key informant guide was used to collect data on service utilization, changes in service utilization, reasons for changes in primary health centres’ (PHCs) service volumes, challenges experienced by health facilities in maintaining EHS, mitigation strategies implemented and adaptations to service delivery. Emerging sub-themes were categorized under the appropriate pillars of the health system.

A total of 22 respondents were interviewed. The challenges experienced in maintaining EHS cut across the pillars of the health systems including: Human resources shortage, shortages in the supply of personal protective equipments, fear of contracting COVID-19 among health workers misconception, ignorance, socio-cultural issues, lockdown/transportation and lack of equipment/waiting area (. The mitigation strategies included improved political will to fund health service projects, leading to improved accessibility, affordability, and supply of consumables. The health workforce was motivated by employing, redeploying, training, and incentivizing. Service delivery was reorganized by rescheduling appointments and prioritizing some EHS such as maternal and childcare. Sustainable systems adaptations included IPC and telehealth infrastructure, training and capacity building, virtual meetings and community groups set up for sensitization and engagement.

The mitigation strategies and adaptations implemented were important contributors to EHS recovery especially in the high resilience LGAs and have implications for future epidemic preparedness plans.

Peer Review reports

The COVID-19 pandemic remains the biggest global health systems shock of the 21st century leading to about 6.8 million deaths as of 26th February, 2023 [ 1 ]. The interventions implemented to control the pandemic have had far-reaching consequences, ranging from disruptions to socio-economic activities, to decline in health services provision and utilization. According to the World Health Organization (WHO), countries henceforth need to make trade-offs between the scale of direct response to health threats and the actions geared towards maintaining essential health service delivery, to mitigate the risk of system collapse [ 2 ].

Disruptions are defined as “unforeseen events that interfere with the provision of healthcare goods and services” [ 3 ]. During the COVID-19 pandemic, disruptions in health service delivery and decline in essential health services utilization was documented across all health systems including high, medium and low-income countries [ 4 ]. These disruptions were attributed to aspects of the COVID-19 pandemic response including lockdowns and reorganization of health service delivery with a shift in focus to COVID-19 control [ 2 ]. For example, in Europe, screening for cancers decreased by as much as 65 − 95% during the early phase of the pandemic [ 5 ]. In Africa, several health programmes including the malaria elimination programme, HIV/tuberculosis control, diabetes, and hypertension services were deprioritized during the pandemic [ 6 , 7 ]. Heavy declines were also reported for maternal, child health and immunization programmes [ 8 , 9 ]. effectively threatening the gains achieved in health programme outcomes over decades of investment [ 10 ]. These health programmes reported decline in service output as well as set- backs in performance indicators as similarly demonstrated during the West Africa Ebola outbreak pandemic. Analysis of the 2014–2015 Ebola outbreak suggested that the number of deaths caused by measles, malaria, HIV/AIDS and tuberculosis attributable to health systems failure during the Ebola outbreak exceeded deaths from Ebola [ 11 , 12 , 13 , 14 ].

The WHO health systems framework describes the core building blocks or pillars of the health systems which contribute to the resilience of a health system [ 15 ]. The performance of the health system in handling health crisis depends on its baseline capacity predating the crisis, as well as the magnitude of the crisis [ 2 ]. Kruk et al. defined health systems resilience as ‘the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it.’ [ 16 ] Thus, apart from maintaining the core functions of a health system, resilience includes the health system’s ability to transform, evolve and enhance its performance in improving the health of the population [ 17 ].

A well-prepared health system should have the capacity to maintain essential health services delivery to reduce morbidity and mortality from sources other than the cause of the health systems shock, throughout the duration of an emergency. Both demand and supply factors have been documented as challenges mitigating against the maintenance and utilization of essential services across health systems during the COVID-19 pandemic. The pandemic increased the workload for health systems, resulting in pressure and inadequate health workforce all over the world [ 5 ]. However, LMICs have been particularly affected from operating more vulnerable health systems with challenges that predated the COVID-19 pandemic. To compound the challenges of human resource shortages, about 50% of health facilities across Africa reported COVID-19 infection among staff, shortages in personal protective equipment (PPE), underfunding, reduced supply of medications and poor information systems [ 6 , 18 ]. Most African countries are dependent on importation of essential medicines and products. These countries were affected by the disruptions in the global supply chain because drugs were not readily available or were expensive because of the high demand relative to supply [ 19 ]. Patients expressed difficulties in accessing medicines due to the high cost [ 20 ].

Geographic variability in the level of disruptions and restorations to EHS were reported within countries [ 21 ]. The COVID-19 high burden states/areas were likely to have experienced a higher level of restrictions and enforcements of protocols which could affect the levels of disruptions and the time taken for restorations. Furthermore, recovery may be slow, temporary, or partial depending on sub-national health systems resilience. Reported innovative adaptations to halt or reverse decline in EHS delivery included home delivery, use of phones, improved triaging, shift to remote consultations, and expansion of the scope of work of community health workers and task shifting [ 21 , 22 ]. Limited evidence exists on the health systems lens approach to analyzing the challenges encountered in maintaining EHS delivery during the COVID-19 pandemic, particularly at the sub-national levels. Therefore, this study aimed to identify the health system challenges encountered during the COVID-19 pandemic and document the mitigation strategies and adaptations made across the geopolitical zones (GPZs) in Nigeria. The learnings will guide policymakers, decision makers and health administrators on how to improve health systems in Nigeria to ensure that they are resilient and prepared to respond to public health emergencies. Learnings from Nigeria especially on the mitigation and adaptation strategies may be transferrable to similar decentralized health systems.

Study setting

The study was qualitative in design involving interviews of key persons at state ministries of health (SMoH) and State Primary Health Care Development Agencies (SPHCDA) across the six geopolitical zones of Nigeria. Following the Alma Ata declaration in 1978, the primary health care (PHC) system became the fulcrum of health systems development in Nigeria. Not much progress was made in PHC however, until 1985 when the then Minister of Health adopted 52 Local Government Areas (LGAs) to build models based on the Alma Ata declaration [ 23 ]. Thereafter, the model was expanded to include all LGAs and the responsibility for overseeing the working of the PHC including immunization, antenatal care services was devolved to the LGAs [ 23 ]. PHC in Nigeria focuses on preventive services including immunization, antenatal care services, as well as the provision of basic health care services at the grass root level [ 23 ].

The Primary Health Care Under One Roof policy was introduced in 2010 and approved in 2011 [ 24 ]. It aims to strengthen the national health system by integrating all PHC services under one authority. By implications, all resources for PHC implementation are to be repositioned from all agencies, departments and ministries to the new State PHC development agencies or boards [ 24 ]. This initiative produced some improvements in health outcomes [ 25 ].

Like many other African countries, Nigeria has consistently failed to implement the 2001 Abuja declaration at which African heads of state pledged to allocate 15% of the annual national budget to health [ 26 , 27 ]. Currently, the PHC system has deteriorated with most of the 30,000 PHC facilities across the country lacking the capacity to provide essential healthcare services thereby, transferring enormous pressure to the higher levels of healthcare [ 28 ]. The challenges PHC facilities experienced before COVID-19 included poor staffing, inadequate equipment, poor distribution of health workers, poor quality of healthcare services, poor condition of infrastructure, and lack of essential drug supply.

Study design and approach

The study was part of a large national qualitative survey on resilience of the health system which aimed at identifying the key challenges to maintaining essential health services during the pandemic, from the perspective of subnational actors. This current report focused on the regional level data, but the other aspect of the study focused on comparative LGA-level data on how some LGAs overcame challenges and sustained essential health services, while comparable, neighbouring LGAs experienced ongoing disruptions [ 29 ].

Study site and participants’ selection

The study enrolled subnational actors at the state level, across the six geopolitical zones of Nigeria. These participants were engaged in the COVID-19 response and were at decision-making levels such as directors, assistant directors and heads of programmes.

Selection of study sites was guided by multiple criteria namely High Resilience (HR) LGAs; COVID 19 disease burden and regional hotspots such as LGAs with the highest cumulative cases and those with international airport or land borders; security considerations, by avoiding LGAs with considerable security challenges such as LGAs with insurgents and banditry. The procedure for identifying high resilience LGAs has been described in detail elsewhere [ 29 ]. In brief, the general outpatient (GOPD) and Ante-natal care (ANC) health services data from the National Health Management Information System (NHMIS) (January 2019 – December 2021) was analyzed using the interrupted time series. The analysis identified HR LGAs. HR LGAs were defined as LGAs which experienced a recovery in service volumes within three months of decline precipitated by the COVID-19 pandemic. LGAs were then stratified and ranked within each geopolitical zones and, in combination with COVID-19 burden and security considerations, 12 h LGAs were finally selected from 10 states and the Federal Capital Territory (FCT) across the six geopolitical zones: South-West [ 3 ], South-South [ 2 ], South-East [ 2 ], North-West [ 1 ], North-Central [ 2 ], North-East [ 1 ].

Participants for the parent study were selected purposively across state, LGA, health facilities, and community levels. However, this report is limited to the analysis of response from state-level participants across the GPZs where two participants each were selected per state.

Data collection

A key informant guide was developed following extensive review of literature on health systems resilience and essential health service maintenance (see Supplementary File). The guide was pretested among similar personnel in Nasarawa state before data collection. The interview guide was sectioned according to: profile of the study participants; services used during COVID-19; data monitoring and use; self-regulation; adaptive-short term; integrated capacities or planning; relevance to maternal neonatal and child health (MNCH); and adaptive-long term. The data presented in this report focuses on the following sections of the tool: services used during the COVID-19 pandemic and self-regulation which contained information on participants’ assessment of changes in service utilization during the COVID-19 pandemic; reasons for the changes in Primary Health Centres (PHCs) attendance, challenges experienced by facilities to maintain routine services during the pandemic, specific countermeasures that the state governments took to overcome the challenges and activities done by the state governments to encourage clients to continue to utilize the PHCs.

The Federal Ministry of Health (FMoH) led the project and played an oversight role in data collection with supervisors leading research teams to the states. The interview teams paid advocacy visits to explain the purpose of the research and obtain the support of stakeholders in the ministries of health. The interview team comprised of a supervisor, a moderator and a note taker per state. All data collectors and supervisors were trained for the purpose of this research. All participants gave informed consent before they were interviewed face-to-face and audio-recorded in their offices. A data collection pause was implemented after the first few interviews during which the interviews conducted were transcribed, reviewed and feedback were communicated to the field teams. The interview took an average of 73 min. Data was collected between June through July, 2022.

Data management

The recorded interview audios were transcribed verbatim in the original language of the interview. Transcripts were complemented with notes taken during the interviews. The transcripts, audio files and notes were labelled with unique identifiers that enabled data linkage across files. A data security protocol was implemented to safeguard against data breach. A Dropbox folder, which was only accessible to designated research team members, was created for the safe storage of the audio files, transcripts and summary notes.

Coding was done using Atlas.ti. One coder was involved in the coding the data while multiple coders coded subsets of the data for agreement. The entire research team interrogated the data and review the coding. Emerging sub-themes were categorized under the appropriate pillars of health system including (i) service delivery, (ii) health workforce, (iii) health information systems, (iv)medicines and supplies, (v) financing, (vi) leadership/governance [ 15 ].

Respondent socio-demographic characteristics

A total of 22 state-level participants were interviewed from 10 states and the Federal Capital Territory (FCT). Respondents’ age ranged from 40 to 60 years. The majority 18(82%) were male while the median total duration of employment was 23.5 years. The respondents held leadership positions in SMoH and SPHCDA, with many being Deputy/Acting Directors 6 (27%) and Directors 5 (23%) and commissioners for health 2 (9%) (Table  1 ). Most 20 (91%) had been in their current position for at least 2 years.

Health services delivery volumes at the PHC during the COVID-19 pandemic

All participants acknowledged reduction in patients’ attendance at the PHCs while some also mentioned interruption in health services delivery. The decrease in facility utilization was more pronounced during the early stage of the pandemic particularly from March 2020 through June/July, 2020. Notably, there was a drastic reduction in the antenatal clinic attendance by pregnant women and the under-5 children outpatient visits across all regions of the country.

The movement restriction during lockdowns and the fear of contracting COVID-19 were the two most prominent reasons stated for reduction in health facility patients’ attendance. Where facilities were still in operation, fear of contracting the virus among patient and health workers was common in all regions.

On the supply side, some health workers did not go to work, while some facilities were instructed to close completely. The lockdown reduced the number of health workers who were able to commute to work especially those who did not have personal means of transportation. Some state governments (such as Lagos) tried to ameliorate this by providing ambulances that took frontline workers to work. Health workers were also given stickers to identify them as essential workers so that the law enforcement agents would allow them to move through the lockdown. Like the patients, the health workers were also scared of contracting COVID-19 infection and they encouraged patients that could be managed at home to stay away from the health centers. They also referred patients very readily to the next level of health care with minimal investigations. The decline in services were attributed majorly to the COVID-19 pandemic.

On the demand side, patients were unable to travel to health facilities because of lockdown restrictions. Participants also emphasized on the economic challenges and bank closures which reduced people’s ability to purchase goods and services including healthcare. Community members exhibited fears from the belief that COVID-19 was domiciled in the health facilities. People were further afraid of being isolated in the event that they were diagnosed with COVID-19.

Differential impact of COVID-19 on LGAs

There was consensus between the participants from the different regions that urban areas had a higher burden of COVID-19 infection including disease incidence and case fatality. Consequently, there were more COVID-19 response activities in urban areas.

Participants in all regions believed that health service provision had returned to normal by June, 2022 especially for some suspended activities in the pandemic. Such activities included the integrated supportive supervision of health facilities which was believed to have returned to pre-COVID-19 levels. The isolation centers were no longer in existence and ad-hoc workers were no longer in employment. However, some COVID-19 prevention strategies such as the social mobilization, advocacy and risk communication were still on-going at the time of data collection.

Challenges faced in maintaining essential health services

Key challenges were identified by participants. Human resources shortage was the most commonly mentioned challenge from 4 GPZs, 6 states (Lagos, FCT, Imo, Kano, Abia, Ogun) of the country. Other commonly mentioned challenges included: Shortages in the supply of Personal Protective Equipments (PPEs) 4 GPZs, 5 states (Imo, Lagos, Ogun, FCT, Gombe); fear of contracting COVID-19 among health workers 4 GPZs, 4 states (Imo, Ogun, FCT, Rivers); misconception, ignorance, socio-cultural issues 2 GPZs, 2 states (Rivers, Imo); lockdown/transportation 2 GPZs, 2 states (Abia, Lagos); and lack of equipment/waiting area 2 GPZs, 2 states (FCT, Oyo). Less commonly mentioned challenges included: training gap, inadequate referral, diversion of other facility budget lines to PPEs purchase, and insecurity. The challenges considered to pre-date COVID-19 included: human resources shortage, shortages in equipment and PPEs, poor infrastructure and inadequate funding.

The challenges faced in maintaining essential health services in different health systems pillars are highlighted below with sample quotes from individual respondents (Table  2 ):

Leadership and governance

The respondent from the North Central (NC) zone explained that most of the resources allocated to various other activities in health facilities were redirected to meet the needs of COVID-19 response especially the provision of PPEs (Table  2 ):

…. the challenge of diversion… of resources [budget for other facility needs]… for PPEs.

From the Southwest (SW) zone, a respondent stated that insufficient funding had always been a challenge in carrying activities such as providing electricity in the PHCs. The challenge pre-dated COVID-19 pandemic.

“Insufficient funding has always been on ground. It is not really related to COVID-19. It has always been a case in most of the PHCs getting stipend to run the PHC like lightings, generators, pumping of water.” ( SW , )

Service delivery

The majority of the PHCs lacked infrastructure that could aid organization of services to provide physical distancing for the patients. A participant in the SW was quoted:

…majority of the health facilities do not have waiting area….

The health facilities experienced difficulty in transporting COVID-19 patients referred to isolation center for care. This was expressed by a participant in the NC zone:

“…referral, when somebody is positive having to evacuate from the hospital to the treatment center was a challenge” ( NC ) .

In the South-south (SS) and Southeast (SE) zone, the participants expressed concerns about patients’ misconceptions about COVID-19. Many patients did not believe that COVID-19 exist and as a result, were unwilling to adhere to facility COVID 19 prevention protocols. These misconceptions were reinforced by socio-cultural norms and reliance on dictates of religious leaders.

“.Misconceptions about the disease… with thoughts that there was no COVID-19 in the first place” ( SS ) .

“…the person [patient], and/or.relatives are not willing to adhere to the protocols, …what do you do?.socio-cultural issues,…where some people will say my pastor said…” ( SE ) .

Human resources

Inadequate human resource which predated the COVID-19 pandemic was expressed by both northern and southern zone respondents across six states. However, this challenge was amplified by the pandemic. There was limited number of personnel with the requisite skills to perform tasks related to the response. The task shifting strategy implemented to share task and thereby, reduce the number of health workers in facilities at any one time, also reduced the human resource capacity in the PHCs.

“The major challenge is… inadequate man power which has existed before COVID-19….” ( SW ) .

“Then during the pandemic too some health care workers absconded….health workers who had the requisite capacity were quite few” ( SE ) .

“….there was some sort of shifting done to reduce the number of health workers working at the same time…” ( NC ) .

Respondents in SW and SE also described the challenges that health workers encountered in getting to the health facility during the early period of the pandemic due to the lockdown. This was said to compound the human resource shortages.

“They [workers] find it a bit difficult to get to their work place some of them have to use their workplace as home …” ( SW ) .

“It included even the health service providers. They were locked down. They could not even access the facilities” ( SE) .

The human resources shortages in the facilities was confirmed to have been a long-standing problem that existed before the pandemic across all regions of the country which was now amplified by the pandemic.

“It [staff shortfalls] was on ground before …” ( SW ) .

“Yes, I said it that staff shortfall has been a long-term issue. The work is becoming voluminous everyday” ( SW ) .

“Of course, we have human resources gaps, before and even during the pandemic” ( NC ) .

“Well, I will say the issue of the human resource for health, it has been a long-lasting challenge even before the pandemic. So, it was now heightened by the pandemic…” ( SE ) .

Health workers’ attitude to work was stated as being a challenge to utilization of PHCs by clients. Due to the fear of contracting COVID-19, health workers were not committed to work.

“We had challenges with attitude to work you understand? Some people were more reluctant” ( SS ) .

“…health workers had a ground to be afraid because there were gaps [in] science” ( SE) .

“…even health workers were scared and they were not so committed to work because there was risk [of infection]” ( NC) .

Medicines and supplies

Respondents across most of the regions reported shortages in medical consumables such as PPEs, face masks and sanitizers especially at the beginning of the pandemic. One respondent decried challenges with the supply chain because of restricted access to PPEs even though some facilities had supplies locked up in the store.

“… it was so bad that some doctors will even use their money to buy sanitizers and face masks so as to protect themselves” (SW) .

“…dearth in supply of PPEs….but that was at the initial period. Before COVID − 19, there were no local manufacturers” (SE) .

“…when we started there was really a challenge in the facilities because even face masks were running out. Sanitizers were running out because of the increased use.” (NE) .

“…challenges about the supply chain in terms of internal access to the PPE. We put the PPE in the store and health workers in the emergency unit were not having access” (NC) .

“Rapid test for SARS-CoV-2 was not available at the beginning [of the pandemic]” as expressed by a respondent from the FCT (NC) .

The dearth in supply of consumables was confirmed to be a challenge that existed before the COVID-19 pandemic. However, the increase in the cost of some consumables such as PPE, gloves and face masks was a challenge that came with the COVID-19 pandemic.

“Dearth in supply of PPEs was actually a challenge that was in existence beforehand” ( SW) .

Mitigation strategies to health systems challenges during COVID-19 pandemic

Several interventions were implemented by state governments to address the challenges of maintaining essential health services (Table  3 ). State governments focused on the provision of consumables; recruitment, redeployment and provision of training for health workers; expansion of the infrastructural capacity; provision of vaccines, stipends, security and subsidizing health services costs. These interventions were in all regions of the country.

Political will improved during the COVID-19 pandemic, state governments were positively disposed to improving health services delivery.

“Government was ready to approve all the ongoing projects, all the ongoing services, basic medical services were being provided, they also were fighting stigma within the facilities” (NC) .

“They [government] made some services affordable, available and accessible and within the reach of the community member. They were taking services even to the community outside the facilities, services like outreach services, information dissemination and empowerment. ” (NC) .

Key interventions implemented across the regions were cascaded from state level to the LGA and facility levels down to the community. Across all regions, training and capacity building were stepped down to LGAs, facility heads and community. These activities were facilitated through LGA officers and community stakeholders.

“Health worker training was also done for health workers at the primary care centres and the secondary facilities at each of the area council. So, all the activities, all the IPC was also done.” ( NC ) .

“At the state, we have a state officer, we have the Local Government officers, we also have the health facility officers. These trainings were cascaded down from the State to the Local Government and to the health facilities to ensure that the various layers of response are well equipped in terms of capacity.” ( SE ) .

“We train and monitor. We also conduct supportive supervision from the state level down to the local government levels then to the ward and facility level; we do that routinely. We check their knowledge gap and also do on the spot training for whichever gap that we are able to identify.” ( SE ) .

“…there were trainings that we received, training upon training which usually comes from the national to the State and then we step it down to the local government and then from the local government to the wards within local governments and the facilities.” ( SW ) .

“We work with the medical officers of health in the twenty-three LGAs and the heads of facility to redistribute our staffs.” ( SS ) .

Coordination across levels of the health systems also ensured timely distribution of health facility materials:

“The moment the supply comes into the state with immediate effect they write to the MOHs (Medical office of health) in the local government stating we have some materials for you, because we do not wait until the MOHs come to collect the materials, so we send a letter to them via email communicating the delivery time. E.g. we are bringing it tomorrow morning or we are bringing it this evening be available to receive it. The moment it gets to the MOHs, the MOHs step it down to all the facilities and PHCs with immediate effect.” ( SW ) .

“The state primary health board makes funds and logistics available at the local government level” ( SW ) .

“The intervention trickles down to the facility level. The State made sure that the issue of man power, issue of adequacy of jobs you know and consumables at the health facility are addressed at the highest decision level” ( SW ) .

The COVID-19 response was supported by donor partners such as in the provision of PPEs. The government also mobilized funds from the private sector which was made available to the hospitals and PHCs.

“The state government provided PPEs, because there were also donations to them, many private sectors also donated and… they made it available for the public hospitals” ( SE) .

Regarding service delivery during the pandemic, interventions implemented included reorganizing service delivery for more facilities to render more services.

“We had to reorganize our system to ensure that more facilities in some strategic locations were rendering more services, had more people to render services, you understand, 24/7. We actually had to do that” ( SS) .

The government also built COVID-19 isolation and treatment centers to relieve the pressure on the hospitals and ensure COVID-19 patients had good care.

“They [state government] provided treatment centers for those who required admission,” ( NC) .

“Government-built isolation centers all across the 20 local government in Ogun state that is the jurisdiction.” ( SW ) .

In the Northwest (NW) zone, the government organized the Emergency Maternal and Child (EMC) services where they provided ambulances to pick up pregnant woman that required emergency surgery. Provision of ambulances was not limited to the NW region as other regions also mentioned government support by providing ambulances.

“For example, during COVID-19 pandemic people there had emergency cesarean sections especially pregnant women. There is an ambulance that picks them and there is also another one that is called EMC services, it is a special service provided by the State government for Maternal and newborn child free up to this moment” (NW) .

Intervention strategies in facilities also included prioritization of facilities in terms of services and staffing needs, rescheduling of patients’ appointment that were not emergency cases.

Clients were also redirected from facilities that were shutdown to nearby facilities that could provide treatment services. Services prioritized included patient monitoring/treatment, immunization services and provision of ambulance for transportation.

“Well, the patient monitoring evaluation and treatment were prioritized because we do not want to come down with a lot of mortality. So adequate equipment [and] consumables were provided by the State and the manpower involved were adequately remunerated and then the State paid a lot of money for them to maintain this service” ( SE ) .

“The services like maternal and child care…. those services are key. We want to make sure that mothers, pregnant mothers access care on time, the children too… Those that need to be immunized and all of that.” ( SW ) .

“The maternal, new born and child health services were prioritized and also the health workers themselves were prioritized because they are the frontliners” ( SE ) .

“…anybody that falls sick and gets to the hospital will receive care but we pay attention on pregnant women and little babies more because their own case is peculiar” ( SW ) .

“The mother too who attended antenatal clinic and even the test that will be run everything was done for free and was sponsored bby the PHC Board to the extent that they printed cards and gave it to them for free that they were not supposed to pay. The registration, everything was made free at that time. This is just to act as reliefs at that time for those who access health at the health facilities” ( SW ) .

To address the shortfall in human resources, the SW region employed health worker cadres such as doctors and nurses in batches per time, as the budget could accommodate. In some other regions such as the SE, health workers were redeployed to work at facilities which were near where they lived to improve delivery. Ad hoc staff were also engaged to work for a few months.

Workshops were organized by the state governments to train and inform the health workers on IPC and to improve their skills. This helped to alleviate their fears on contracting the virus so as to alleviate their apprehension.

Health workers including adhoc staff were motivated by increasing the hazard allowance, which led to the increment in their monthly salary.

“They [government] gave some allowances to adhoc workers for a few months. So those adhoc workers helped….The state government also provided ambulances, one ambulance to one local government. They gave ambulances and drivers…also provided security…” ( SE ) .

“Health care workers were also provided with the relief materials to also help them continue in their work” ( SE ) .

“Increasing the health workers hazard allowance is something that the government did….” ( SW ) .

“Yes, the government provided allowances to encourage those who were at the frontline to ensure that they [health workers] at least had something reasonable to hold on to while offering their services and apart from that government was coordinating the activities of the various fronts including that of security.” ( SE ) .

“Giving reliefs, packages, and giving us bonus that was all.” ( SW ) .

“Those that took part in surveillance were given certain stipends, those that did case management were given certain stipends, those that took part IPC, risk communication, point of entry was given certain stipends.” ( SS ) .

“Governor continued, was even giving transport stipends to surveillance officers, laboratory personnel, just to encourage them to do the work and so, these things were going on as a kind of stimulant, a kind of motivation to assist in getting the job done. So as at that period those things were not lacking for us, so that is what I can say about that .” ( SS ) .

“The support is the trainings that were done, stipends were paid adequately as at when due and the health workers were happy with that, as they carried out their duties” ( SE ) .

“The hazard allowance was increased, I think to about 15% or thereabout, so all those incentives were there for health workers to actually motivate them to do more, so the State government did that.” ( SW ) .

“Palliatives, all the health workers were given palliatives.” ( SW ) .

“All the health workers were given adequate and reasonable support; number one, in the FCT, they were well paid. Those that were directly involved [in COVID-19 control] were well paid by the honorable minister of the FCT, secondly, they were all provided at any given point in time with PPEs, they were also well trained to monitor patient, and even the family of those who died were given some support, I think some were promised land, I don’t know if they have given them. They were given high level of support.” ( NC ) .

Other support granted by the State to motivate health workers included training, recruitment to support existing staff, provision of security, relief packages and ambulances.

“I know I have talked about redistribution of workers, of course ad-hoc workers for those very few months, then some of the PPEs and some of the security, I think that’s the only thing I can say.” ( SE ) .

“To be sincere we have to appreciate the state government, at that time they even gave us accommodations, food and everything during the first pandemic. They support us with training of case management for us to take care of patients as well as series of other training. We all attended online training on oxygen therapy and it was even paid for” ( NW ) .

“At one point, it was difficult for health workers to move from one point to the other, so government aided the movement of health workers by providing certain things to identify them, also providing ambulances, movement support to enable them move from their homes. They also provided accommodation for health workers at the isolation center.” ( SE ) .

“And also, they bring in special teams to also support the teams on ground.” ( SE ) .

“Well, we did some form of reorganization and that did include the personnel. So, we had to increase the number of personnel in our focal facilities which increase the services” ( SS ) .

“Yes training has always been in existence so they do refresher training but during the COVID it become more intensified because of the session or season we are.” ( SW ) .

Information systems

Respondents mentioned that government engaged in communication/sensitization programmes to improve service utilization using different media including the traditional and social media. The targets of the communication programmes were the community members including religious and ethnic groups. Communities, markets, churches and mosques were some of the places where the health promotion campaigns took place (Table  3 ).

Adaptations of the health systems during COVID-19

Sustainable adaptations.

Table  4 shows the emerging themes on sustainable adaptations done by the health systems. Respondents considered the infection, prevention and control (IPC) infrastructure (taps for running water), the telehealth call center, the IPC protocols and the service reorganization, as sustainable. A respondent mentioned that each health facility had an IPC focal person and also IPC teams which the health system can continually optimize.

Respondents considered that the training programs and capacity building efforts (especially the ‘network electronic platform’), implemented during the pandemic were sustainable. They opined that IPC training should be mainstreamed because the topic was broad and had impact on prevention of other infectious disease areas apart from COVID-19.

Respondents also mentioned that the volunteer groups formed during the pandemic for community sensitization and community engagement, were retained and would be used for other intervention programmes. Health teams have also retained the virtual mode of conducting team meetings.

Unsustainable adaptations

Respondents considered some adaptations in financing, service delivery and supplies, as unsustainable (Table  5 ). The funds that the government mobilized in form of incentives to health workers, stipends for campaigns team members and payment for other ad hoc staff such as town criers, were no longer being provided. The free testing and healthcare for COVID-19 patients which governments implemented was not sustained. The health workers who were redeployed have returned to their pre-pandemic assignments. In addition, all the services rendered to patients at the COVID-19 treatment centers including treatment, accommodation, consumables, were free and therefore, considered unsustainable. This also included the free consumables supplied to the health workers.

Summary of findings

The qualitative study selected senior persons in decision-making positions. Respondents acknowledged a reduction in patients’ attendance at the PHCs and interruption in service delivery. This prominently affected antenatal care attendance by pregnant women and the care for the under-5 children across all regions in the country. There was consensus among the regions that the urban communities had a higher burden of COVID-19 infection making the activities around COVID-19 control more intense in these communities. Unfortunately, this negatively impacted the provision of care in health facilities in these communities, leading to a negative impact on provision of EHS.

The challenges experienced in maintaining essential health services cut across the pillars of the health systems. Resources were reallocated to COVID-19 control activities from other budgetary lines due to insufficient funds to implement control activities. The infrastructure of most of the PHCs could not accommodate changes in service reorganization which was needed to enable physical distancing. It was also challenging to transport referred COVID-19 patients to isolation centers. Patients had misconceptions on the cause and transmission of COVID-19 and were unwilling to adhere to facility protocols. There was severe shortage of human resources which predated and was accentuated by COVID-19 control interventions such as lockdowns, staff redeployment and task shifting. Health workers were reluctant to discharge their duties because of fear of contracting the infection. There was inadequate consumables for use albeit sometimes due to deficient supply chain management.

Several mitigation strategies were implemented to address the challenges encountered. Political will towards improvement of health service projects was increased during the COVID-19 pandemic. This was reflected in government efforts to make health services available, accessible and affordable. Efforts were also made to provide consumables, recruit both permanent and ad-hoc staff, motivate existing health workforce, and redeploy/train health workers. The health infrastructure capacity was also expanded across regions, to free up spaces for provision of EHS by building/renovating COVID-19 isolation and treatment centers. Service delivery was also reorganized by rescheduling appointment for non-emergency to a later date and prioritizing essential services such as immunization, maternal and child care. Health promotion campaigns to groups and communities, were conducted to improve service patronage. Sustainable systems adaptations included IPC and telehealth infrastructure, IPC protocols, IPC teams and focal persons, training and capacity building, virtual meetings and community groups set up for sensitization and engagement. Unsustainable adaptations included funding, free healthcare and consumables, redistribution of staff, and the maintenance of COVID-19 treatment centers.

Results in the context of the literature

The COVID-19 pandemic disrupted EHS in almost all countries of the world and the disruption continued for over two years in more than 90% of countries surveyed by the WHO [ 30 ]. Particularly affected were the maternal and childcare services as corroborated in both quantitative and mixed methods design studies [ 31 , 32 , 33 ]. Our study corroborated findings from surveys among health workers and community members in Burkina Faso, Ethiopia and Nigeria, confirmed partial-to-total interruptions in health services delivery and utilization especially maternal and child health services [ 34 ] due to lockdowns, fear of infection/stigmatization, misconceptions/misinformation about the disease, stockout of drugs, and lack of transportation due to lockdowns [ 35 , 36 ]. As noted in this study, the disruption affected most services to the extent that some PHCs with low capacity were closed down. Studies indicated that disruptions appeared to affect disproportionately maternal and child care including immunization [ 30 ]. As noted in the WHO survey and as corroborated by our study, the major barriers to health service recovery were health systems challenges which predated the COVID-19 pandemic. Very prominent pre-existing health systems deficiencies identified by our study were in the human resources, service delivery and the finance pillars.

The adaptations to service delivery implemented in healthcare facilities were similar across regions in Nigeria and notably, were designed to reduce patient inflow. Non-emergency cases were discouraged from accessing clinics and follow-up appointments were rescheduled because the facilities lacked the capacity to implement the recommended physical distancing between patients. In Ghana [ 37 ] similar adaptations were made to routine healthcare service delivery which also aimed at reducing patient flow to the health facilities. In this study, only clients with extremely important conditions were encouraged to visit the health facilities, appointments were reduced, non-essential medical and surgical procedures were less prioritized.

Although, facility closures occurred in most settings around the world during lockdowns because there was no health manpower to provide services [ 3 ], the telemedicine infrastructure which existed before the pandemic in some settings, were deployed to bridge the gap in consultation demands [ 3 , 38 ]. Nigeria developed a telehealth call center which was mainly for COVID-19 case finding but provides opportunities for general health consultations use.

Also, some health professionals were reassigned to COVID-19 control programmes which ultimately affected services such as home visits, immunization and other community health services [ 37 ]. A study conducted in Lagos, Nigeria highlighted the willingness of community health workers to function as care providers during the pandemic but were challenged by heavy workload and lack of transportation [ 39 ]. These recommendations informed some of the decisions to improve health workforce care packages including financial incentives and employment of additional staff [ 39 ].

Limited evidence exist in the literature on the challenges encountered in maintaining EHS in health systems. In Bangladesh, similar challenges were reported as we found in our study. The demand pull challenges in Bangladesh included fear of COVID-19 infection, difficulty with commuting during lockdown and reduction in health seeking behavior emanating from closure of health facilities without providing alternatives [ 40 ]. Also, as found in our study, health resources were redirected to COVID-19 leaving other important health programmes deprived. Likewise, there were staff shortages which predated COVID-19: Acting in synergy with panic among health workers, more health facilities and programmes were further abandoned as similarly documented in our study.

The literature was richer in terms of mitigation and adaptation strategies implemented to maintain EHS during the COVID-19 pandemic. Kabwama et al., used the same health systems pillar thematic framework to analyze the interventions implemented in maintaining EHS in Uganda [ 41 ]. Prominent in the Uganda analysis was the private sector engagement for public-private partnership in fund mobilization as reported in our Nigeria analysis. Unique adaptation in service provisions in Uganda involved leveraging patient networks to deliver medicine which was not found in our analysis. The Ugandan study appeared to focus more on general interventions that were not specifically directed at challenges in maintaining EHS contrary to what our study did. The mitigation strategies implemented in Bangladesh closely mirrored what our study found such as provision of consumables under the medicines and supply pillar, fund mobilization under the leadership/governance and finances pillars among others [ 40 ].

Perhaps, the most robust survey on service adaptations involved 129 countries and was conducted by the WHO [ 30 ]. It was clear that in all countries, services were shifted off the health facilities and moved to home-based or to tele-infrastructure. Low and middle income countries like Nigeria may benefit from such easily adaptable strategies because creating separate facilities for COVID-19 and EHS delayed implementation as a result of the considerable financial investment required. Policy makers involved in emergency and epidemic preparedness plans may incorporate proactive plans to achieve rapid implementation of similar strategies. Other prominent cross-cutting mitigation strategies reported across countries in the WHO survey included healthcare financing, health workforce training and capacity building, procuring of essential medicines and consumables, risk communications and community engagement.

Implication of findings and lessons learned

The WHO recommends that advanced planning and long-term investments in health systems is important for epidemic preparedness and in safeguarding the continued provision of EHS during a health crisis [ 42 ]. Findings derived from this study are imperative for a robust epidemic preparedness plan. Strategies to maintain supply and demand for EHS should be incorporated as essential elements of epidemic preparedness plans. Response to health crisis require a more holistic and proactive approach at planning. The challenges facing the Nigerian health system are long-term which will require considerable and consistent efforts to resolve. Thus, learnings on mitigation strategies and adaptations during the COVID-19 pandemic would be applicable for future public health emergencies as well as routine health services delivery. The sustainable adaptations can potentially serve as a foundation for a gradual, planned, and intentional investments in the core functions of the Nigerian health system in order to improve its resilience and preparedness. For example, maintaining a pool of potential ad hoc volunteers consisting of retired health workers and community volunteers who can be mobilized at short notice. Also, the partnership built during the COVID-19 pandemic between the government of Nigeria and the private sector could be strengthened and optimized for epidemic preparedness and EHS delivery. The government at all levels received funds and donations from the private sector which was channelled to COVID-19 control and health care service delivery.

Our study also highlights the importance of adequate and timely public health messaging. Misconceptions and misinformation were rife during the COVID-19 pandemic in Nigeria [ 23 ]. Also noted [ 23 ], most of the information provided were technical and focused on prevention of COVID-19, with only minimal messaging on the provision/utilization of EHS. Thus, on the social media, misconceptions festered and was a major cause of demand-pull decline in EHS utilization by communities. Both patients in need of treatment and those who were on follow-up appointments, largely stayed away from the health facilities due to fear of contracting COVID-19. Health facilities were stigmatized, and health providers discriminated against for fear of contracting the virus. Another driver of decline in demand was the fear of testing positive and being isolated [ 43 ]. Although, adaptations to EHS later reduced the need for physical contact with the health facilities, a large proportion of potential clients stayed away from the formal health system. The learnings derived from adaptations during the pandemic could provide opportunities for a transformative evolution of the primary health care system in Nigeria. Before the pandemic, across the country, only about 20% of the PHCs were assessed as functional [ 28 ], resulting in consultation overload of the secondary and tertiary facilities. The participants considered the telehealth call center to be a sustainable innovation. The Nigerian health system could benefit from upgrading and expanding telemedicine infrastructure to shift some of the PHC overload to this platform. This will enhance an elastic, epidemic prepared EHS delivery system.

As confirmed in this study, poor funding was a systemic challenge that predated COVID-19 pandemic. EHS delivery suffered major set-backs partly because the meagre financial resources available for healthcare delivery were diverted to COVID-19 control. The budget for the State PHC Board in a state in North Central zone of Nigeria was reduced by 11.5% in order to secure funds for COVID-19 control activities [ 44 ]. The government was able to raise some funds mainly from the private sector most of which was deployed towards public health measures for COVID-19 control with little investment to strengthen the health system [ 45 ]. Public-private partnership could be strengthened to form an extra-budgetary sovereign wealth fund which will be used for emergency health purpose only and which can be mobilized at short notice. The state governments demonstrated commitment to long-term public health investments and reforms during, and in the immediate post-pandemic period [ 46 ]. A sustained commitment will improve the overall performance of primary healthcare in Nigeria in the near future.

Strengths and limitations of the study

The strength of this study is that participants were actors at the sub-national (state) -level. They were senior personnel who were decision makers in COVID-19 control and provision of EHS. They had good knowledge of activities that transpired in the states during the COVID-19 pandemic. Also, we sampled participants from all geopolitical zones of Nigeria in the interviews, which ensured representativeness. We translated and back-translated tools across zones to ensure accuracy.

The tool was designed using the conceptual framework developed by Kruk et al. [ 16 ], which was not initially based on the health systems pillars. It is possible that data on some health systems pillars exist which were not captured during the interviews. Conceptual framework used in the Kruk’s framework are not strictly health systems pillars or building blocks. Our study recruited mainly senior personnel in the ministries which might skew observations without the views of the junior personnel. Readers should interpret the findings with the view that potential richer health systems context may exist.

This study showed that there were significant challenges in maintaining essential health services delivery and utilization during the COVID-19 pandemic in Nigeria. The maternal and child care services were particularly affected. The core health systems challenges which prevented the maintenance of EHS delivery were mainly in the human resources, service delivery and the financing pillars. The mitigation strategies and adaptations implemented were important contributors to EHS recovery especially in the high resilience LGAs and have implications for future epidemic preparedness plans.

Data availability

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

Acknowledgements

The authors appreciate all participants who invested their time in responding to the interviews, colleagues at the FMoH who guided the smooth execution of this work and Hanovia Limited colleagues for the implementation of the qualitative data collection and transcription. Mohammad Tawab Hashemi provided additional support from the Global Financing Facility for Women, Children, and Adolescents.

Funding for this study was provided by Gates Ventures and the Global Financing Facility for Women, Children, and Adolescents. The funders of this study were involved in the study design, data collection, interpretation, and reporting. The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of the funders.

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SB, RN, ASJ, EAB, MMS, RFA, CN, NA, AA, MO, SUY, WW, AL, & OIF were involved in the conceptualization and/or design of this study. RN, SB, ASJ, NA, CN, AA, MO, SUY, & OIF were involved in data collection and analysis. SB and OIF developed the first draft of the manuscript. SB, RN, ASJ, EAB, MMS, RFA, CN, NA, AA, MO, SUY, WW, AL, & OIF reviewed and revised the manuscript. All coauthors have approved the manuscript for publication.

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Bello, S., Neill, R., Jegede, A.S. et al. Health systems challenges, mitigation strategies and adaptations to maintain essential health services during the COVID-19 pandemic: learnings from the six geopolitical regions in Nigeria. BMC Health Serv Res 24 , 625 (2024). https://doi.org/10.1186/s12913-024-11072-2

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Tracking Changes in Program Implementation: Findings from Multiple Rounds of the Reemployment Services and Eligibility Assessments (RESEA) Implementation Survey

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In 2018, amendments to Section 306(c) of the Social Security Act (SSA) permanently authorized the Reemployment Services and Eligibility Assessments (RESEA) program and introduced substantive changes, including formula-based funding to states and a series of requirements intended to increase the use and availability of evidence-based reemployment interventions and strategies. The RESEA program aims to help Unemployment Insurance (UI) claimants return to work quickly and improve employment outcomes. It is also intended to strengthen UI program integrity and promote alignment between UI and the broader workforce development system. This brief describes changes in implementation of the RESEA program and the findings from multiple rounds of a survey of states.  

• States consistently reported that they targeted claimants identified as most likely to exhaust UI benefits when selecting participants for the RESEA program.
• The timing of the initial RESEA meeting relative to the notification of selection remained relatively consistent between Waves 1 and 4. Across the four waves, the initial RESEA meeting most often occurred within two weeks after notification of RESEA selection.
• Overall, states provided more flexibility in scheduling and location of the RESEA meetings than they did prior to the COVID-19 pandemic. The use of remote service delivery options, including phone calls and videoconferences, increased. Despite increased flexibility, the content and services provided during the initial RESEA meetings remained similar between 2020-2023.
• In Waves 1, 3, and 4, more than half of states reported conducting a subsequent RESEA meeting after the initial RESEA meeting. In Wave 4, the number of subsequent meetings conducted increased with several states conducting more than one subsequent meeting. 
• States reported increases in activities designed to promote attendance and service delivery, such as reminder notifications to claimants. Many states leveraged the use of letter, phone, email, and text reminders to increase attendance at mandatory RESEA meetings, thereby reducing the failure to report rate.
• By Wave 4, nearly all states had resumed pre-pandemic, staff-led reviews while sustaining more flexible and online review procedures. Before the pandemic, RESEA staff were required to review claimants’ work search logs. During the pandemic, their approach to work search reviews changed by either suspending the requirement or transitioning to an online system.
• Relative to the first wave in 2020, states reported conducting more data analyses of RESEA participants to assess program effectiveness by Wave 4.
• In Wave 4, 12 states reported having completed an evaluation of their RESEA program and 37 states reported planning for future RESEA evaluations of program components. Some states plan to conduct program component evaluations on job readiness workshops, intensive career services, RESEA meetings, or service delivery modes.

Brief: Tracking Changes in Program Implementation: Findings from Multiple Rounds of the Reemployment Services and Eligibility Assessments (RESEA) Implementation Survey

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Qualitative study.

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• Introduction

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

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

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

Qualitative Research Approaches

Ethnography

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

Grounded theory

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

Phenomenology

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

Narrative research

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

Research Paradigm

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

Positivist versus postpositivist

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

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

Constructivist

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

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

Data Sampling 

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

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

Data Collection and Analysis

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

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

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

Dissemination

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

Applications

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

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

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

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

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

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

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

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

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

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

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

• Issues of Concern

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

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

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

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

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

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

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

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

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

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

• Enhancing Healthcare Team Outcomes

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

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

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

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• Cite this Page Tenny S, Brannan JM, Brannan GD. Qualitative Study. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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