qualitative research method metaphor

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Using Metaphors to Make Research Findings Meaningful

Rose steele.

1 School of Nursing, Faculty of Health, York University, Toronto, Ontario, Canada

Jennifer Baird

2 Clinical Services Education and Research, Children’s Hospital Los Angeles, Los Angeles, CA, USA

Betty Davies

3 School of Nursing, University of Victoria, Victoria, British Columbia, Canada

4 Department of Family Health Care Nursing at the University of California, San Francisco, USA

Researchers, educators, and funding agencies frequently lament that research is seldom read or put into practice by clinicians. Clinicians, on the other hand, note that they are busy and do not have the time or even the knowledge to read research articles that may be dense and filled with jargon. Traditional ways of disseminating knowledge are often insufficient; therefore, many funding agencies encourage researchers to find innovative ways to help their funded research be applied in practice. The Canadian Institutes of Health Research (CIHR; CIHR, 2012 ), for example, emphasized that varied strategies for knowledge translation, including non-academic modes of communication, are often needed to reach potential knowledge-user audiences beyond the research community. The CIHR encourage researchers to adapt their language of publication to fit target audiences and to present findings in alternative formats. In this column, we propose the use of metaphor as one innovative way to make knowledge useful for application in healthcare settings, so that, as noted by Straus et al. (2011) , findings can be easily understood and capture the attention of the intended users of the knowledge.

As researchers with many years of combined experience and multiple funded studies, we were confident in our abilities to successfully complete a recent study in which we aimed to develop an empirically-grounded and theoretical conceptualization of what makes it possible for some healthcare providers, more than others, to engage in excellent interactions with parents of children with serious illness despite having similar time and other constraints. However, during our concurrent data analysis we realized that the dynamic complexity of what we were finding could not easily be expressed through our usual approaches. Therefore, we sought creative ways to make meaningful sense of the findings so that students, clinicians, educators, and administrators could understand and then use them. As we searched for the most suitable approach, we began to learn more about metaphors and eventually we chose a prairie windmill metaphor to make sense of the findings and bundle them together in the fullness of details ( Davies et al., 2022 ). Our metaphor made the findings clearer and more manageable while also allowing various audiences to make sense of their own experiences of interactions with parents, patients, families, colleagues, and others:

The metaphor shows the whole of interaction, the movement back and forth of the many facets that are important. It captures the mystery of interaction, of the connection that really makes things happen. It's fun to play with because it really makes you think in a different way about excellence in interaction. ([study participant]; Davies et al., 2022 , p. 13)

For many centuries, metaphors have frequently been used to express understanding of complex concepts. For example, as humans we know that when we talk about building bridges between people we are talking about the connections and not actual physical structures. Metaphors are useful for inviting people into worlds that they might not otherwise have seen. They can stimulate imagination, incite feelings, help people to see new meanings, and even lead to change. In qualitative research, metaphors can help simplify complex and/or multidimensional concepts through connecting one familiar concept to another familiar one, resulting in the comparison between the two concepts opening up new possibilities and perspectives ( Schmitt, 2005 ). Metaphors provide structure to data and aid understanding of a familiar process in a new light. Thus, finding the right metaphor can help researchers describe complex findings in ways that others find meaningful.

We knew we had found the right metaphor when clinicians from many settings and disciplines, as well as parents, patients, and other family members, told us that the metaphor spoke to them and that the model made sense:

The windmill is really insightful, much more creative, dynamic, and transformational. I think what's brilliant to me about this model is that there are so many elements and to try to figure out which ones are connected at which level or layer and how they all work, the wholeness of it—I think it's really wonderful. ([study participant]; Davies et al., 2022 , pp. 24–25)

As indicated by the previous quote, metaphors can be transformational and so can effect change. Effective change typically occurs incrementally, so if metaphors are used to tap the imagination and emotions of an audience, then a more evolutionary change may result that is, in the long run, more effective in putting new knowledge into practice. However, while the right metaphor can be extremely useful, it also is important to understand that using metaphors to translate research results is not just a new way of offering information. Rather, it is the comparison process within the use of metaphor that allows the audience to experience and understand one concept in terms of another; the metaphoric structure is what helps facts become interpretable or make sense ( Richardson, 2003 ). We propose that if researchers are serious about helping practitioners and educators use research results, then they must present their findings in such a way that they touch or capture the personal experiences of practitioners and educators so they can find personal meaning in the new knowledge. Metaphors provide one intriguing approach to achieving this aim.

Author Biographies

Rose Steele , RN, PhD, has been a registered nurse for almost 45 years and is an accomplished researcher in pediatric palliative care. She is a Full Professor, York University School of Nursing, Toronto, ON, Canada

Jennifer Baird , RN, MSW, MPH, PhD, is a pediatric nurse scientist, educator, and leader with expertise in the development of interventions to improve the safety and quality of hospital care. She is Director, Clinical Services Education and Research, Children’s Hospital Los Angeles, Los Angeles, CA, USA.

Betty Davies , MSN, PhD, has devoted her career to the field of pediatric palliative care as a practicing nurse, educator, researcher, and author. She is an Adjunct Professor, University of Victoria, Victoria BC, Canada; Professor Emerita, University of California San Francisco, San Francisco, CA, USA.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Institute of Human Development, Child and Youth Health, (grant number MOP-115009).

ORCID iD: Rose Steele https://orcid.org/0000-0003-2822-0366

Teaching qualitative research: a metaphorical approach

Affiliation.

• 1 Mental Health Nursing, Middlesex University and Family and Systemic Family Therapist, London, UK. [email protected]
• PMID: 15324434
• DOI: 10.1111/j.1365-2648.2004.03153.x

Background: In the Western tradition, drawing attention to the linguistic significance of analogy and metaphor can be traced back to the writings of the early Greek philosophers Plato and Aristotle. More recently, philosophers of science have drawn attention to the role of analogy and metaphor in the development of scientific theory. Also, linguists and psychologists now suggest that, in addition to being distinctive uses of language with various rhetorical functions, metaphors constitute fundamental processes of thought with basic epistemological functions.

Aim: Drawing on numerous sources from outside the nursing literature, this paper seeks to show the implications of current theory relating to analogy and metaphor for nursing and educational practice. It also seeks to demonstrate, using a practical example, how this theory can be applied to the teaching of qualitative research.

Method: Using reflection on our experiences of using analogy and metaphor in teaching the qualitative research process on a Master's degree programme, we assess the potential for using analogy and metaphor as a teaching strategy. This experience is also used to explore and discuss the wider implications of the use of analogy and metaphor in health and educational practices.

Discussion: While analogies and metaphors can help students make creative and imaginative links between existing conceptual frameworks and those associated with new knowledge, thereby facilitating its assimilation, the use of analogy and metaphor remains an under-researched area of nursing and educational practice. The cultural specificity of a metaphor does not necessarily prevent its usefulness cross culturally. The use of metaphor and analogy can also facilitate the injection of humour to a subject students frequently find 'dry' and intimidating.

Conclusion: Analogies and metaphors are potentially powerful teaching and learning strategies. However, much is still not known about how they work at the cognitive level. Consequently, there is considerable scope for further research in this area in nurse education and clinical practice.

• Education, Nursing / methods*
• Qualitative Research*
• Research / education*
• Students, Nursing
• Teaching / methods*

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15 Using Metaphors Critically and Reflexively in Empirical Organizational Research

Mats Alvesson is Professor at School of Management, University of Bath and Lund University and affiliated with City University, London and Stockholm School of Economics. He has done extensive research and published widely in areas including qualitative and reflexive methodology, critical theory, organizational culture, knowledge work, identity in organizations, gender, organizational change, and leadership. His latest books include Reflexive Leadership: Organizing in an Imperfect World (2017, with Blom and Sveningsson) and Return to Meaning: A Social Science with Something to Say (2017, with Gabriel and Paulsen).

Yiannis Gabriel is a social psychologist, currently Professor Emeritus at the University of Bath and Visiting Professor at Lund University. Yiannis has written on organizational storytelling and narratives, leadership and followership, management learning, and the culture and politics of contemporary consumption. He has used stories as a way of studying numerous social and organizational phenomena including leader–follower relations, group dynamics and fantasies, nostalgia, conspiracy theories, insults, and apologies. He maintains an active blog at www.yiannisgabriel.com, where he presents popularized versions of his research and also discusses his musical, political, and other interests.

Jörgen Sandberg is Professor at the University of Queensland (UQ) Business School, Australia, Honorary Professor at Warwick Business School, UK, and Co-Lead of Practice and Process Studies, a multidisciplinary research hub within the UQ Business School. He has published extensively in the areas of competence and learning in organizations; practice, process, and sensemaking theory; theory development; philosophy of science; and research methodology. His most recent books include Re-imagining the Research Process: Conventional and Alternative Metaphors (2021, with Alvesson) and Skillful Performance: Enacting Capabilities, Knowledge, Competence and Expertise in Organizations (2017, with Rouleau, Langley, and Tsoukas).

• Published: 22 February 2024
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This chapter addresses the metaphors that guide our thinking and our practices in research. It suggests that a critical and reflexive approach to underlying metaphors in various parts of the research process may increase awareness and considerations of alternative ways of thinking about and doing empirical research. The chapter identifies and discusses different metaphors used by researchers. It also highlights common and less common metaphors of the key elements of the research process: literature review and theory; design and method; and analysis and writing. Finally, the chapter provides some guidelines for how to use metaphors in research in more creative ways.

Introduction

The focus of this chapter lies in the metaphors that guide our thinking and our practices as organizational researchers, when we do empirical research. The chapter develops the argument expounded by Chia (1996) , Alvesson and Sandberg (2021) , and others that the process of generating, critiquing, merging, and demerging metaphors—in short, metaphorization —is vital for being able to generate more original and impactful research. In particular, we argue for a critical and reflexive deployment of metaphors in social research. By analogy to the ways that narratives can spawn counter-narratives, we argue that each metaphor, instead of blocking alternative ones, may prompt a variety of counter-metaphors. A careful scrutiny of these counter-metaphors can reveal existing blind spots in different moments of the research process, including the initial planning, the fieldwork, the analysis and reflection, the writing, and subsequent dissemination and publication. We will encourage researchers to question and probe the metaphors that, explicitly or implicitly, guide the research process and to develop thinking about new and alternative metaphors that may promote original and probing insights into their subjects.

Researchers can, of course, consider metaphors in empirical research in a multitude of ways, such as studying the metaphorical expressions of people in research sites, or using metaphors as part of the theoretical framework to analyze organizations ( Morgan 1997 ), leadership ( Alvesson and Spicer 2011 ), or consumption ( Gabriel and Lang 2015 ). As this is addressed in other chapters in this Handbook, we here concentrate on metaphors for the research process.

The purpose of the chapter is, then, to discuss how metaphors can be used reflexively in the process of research to generate increased awareness and more informed choices that can result in the generation of more incisive, original, and imaginative research. We begin by briefly introducing the notion of metaphorical reflexivity. Against this background, we identify and discuss different metaphors of the researcher, who is often seen as the central element in the research process, particularly in qualitative research. We thereafter identify and discuss common and less common metaphors of the following key elements of the research process: literature review and theory; design and method; and analysis and writing. Finally, we provide some guidelines for how to use metaphors in research.

Metaphorical Reflexivity

In order to question and probe the metaphors that underlie the research process, reflexivity is central. Reflexivity is to a significant degree a matter of directing attention to the assumptions, frameworks, and language that we work with and which guide our interpretations. Much of this goes beyond what specific metaphorical expressions in texts can capture, searching for the root metaphors that shape the thinking and practice of social research. Working with metaphors may sharpen reflexivity at the same time as reflexive exercises may lead to the clarification of metaphors in use and trigger ideas for new metaphors. We thus see metaphorical reflexivity as a good combination of resources for generating more informed and, in particular, more creative research.

Metaphors illuminate the partial and, in a sense, arbitrary ways in which we approach phenomena and research ideas. The very idea of metaphor and the formulation of metaphors remind the researcher of the significance of perspectives and imagination. As Brown (1976 : 173) writes, “the logical, empirical or psychological absurdity of metaphor thus has a specifically cognitive function: it makes us stop in our tracks and examine it.” Through the active and conscious use of metaphors, it becomes obvious that there are alternative ways of conceptualizing and relating to a phenomenon. This is often best indicated by other metaphors. Such awareness forces or, at least, encourages the researcher to be reflexive of this: to realize that the phenomenon under scrutiny is formulated in a specific way—not The Way—and that there are alternatives.

At the same time, reflexivity suggests a careful consideration of the social, cultural, and theoretical forces that are in operation, and direct attentions to the images or metaphors that play key roles in these aforementioned forces (e.g., Alvesson and Sköldberg 2018 ; see also Finlay 2002 ; Rivera 2018 ). The ideal of reflexivity makes it difficult to stick to just one metaphor—or to avoid thinking about the existence and centrality of governing images. Reflexivity thus means—or at least in principle it can mean—awareness and exploration of the researcher’s metaphors, both for the phenomenon under study and for his/her self-understanding and the research community’s role in forming this understanding. Such reflexivity may involve considerable effort, particularly if the metaphor is taken for granted, which is often the case. Reflexivity thus includes awareness of the metaphor used and with this also a possible opening up for consideration of alternatives.

Hence, a reflexive use of metaphors thereby implies a conscious scrutiny of the ways metaphors enter our thinking, our actions, and our writing, sometimes consciously, sometimes unconsciously. It also prompts a questioning of power and legitimacy entailed by different metaphors. Thus, for example, the family metaphor that features in some discussions of organization can be seen as implying a unitary, paternalistic power perspective. And yet, given the unhappy state of many families, it may also be subverted into a pluralistic or conflict perspective or even be seen as a neurosis. Metaphors are, of course, not the only way to work with reflexivity and, similarly, you can develop insights about metaphors without being specifically reflexive, but here we regard metaphors and reflexivity as natural bedfellows that can support each other.

Metaphors of the Researcher, Metaphors of Identity

Researcher identity is widely regarded as one of the central elements of the research process, since the way researchers understand themselves often shapes what research they conduct and how. Occupational identities, such as the identity of the researcher, emerge as communities of employees deploy various rhetorical and other discursive devices to differentiate themselves from other occupational groups and support their individual identities ( Fine 1996 ; Ashcraft 2007 ). These identities can be viewed as narrative webs blending elements from a group’s past successes and trials, entrenched habits and values, current challenges, and future aspirations. They also incorporate various idealized images and fantasies that shape the experiences and practices of each occupation’s members.

In this connection, the metaphor of science as a vocation used by Max Weber ( Weber 2004 ) has long captured something essential about the work of researchers. It links research to a calling akin to a religious one, which makes the metaphor especially effective as religion is often viewed as a set of faith-based beliefs, which science opposes. The metaphor of science as vocation accords research many qualities that prima facie characterize the practices and experiences of its practitioners—these include a dedicated apprenticeship, long hours devoted to learning and searching, a firm commitment to method (this is what differentiates scientist from dilettante in Weber’s view), and many sacrifices and frustrations before dedicated work yields fruit . Yet, the figure of Faust, willing to sacrifice the noble but contingent values of the scientific enterprise for earthly success, power, and fame, emerges as emblematic of the concept of the scientist who realizes that noble ideals cannot put bread on the family table , let alone quench the deeper thirst for meaning, pleasure, and recognition ( Alvesson et al. 2022 ).

In recent times, a starkly different metaphor for the researcher’s identity, the game metaphor , has installed itself and perhaps even supplanted the vocation metaphor (e.g., Butler and Spoelstra 2020 ). The game metaphor is rooted in academic publishing, the arena where careers are forged, and departmental reputations are built. Research rankings of universities, nations, departments, and individual researchers dominate a scene that increasingly looks like the medals table in the Olympics. Young researchers must learn how to play the game effectively by collaborating with seasoned veterans, attending “Meet the editors” sessions that feature in every major conference and making themselves known to the big players in their field through networking ceaselessly. In sharp opposition to the religion-inspired metaphor of vocation, the researcher as gamesman emphasizes opportunism, flexibility, and a constant screaming for attention. Winning is all that matters, and winning means getting “the paper” published in a high-ranking journal—a virtual platitude that nearly every researcher today recognizes.

The researcher as gamesman has gradually eroded the hegemony of the researcher as vocationist. At the margins of the discursive webs that constitute today’s researcher, however, a number of other metaphors surface. In the field of organization studies, older researchers are liable to envision themselves as intellectual craftspersons and lament the erosion of traditional research skills under regimes of Fordist production of research papers, calling for standardization, specialization, speed, and volume. Research as craft overlaps with the ambit of another metaphor that surfaces as a description of researchers’ identity, that of research as a labor of love , an image that has been explored in detail by Clarke et al. (2012) , where research is an end in itself, an image not far from that of a vocation, except that love underemphasizes discipline and overemphasizes pleasure. Interestingly, these researchers found that research as a labor of love is sorely tested in our times by pragmatic instrumental demands, such as the need to put bread on the family table and maintain a position in the rat race.

The instrumental demands on researchers’ identities have fueled the increasing prominence of two further metaphors—researchers as part of an academic proletariat or even precariat , slaving away in constant insecurity, exploited and oppressed (e.g., Ylijoki and Henriksson 2017 ), and researchers as resisting or rebelling . Both of these metaphors surface frequently but not solely among early career academics, who are liable to cast older academics, mostly white and male, as their oppressors from the positions of power they occupy as deans, editors, reviewers, and so forth. Identifying with the underdog, exploited, or discriminated against—the working class, the criminal or criminalized underclass, groups discriminated against on the basis of their gender, race, or sexual orientation—has long been a driver of social researchers seeking to unveil social injustice and inequity in every form, explicit or implicit. Identifying with the underdog, as oppressed or resisting, is then liable to raise the profile of the researchers’ own grievances, whether on the basis of age, gender, race, geographical location, or linguistic skills, and so forth.

The metaphors above may describe the occupational identities of researchers in different life stages, by distilling and purifying various elements from other occupations or social positions. The individual identity of each researcher may involve hybrids or combinations of several of the above. These may, in turn, cross-fertilize or hybridize with other identity markers, such as class, race, gender, ethnicity, sexual orientation, family, politics, religion, sports, consumption patterns, and so on. Academic identities, in line with current views on identity, are generally viewed as more or less transient, precarious, and deep-seated ( Knights and Clarke 2014 ). The metaphors themselves should therefore not be viewed as capturing something fixed or permanent, but may be viewed as consciously or unconsciously shaping the experiences and practices of different researchers. Different practices are imbued with different meanings depending on the metaphor that dominates a particular researcher’s self-identity at a particular moment in time. Thus, a laborious and not very interesting piece of qualitative coding may be experienced as:

a necessary form of work discipline for a researcher working within a science as vocation metaphor;

the price to be paid for a successful hit for a gamesman researcher; also as the contribution to be made for a successful collaboration and networking with the star researcher in the field;

part of a time-honored ritual, enjoyable in its own right, for a craftsperson researcher;

part of the labor of love, not always enjoyable but meaningful nonetheless, for a researcher who loves their work;

an activity that puts bread on the table for a proletarian researcher;

a subversive activity for the rebel researcher, one that brings to light the inequities and injustices of the system.

Reflexive researchers will, as a matter of course, question their own assumptions, the interests served by their research, the ramifications of their findings, and the ethical foundations of their practice. They will also reflect on the way in which their own presence shapes the object of their investigation. Examining any identity metaphors that directly or indirectly shape the agenda and execution of their research enhance their claims to be reflexive. A researcher adhering to a Weberian ideal of value-free vocation may question whether their values indirectly and invisibly seep into their research agenda, or conversely whether their value neutrality is blinding them to some patent injustices or introducing prejudices of its own. A gamesman researcher may usefully ask themselves whether their research has any value or meaning at all. A proletarian researcher may question whether they project their own disenchantment and alienation onto their subjects, just as a rebel researcher may question whether they envision resistance and rebellion where none exists. In this way, by questioning their own identity by means of identity metaphors like those outlined above, reflexive researchers may reach a deeper understanding of their own influence and effect on what they are researching. And in doing so, they may problematize what appeared unproblematic and question what appeared unquestionable.

Metaphors of Methodology

Methodology covers several central elements in the research process including deciding purpose, producing research questions, relating to earlier research, adapting a theory, producing a design, doing field work (e.g., data collection), handling data, doing analysis, relating to theory, producing research results (e.g., findings, contributions), and doing text work (writing up). Alvesson and Sandberg (2021) suggest a range of conventional and not so conventional—perhaps even a bit weird—metaphors for all these parts of the research process. Here we concentrate on metaphorizing the following elements: (a) literature review and theory; (b) design and method; and (c) analysis and writing, thus combining parts that could be addressed in more nuanced way.

Literature Review and Theory

Most research takes off from a more or less thorough review of existing work within an area, in combination with some theory to structure thinking and empirical work. The literature review is commonly seen as “a critical evaluation of what is seen as relevant to the problem, what is known and not known about it” ( Hesse-Biber and Leavy 2011 : 336). In other words, the literature review is supposed to provide a map-like overview of the existing knowledge domain within which the researcher can position the study by highlighting some gap that needs to be filled. The metaphor of gap-spotting is common here ( Alvesson and Sandberg 2013 ). Literature review as gap-spotting focuses on what (pieces) are lacking or missing in the current knowledge map of the world, as a way to point out what needs to be added to make the picture more complete. Elsbach and van Knippenberg (2020 : 1277), for example, argue that “we advance knowledge through programs of research in which studies build on previous work and set the stage for future research.”

Some researchers, however, fear that the literature review and a clear theoretical positioning will lead researchers into a predefined track, obstructing openness and the ideal of the data showing the way. Here the literature review appears to be a blinker , blocking the wide-angle view and encouraging tunnel vision , or box thinking , and missing the open-minded exploration of reality. Extensive readings within a specialized area mean a strong commitment to a specific perspective and that the dominant assumptions are taken for granted, leading the well-read researcher to imitate others. Being specialized means the risk of becoming functionally stupid—that is, being competent within a narrow domain but incapable of thinking and dealing with issues outside this domain—and thereby limits people’s reflexive abilities and imagination in research ( Alvesson and Spicer 2016 ). The implication here is that reading not too much but somewhat broadly may be sufficient to get some interpretive support and avoid research reinventing the wheel, while working too systematically with reviewing earlier studies and optimizing the use of a specific theoretical perspective may act as blinkers.

A somewhat different approach is to view the literature review as well as existing theory in a domain as an assumption digger— an exercise in identifying and challenging assumptions ( Davis 1971 ; Alvesson and Sandberg 2013 ). Here, the researcher does not look for gaps but digs down under the literature and theory to lay bare its footings and, based on this, to generate a new set of assumptions that form the foundation of an alternative theory. In contrast to the gap-spotting review, which regards reviews as a knowledge-building exercise, or the view of the review as a blinker, the assumption-digger review regards the process as an opening-up project that enables researchers to imagine how to rethink existing literature in ways that generate new and better ways of thinking about specific phenomena. Ambitious readings are central here, but in order to selectively negate, rather than positively build upon, existing perspectives and to come up with alternative ideas.

A methodology for such an assumption-digger review could include the following principles: (1) identifying a domain of literature; (2) identifying and articulating the assumptions underlying this domain; (3) evaluating them and focusing on more problematic or limiting elements; (4) developing alternative assumptions with the potential to become the start of a novel theoretical contribution; (5) considering the new assumptions in relation to their audience (what is seen as new, credible, and interesting); and (6) evaluating the alternative set of assumptions ( Alvesson and Sandberg 2013 ). The ambition is to come up with productive and interesting new assumptions that mean novel research questions and lines of theoretical reasoning.

Relating to existing theory and studies in a field is always vital—inductive work also needs to connect to existing literature—and this can be done in different ways. Considering alternative metaphors—we have here only pointed to three of many options (see Alvesson and Sandberg 2021 for more)—may liberate some people from being stuck in certain “musts” and generally encourage alternative views that may work better for at least some researchers in some of their projects.

Design and Method

A common metaphor of research design is blueprint (or master plan) for how to conduct research. In the words of Abutabenjeh and Jaradat (2018 : 238), “a research design is a blueprint to guide the research process by laying out how a study will move from the research purpose/questions to the outcomes.” This is particularly the case when research is seen as knowledge building, where design becomes the master plan for the knowledge to be built, indicating something fixed and solid to be executed. Some advocate a fixed design: “choosing the appropriate design is critical to the success of a manuscript at AMJ, in part because the fundamental design of a study cannot be altered during the revision process” ( Bono and McNamara 2011 : 657). The design is then the principal input and structuring principle for execution. Similarly, Creswell (2009 : 5) states that “research designs are plans and the procedures for research that span the decisions from broad assumptions to detailed methods of data collection and analysis.” The various aspects of the research process are understood as components or building blocks.

An alternative metaphor of design is mystery creation . The researcher encounters or aims for an unexpected empirical observation to challenge dominant understandings in an area. This calls for a more flexible and open study than one informed by a strict design ( Alvesson and Kärreman 2011 ). The mystery creation metaphor highlights that research can be about confronting or preventing a particular logic or modes of thoughts from being outlined, thus creating a breakdown in existing assumptions and beliefs, and calling for rethinking. Agar (1986) views some form of anthropological work as a matter of interaction between the researcher’s home culture and a foreign one, leading to (potentially productive) confusions and misunderstandings calling for investigation and learning. The knowledge-creating process is one of encountering and learning to understand, and thus “solving” breakdowns in understanding. It is the unanticipated and the unexpected—the things that puzzle the researcher due to the deviation from what is expected—that are of particular interest to a reflexive researcher drawing upon the mystery (or breakdown of understanding) metaphor. The ideal research design then includes work allowing and encouraging two key elements: (1) to create a mystery; and (2) to solve it ( Asplund 1970 ). Both elements call for imagination and a willingness to avoid the temptation to simply use a favored approach—whether leadership, institutional theory, feminism, or discourse—to order and explain what the researcher encounters. They call for an empirically flexible approach, more interested in what goes on when, for example, shadowing a manager or observing an organizational unit over a time period or asking fairly open and reflection-triggering interview questions.

Somewhat related but with even more emphasis on the creative element in research design is to approach it based on a beachcombing metaphor (Gabriel 2015 , 2018 ). This means scanning a terrain in search of empirical material that may serve as golden nuggets and trigger ideas or valuable clues for developing something interesting. In this sense a beachcomber is in a quest not for objects themselves, but rather for the possibilities offered by different objects. To a beachcomber, a piece of driftwood may suggest things as diverse as a bonfire on the beach, an artistic installation, or the existence of a nearby shipwreck. A seashell may suggest an addition to a child’s mobile or may spark the inspiration for a collage or a painting. The key point of a design would then be to optimize possibilities for the creative and novel line of thinking.

Similar to research design, method also refers to specific tactics or techniques for collecting and processing data. Perhaps the most common image of method is to regard it as a rational technique for developing valid and reliable scientific knowledge of reality. As a technique, method is seen to be made up of a set of specific tools and procedures for carrying out research ( Hammersley 2011 : 5). The metaphor of instruction manual captures this. Many views have in common that method offer a set of principles, tools, and procedures for how to avoid researcher biases and prejudices or prevent them contaminating formal data and theory in the process of knowledge development. A rational and transparent procedure is key.

Method may also be seen as a construction process , in the sense of how social reality is actively constructed: that is, being invented and shaped by the researcher through their language use, interpretations, and writing practices ( Law 2004 ). In these methodological constructions of reality, the researcher is the central driver rather than the people studied. Construction indicates choice, uncertainty, and a level of arbitrariness. What others may refer to as codification would, given the construction metaphor, be less about reflecting data than about the interpretative inclinations of the construction-engaged researcher, informed by pre-understandings, imagination, theoretical ideas, paradigms, societal culture, and other construction-supporting elements.

Another metaphor of method is picking someone’s brain . Here the assumption is that method is very much about finding and mobilizing qualified people who can produce not only relevant information but also analysis. Method as picking someone’s brain means that participants are assumed not only to offer data that can be used, but also to be qualified thinkers who can support the turning of data into insights as a vital in-between step to the final research results. Holmes and Marcus (2005 : 1104), for example, address some informants as “experts” to be treated “not as collateral colleagues helping to inform fieldwork to occur elsewhere but instead as subjects fully within their own analytical ambit.” These subjects should be seen and worked with as collaborators or partners in research. The metaphor of method as picking someone’s brain may be used more broadly to inform work with all participants, who are viewed as being analytically skilled on the subject matter of the study. But the metaphor could perhaps more typically inform efforts to find and work with people who are highly suitable for insight generation and communication.

In the Field

A more mundane use of metaphors in social research may involve their deliberate use as part of the research design. Metaphors can overcome the tendency of respondents to offer mundane or formulaic answers, and encourage them to move beyond factually accurate but symbolically barren responses. Respondents to an interview may be told, “People sometimes think of their workplace through an image or a metaphor—here are some examples on a card. Does your organization feel like any of these on the card?” The card may include:

a football team;

a pressure cooker;

an episode from a soap opera;

a nest of vipers;

a castle under siege;

a dinosaur;

a conveyor belt;

an orchestra;

a rose garden.

The researcher may read each line slowly, noticing how respondents react to each metaphor, perplexed about some, amused by others, strongly rejecting some, instantly alighting on others. It then becomes possible to explore the meanings and emotions raised by the appropriate metaphor, through follow-up questions like:

a machine: Is it a well-oiled one? Is it a creaky one? How often does it break down?

a family: What kind? A happy one? Who is the father/mother? How do they treat their children?

a football team: Who are the stars? Who are the opponents?

a pressure cooker: Where does the pressure come from? How do people let off steam?

A follow-up question may then be asked that frequently elicits a story, revealing the emotional associations of the metaphor: “Can you think of an incident that illustrates how this organization works as a family/pressure cooker/prison etc?” ( Gabriel and Ulus 2015 ). The use of metaphors during field research can probe some of the assumptions held by individuals by triggering their imaginative and symbolic abilities in ways that direct questioning often fails to do.

Analysis and Writing Up

When data are approached as building blocks of reality, the analysis is typically seen as taking a reliable control over the often complex and messy qualitative material, made up of interview statements, field notes, and written documentary material. Key here are the ideal and practice of analysis as data coding , which is often not recognized as a metaphor. It involves classifying and sorting the collected data into distinct categories and gradually abstracting those categories into a new piece that will add to the never-ending theoretical jigsaw puzzle. Here one may somewhat ironically see the code as a way of turning the well known into something cryptic and secretive, as it tends to transform something that may appear to be natural, like interview talk, into something decontextualized, abstract, and standardized—often with the loss of sensitivity for social context and meaning ( Potter and Wetherell 1987 ; Brinkmann 2014 ). This loss is acceptable as the means of attaining rigor and reliability are viewed as more important —loose and uncodified texts may tempt the researcher to impose their own opinions or values on the data.

Another common metaphor of data analysis is data processing , indicating a factory-like treatment of empirical material. The researcher then engages in a refinement project, where the raw material, through the analysis, becomes processed, filtered, refined, and combined, leading to knowledge products. Here, analysis is seen as a fairly straightforward production process, where the raw material is gradually transformed into something refined and sophisticated. But, of course, processing may also be understood in more complicated ways.

A very different metaphor of data analysis is thick description . It means addressing “a multiplicity of complex conceptual structures, many of them superimposed upon or knotted into one another, which are at once strange, irregular, and inexplicit, and which [the researcher] must contrive somehow and then to render” ( Geertz 1973 : 10). Coding what interviewees say they mean is not seen as sufficient. Instead, thick description emphasizes the ambitious interpretative nature of the enterprise. Here, it is not so much the marshaling of a great body of data as the strength of the (ambitious) interpretation that matters, typically going far behind just presenting empirical detail. This is, in a sense, the opposite of codification; instead of reduction and standardization to reduce complexity and ambiguity, thick description embraces layers of meaning and celebrates complexity.

When it comes to writing, language is commonly seen as a representation tool, a transparent medium for the objective transport of information about reality. In the words of Hatch (2002 : 211), writing is about “turning the hard-earned products of design, data collection, and analysis into findings that communicate what has been learned.” Writing is then the transmission medium between the analysis and findings from the researcher to the audience, an instrument “for mediating and communicating findings and knowledge” ( Flick 2018 : 569). This view of writing often leads to monological texts.

Another common metaphor for writing is conversation , which indicates that writing should be dialogic rather than monologic in character by relating to ongoing talks between people wanting progress in a particular knowledge area. As Patriotta (2017: 753–4) notes, “the conversation metaphor foreshadows a text‐building strategy that unfolds according to the following ‘moves’: 1) identifying a ‘good’ conversation, 2) analyzing the conversation, 3) adding to the conversation.” Hence, in contrast to text as a monologue, in writing as conversation it becomes central to how the text relates to other texts, considers earlier findings and arguments, and anticipates how the research text will add to these, such as offering critique, confirmation, or a challenge.

It is also common to refer to writing through the metaphor of storytelling , which sometimes merges with the metaphor of research as a whole—its overall purpose, method, and contribution—as storytelling. Writing and research become one and the same thing. Van Maanen (1988) uses the notion of “tales of the field” to point to variations in ethnographic writing. He uses the term to highlight the “representational qualities of all fieldwork writing. It is a term meant to draw attention to the inherent story-like characters of fieldwork accounts” (8). Van Maanen identifies three major tales: realist tales, where the text is narrated in a dispassionate, third-person way; confessional tales, which emphasize the fieldworker’s personal authorship and point of view; and impressionist tales, where the author is inspired by “the impressionists’ self-conscious and, for their time, innovative use of their materials—color, form, light, stroke, hatching, overlay, frame—that provides the associative link to fieldwork writing” (101). Storytelling suggests inspiration from literature and a clear presence of the author as ideals or norms for writing texts, somewhat different from just reporting findings.

Concluding Remarks

In this chapter we have tried to show how one can metaphorize central elements of the research process for imagining a more varied set of options for thinking about and doing research. In most cases, it may be relevant to primarily consider and confront dominating metaphors with alternative ones, or for the person who is much into counter-metaphors to contrast these with dominating metaphors or other counter-metaphors. Our issue is not with metaphors being good or bad per se, but with the tendency of researchers to freeze their understanding of themselves and their research processes and to let favorite or taken-for-granted metaphors control their work. Here, it is important to see taken-for-granted metaphors not only as dominant on a broader scale or in absolute terms—dominating research as a whole—but also dominant within specific research fields or groupings.

Below we outline some general guidelines for how metaphors can be productively used in research. The guidelines are not to be read as a set of formulas or recipes, but as potentially helpful ideas for generating imaginative and impactful research studies.

Identify the current, taken-for-granted metaphors in use. This means stepping back and thinking through the varieties of meanings of what the researcher and their research tribe are doing in terms of their basic understandings of the research process.

Identify a set of counter -metaphors as possible alternatives to the taken-for-granted ones. This often involves going outside one’s own subfield and identifying other possible metaphors.

Identify useful metaphors for the specific research project. Far from all the metaphors that are identified are relevant and valuable for specific people in their specific projects.

In conclusion, being aware of metaphors enables researchers to consider a range of different options for doing research, being more imaginative and thus capable of choosing paths that are likely to lead to more original and interesting results and texts.

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Method: Quantitative and Qualitative Analyses of Metaphor

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• Veronika Koller  

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The method section translates the above integrated theoretical framework into a tripartite research paradigm. This combines computer-assisted quantitative analysis with qualitative investigations along the lines of functional grammar in the Hallidayan tradition. Quantitative corpus analysis is here regarded as a valuable starting point, granting a sound empirical basis to subsequent claims about the metaphoric features of the cognition and discourse prevailing in a particular domain. Although quantitative results alone do not provide for sufficient insights, they can, if recontextualized, support qualitative analyses of particular texts (see Koller and Mautner, forthcoming). To integrate those two fundamental methodologies, the present work has been based on machine-readable data. Let us first look at the corpora and then at the two steps in the analysis.

I wade through the filth of mighty metaphors, meta, meta, meta by metre. (Einstürzende Neubauten, 1993)

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Koller, V. (2004). Method: Quantitative and Qualitative Analyses of Metaphor. In: Metaphor and Gender in Business Media Discourse. Palgrave Macmillan, London. https://doi.org/10.1057/9780230511286_3

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Article contents

Use of qualitative methods in evaluation studies.

• Namita Ranganathan Namita Ranganathan University of Delhi
•  and  Toolika Wadhwa Toolika Wadhwa Shyama Prasad Mukherji College for Women
• https://doi.org/10.1093/acrefore/9780190264093.013.378
• Published online: 26 April 2019

Evaluation studies typically comprise research endeavors that are undertaken to investigate and gauge the effectiveness of a program, an institution, or individuals working in educational contexts, such as teachers, students, administrators, and other stakeholders in education. Usually, research studies in this genre use empirical methods to evaluate educational practices and systems. Alternatively, they may take up theoretical reflections on new policies, programs, and systems. An evaluation study requires a rigorous design and method of assessment to focus on the specific context and set of issues that it targets. In general, research studies that attempt to evaluate a program, an individual, or an institution place emphasis on checking their efficacy. They do not seek to find explanations that have led to the level of efficacy that the variables under study may have achieved. Thus, quite often, they are contested as not being full-fledged research.

Evaluation studies use a variety of methods. The choice of method depends on the area of study as well as the research questions. An evaluation study may thus fall within the qualitative or quantitative paradigms. Often, a mixed method approach is used. The purpose of the study plays a significant role in deciding the method of inquiry and analysis. Establishing the probability, plausibility, and adequacy of the program can be some of the main aims of evaluation studies. This implies as well that the programs, institutions, or individuals under study would have an impact on the course and direction of future programs and practices. An evaluation study is thus of vital importance to ensure that appropriate decisions can be made about efficacy, transferability to different contexts, and difficulties and challenges to be faced in subsequent applications.

Evaluation studies in India have been done in a vast range of areas that include program evaluation, impact studies, evaluations of specific interventions, performance outcome assessments, and the like. Some examples of studies undertaken by the government and the development sector in this regard are the following: assessment of interventions for adolescence education; impact studies of interventions, programs, and policies launched for education of minorities, including girls; and evaluation of performance outcomes stemming from programs for education of the marginalized.

The key challenges in evaluation studies are to gather accurate data in order to establish reliable outcomes, to establish clear relationships between the outcomes and the interventions being studied, and to safeguard against researcher bias.

• evaluation studies
• program evaluation
• qualitative evaluation
• outcome-based evaluation
• project evaluation
• inferring qualitative trends

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CRO Guide   >  Chapter 3.1

Qualitative Research: Definition, Methodology, Limitation & Examples

Qualitative research is a method focused on understanding human behavior and experiences through non-numerical data. Examples of qualitative research include:

• One-on-one interviews,
• Focus groups, Ethnographic research,
• Case studies,
• Record keeping,
• Qualitative observations

In this article, we’ll provide tips and tricks on how to use qualitative research to better understand your audience through real world examples and improve your ROI. We’ll also learn the difference between qualitative and quantitative data.

Table of Contents

Marketers often seek to understand their customers deeply. Qualitative research methods such as face-to-face interviews, focus groups, and qualitative observations can provide valuable insights into your products, your market, and your customers’ opinions and motivations. Understanding these nuances can significantly enhance marketing strategies and overall customer satisfaction.

What is Qualitative Research

Qualitative research is a market research method that focuses on obtaining data through open-ended and conversational communication. This method focuses on the “why” rather than the “what” people think about you. Thus, qualitative research seeks to uncover the underlying motivations, attitudes, and beliefs that drive people’s actions. 

Let’s say you have an online shop catering to a general audience. You do a demographic analysis and you find out that most of your customers are male. Naturally, you will want to find out why women are not buying from you. And that’s what qualitative research will help you find out.

In the case of your online shop, qualitative research would involve reaching out to female non-customers through methods such as in-depth interviews or focus groups. These interactions provide a platform for women to express their thoughts, feelings, and concerns regarding your products or brand. Through qualitative analysis, you can uncover valuable insights into factors such as product preferences, user experience, brand perception, and barriers to purchase.

Types of Qualitative Research Methods

Qualitative research methods are designed in a manner that helps reveal the behavior and perception of a target audience regarding a particular topic.

The most frequently used qualitative analysis methods are one-on-one interviews, focus groups, ethnographic research, case study research, record keeping, and qualitative observation.

1. One-on-one interviews

Conducting one-on-one interviews is one of the most common qualitative research methods. One of the advantages of this method is that it provides a great opportunity to gather precise data about what people think and their motivations.

Spending time talking to customers not only helps marketers understand who their clients are, but also helps with customer care: clients love hearing from brands. This strengthens the relationship between a brand and its clients and paves the way for customer testimonials.

• A company might conduct interviews to understand why a product failed to meet sales expectations.
• A researcher might use interviews to gather personal stories about experiences with healthcare.

These interviews can be performed face-to-face or on the phone and usually last between half an hour to over two hours. 

When a one-on-one interview is conducted face-to-face, it also gives the marketer the opportunity to read the body language of the respondent and match the responses.

2. Focus groups

Focus groups gather a small number of people to discuss and provide feedback on a particular subject. The ideal size of a focus group is usually between five and eight participants. The size of focus groups should reflect the participants’ familiarity with the topic. For less important topics or when participants have little experience, a group of 10 can be effective. For more critical topics or when participants are more knowledgeable, a smaller group of five to six is preferable for deeper discussions.

The main goal of a focus group is to find answers to the “why”, “what”, and “how” questions. This method is highly effective in exploring people’s feelings and ideas in a social setting, where group dynamics can bring out insights that might not emerge in one-on-one situations.

• A focus group could be used to test reactions to a new product concept.
• Marketers might use focus groups to see how different demographic groups react to an advertising campaign.

One advantage that focus groups have is that the marketer doesn’t necessarily have to interact with the group in person. Nowadays focus groups can be sent as online qualitative surveys on various devices.

Focus groups are an expensive option compared to the other qualitative research methods, which is why they are typically used to explain complex processes.

3. Ethnographic research

Ethnographic research is the most in-depth observational method that studies individuals in their naturally occurring environment.

This method aims at understanding the cultures, challenges, motivations, and settings that occur.

• A study of workplace culture within a tech startup.
• Observational research in a remote village to understand local traditions.

Ethnographic research requires the marketer to adapt to the target audiences’ environments (a different organization, a different city, or even a remote location), which is why geographical constraints can be an issue while collecting data.

This type of research can last from a few days to a few years. It’s challenging and time-consuming and solely depends on the expertise of the marketer to be able to analyze, observe, and infer the data.

4. Case study research

The case study method has grown into a valuable qualitative research method. This type of research method is usually used in education or social sciences. It involves a comprehensive examination of a single instance or event, providing detailed insights into complex issues in real-life contexts.  

• Analyzing a single school’s innovative teaching method.
• A detailed study of a patient’s medical treatment over several years.

Case study research may seem difficult to operate, but it’s actually one of the simplest ways of conducting research as it involves a deep dive and thorough understanding of the data collection methods and inferring the data.

5. Record keeping

Record keeping is similar to going to the library: you go over books or any other reference material to collect relevant data. This method uses already existing reliable documents and similar sources of information as a data source.

• Historical research using old newspapers and letters.
• A study on policy changes over the years by examining government records.

This method is useful for constructing a historical context around a research topic or verifying other findings with documented evidence.

6. Qualitative observation

Qualitative observation is a method that uses subjective methodologies to gather systematic information or data. This method deals with the five major sensory organs and their functioning, sight, smell, touch, taste, and hearing.

• Sight : Observing the way customers visually interact with product displays in a store to understand their browsing behaviors and preferences.
• Smell : Noting reactions of consumers to different scents in a fragrance shop to study the impact of olfactory elements on product preference.
• Touch : Watching how individuals interact with different materials in a clothing store to assess the importance of texture in fabric selection.
• Taste : Evaluating reactions of participants in a taste test to identify flavor profiles that appeal to different demographic groups.
• Hearing : Documenting responses to changes in background music within a retail environment to determine its effect on shopping behavior and mood.

Below we are also providing real-life examples of qualitative research that demonstrate practical applications across various contexts:

Qualitative Research Real World Examples

Let’s explore some examples of how qualitative research can be applied in different contexts.

1. Online grocery shop with a predominantly male audience

Method used: one-on-one interviews.

Let’s go back to one of the previous examples. You have an online grocery shop. By nature, it addresses a general audience, but after you do a demographic analysis you find out that most of your customers are male.

One good method to determine why women are not buying from you is to hold one-on-one interviews with potential customers in the category.

Interviewing a sample of potential female customers should reveal why they don’t find your store appealing. The reasons could range from not stocking enough products for women to perhaps the store’s emphasis on heavy-duty tools and automotive products, for example. These insights can guide adjustments in inventory and marketing strategies.

2. Software company launching a new product

Method used: focus groups.

Focus groups are great for establishing product-market fit.

Let’s assume you are a software company that wants to launch a new product and you hold a focus group with 12 people. Although getting their feedback regarding users’ experience with the product is a good thing, this sample is too small to define how the entire market will react to your product.

So what you can do instead is holding multiple focus groups in 20 different geographic regions. Each region should be hosting a group of 12 for each market segment; you can even segment your audience based on age. This would be a better way to establish credibility in the feedback you receive.

3. Alan Pushkin’s “God’s Choice: The Total World of a Fundamentalist Christian School”

Method used: ethnographic research.

Moving from a fictional example to a real-life one, let’s analyze Alan Peshkin’s 1986 book “God’s Choice: The Total World of a Fundamentalist Christian School”.

Peshkin studied the culture of Bethany Baptist Academy by interviewing the students, parents, teachers, and members of the community alike, and spending eighteen months observing them to provide a comprehensive and in-depth analysis of Christian schooling as an alternative to public education.

The study highlights the school’s unified purpose, rigorous academic environment, and strong community support while also pointing out its lack of cultural diversity and openness to differing viewpoints. These insights are crucial for understanding how such educational settings operate and what they offer to students.

Even after discovering all this, Peshkin still presented the school in a positive light and stated that public schools have much to learn from such schools.

Peshkin’s in-depth research represents a qualitative study that uses observations and unstructured interviews, without any assumptions or hypotheses. He utilizes descriptive or non-quantifiable data on Bethany Baptist Academy specifically, without attempting to generalize the findings to other Christian schools.

4. Understanding buyers’ trends

Method used: record keeping.

Another way marketers can use quality research is to understand buyers’ trends. To do this, marketers need to look at historical data for both their company and their industry and identify where buyers are purchasing items in higher volumes.

For example, electronics distributors know that the holiday season is a peak market for sales while life insurance agents find that spring and summer wedding months are good seasons for targeting new clients.

5. Determining products/services missing from the market

Conducting your own research isn’t always necessary. If there are significant breakthroughs in your industry, you can use industry data and adapt it to your marketing needs.

The influx of hacking and hijacking of cloud-based information has made Internet security a topic of many industry reports lately. A software company could use these reports to better understand the problems its clients are facing.

As a result, the company can provide solutions prospects already know they need.

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Qualitative Research Approaches

Once the marketer has decided that their research questions will provide data that is qualitative in nature, the next step is to choose the appropriate qualitative approach.

The approach chosen will take into account the purpose of the research, the role of the researcher, the data collected, the method of data analysis , and how the results will be presented. The most common approaches include:

• Narrative : This method focuses on individual life stories to understand personal experiences and journeys. It examines how people structure their stories and the themes within them to explore human existence. For example, a narrative study might look at cancer survivors to understand their resilience and coping strategies.
• Phenomenology : attempts to understand or explain life experiences or phenomena; It aims to reveal the depth of human consciousness and perception, such as by studying the daily lives of those with chronic illnesses.
• Grounded theory : investigates the process, action, or interaction with the goal of developing a theory “grounded” in observations and empirical data. 
• Ethnography : describes and interprets an ethnic, cultural, or social group;
• Case study : examines episodic events in a definable framework, develops in-depth analyses of single or multiple cases, and generally explains “how”. An example might be studying a community health program to evaluate its success and impact.

How to Analyze Qualitative Data

Analyzing qualitative data involves interpreting non-numerical data to uncover patterns, themes, and deeper insights. This process is typically more subjective and requires a systematic approach to ensure reliability and validity. 

1. Data Collection

Ensure that your data collection methods (e.g., interviews, focus groups, observations) are well-documented and comprehensive. This step is crucial because the quality and depth of the data collected will significantly influence the analysis.

2. Data Preparation

Once collected, the data needs to be organized. Transcribe audio and video recordings, and gather all notes and documents. Ensure that all data is anonymized to protect participant confidentiality where necessary.

3. Familiarization

Immerse yourself in the data by reading through the materials multiple times. This helps you get a general sense of the information and begin identifying patterns or recurring themes.

Develop a coding system to tag data with labels that summarize and account for each piece of information. Codes can be words, phrases, or acronyms that represent how these segments relate to your research questions.

• Descriptive Coding : Summarize the primary topic of the data.
• In Vivo Coding : Use language and terms used by the participants themselves.
• Process Coding : Use gerunds (“-ing” words) to label the processes at play.
• Emotion Coding : Identify and record the emotions conveyed or experienced.

5. Thematic Development

Group codes into themes that represent larger patterns in the data. These themes should relate directly to the research questions and form a coherent narrative about the findings.

6. Interpreting the Data

Interpret the data by constructing a logical narrative. This involves piecing together the themes to explain larger insights about the data. Link the results back to your research objectives and existing literature to bolster your interpretations.

7. Validation

Check the reliability and validity of your findings by reviewing if the interpretations are supported by the data. This may involve revisiting the data multiple times or discussing the findings with colleagues or participants for validation.

8. Reporting

Finally, present the findings in a clear and organized manner. Use direct quotes and detailed descriptions to illustrate the themes and insights. The report should communicate the narrative you’ve built from your data, clearly linking your findings to your research questions.

Limitations of qualitative research

The disadvantages of qualitative research are quite unique. The techniques of the data collector and their own unique observations can alter the information in subtle ways. That being said, these are the qualitative research’s limitations:

1. It’s a time-consuming process

The main drawback of qualitative study is that the process is time-consuming. Another problem is that the interpretations are limited. Personal experience and knowledge influence observations and conclusions.

Thus, qualitative research might take several weeks or months. Also, since this process delves into personal interaction for data collection, discussions often tend to deviate from the main issue to be studied.

2. You can’t verify the results of qualitative research

Because qualitative research is open-ended, participants have more control over the content of the data collected. So the marketer is not able to verify the results objectively against the scenarios stated by the respondents. For example, in a focus group discussing a new product, participants might express their feelings about the design and functionality. However, these opinions are influenced by individual tastes and experiences, making it difficult to ascertain a universally applicable conclusion from these discussions.

3. It’s a labor-intensive approach

Qualitative research requires a labor-intensive analysis process such as categorization, recording, etc. Similarly, qualitative research requires well-experienced marketers to obtain the needed data from a group of respondents.

4. It’s difficult to investigate causality

Qualitative research requires thoughtful planning to ensure the obtained results are accurate. There is no way to analyze qualitative data mathematically. This type of research is based more on opinion and judgment rather than results. Because all qualitative studies are unique they are difficult to replicate.

5. Qualitative research is not statistically representative

Because qualitative research is a perspective-based method of research, the responses given are not measured.

Comparisons can be made and this can lead toward duplication, but for the most part, quantitative data is required for circumstances that need statistical representation and that is not part of the qualitative research process.

While doing a qualitative study, it’s important to cross-reference the data obtained with the quantitative data. By continuously surveying prospects and customers marketers can build a stronger database of useful information.

Quantitative vs. Qualitative Research

Image source

Quantitative and qualitative research are two distinct methodologies used in the field of market research, each offering unique insights and approaches to understanding consumer behavior and preferences.

As we already defined, qualitative analysis seeks to explore the deeper meanings, perceptions, and motivations behind human behavior through non-numerical data. On the other hand, quantitative research focuses on collecting and analyzing numerical data to identify patterns, trends, and statistical relationships.  

Let’s explore their key differences: 

Nature of Data:

• Quantitative research : Involves numerical data that can be measured and analyzed statistically.
• Qualitative research : Focuses on non-numerical data, such as words, images, and observations, to capture subjective experiences and meanings.

Research Questions:

• Quantitative research : Typically addresses questions related to “how many,” “how much,” or “to what extent,” aiming to quantify relationships and patterns.
• Qualitative research: Explores questions related to “why” and “how,” aiming to understand the underlying motivations, beliefs, and perceptions of individuals.

Data Collection Methods:

• Quantitative research : Relies on structured surveys, experiments, or observations with predefined variables and measures.
• Qualitative research : Utilizes open-ended interviews, focus groups, participant observations, and textual analysis to gather rich, contextually nuanced data.

Analysis Techniques:

• Quantitative research: Involves statistical analysis to identify correlations, associations, or differences between variables.
• Qualitative research: Employs thematic analysis, coding, and interpretation to uncover patterns, themes, and insights within qualitative data.

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Systematic metaphor analysis as a method of qualitative research (2005)

2005, The Qualitative Report

Related Papers

The Qualitative Report

Rudolf Schmitt

George Lakoff and Mark Johnson’s theory of metaphor (1980, 1999) provides a basis for describing everyday cognitive structures using linguistic models and thus, making it possible to uncover both individual and collective patterns of thought and action. Lakoff and Johnson have not, however, developed a workable system for carrying out qualitative research. This paper outlines the fundamentals of this approach and proposes a procedure for the reconstruction of metaphorical concepts. As is normally the case in qualitative research, such guidelines can only ever represent the interplay between the ability of the researcher to understand the sense of things and the rules of the methodology. An overview of the typical interpretations that a metaphor analysis allows is also given. Key Words: Metaphor Analysis, Subjectivity, Hermeneutics, and Qualitative Research

International Journal for the Advancement of Counselling

Journal of Contemporary Psychotherapy

Eliezer Witztum , Onno van der Hart

Peter Aubusson

Configurations

Cor van der Weele

BMC Psychiatry

Julie Evensen

Background Research suggests that metaphors are integral to psychotherapeutic practice. We wanted to explore how 10 therapists reflect upon the use of metaphors in therapy, and how they react to some metaphors expressed by patients treated for of major depressive disorder (MDD). Methods Five therapists practicing psychodynamic therapy (PDT) and five practicing cognitive behavioral therapy (CBT) were interviewed with a semi-structured qualitative interview. Transcripts were analyzed using a thematic analysis approach. Results Our analysis resulted in two main themes: the therapeutic use of metaphors, and conflicting feelings towards metaphors used by depressed patients. Most therapists said that they do not actively listen for metaphors in therapy and many said that they seldom use metaphors deliberately. While PDT-therapists appeared more attentive to patient-generated metaphors, CBT-therapists seemed more focused on therapist-generated metaphors. Most therapists did not try to alte...

People traditionally view metaphor as a kind of language play where one thing is described in terms of another for literary or rhetorical effect, as when Shakespeare famously wrote Juliet is the sun. In the past decades, however, psychologists and linguists have put forward a very different cognitive theory which claims that metaphors in language reflect a fundamental cognitive tendency to understand one concept in terms of another (Gibbs, 2013; Lakoff & Johnson, 1999). This potential link between language and conceptualisation has motivated some psychotherapists to theorise how metaphors could be used to explore and possibly change clients’ feelings, values, attitudes, and behaviours (Wickman, Daniels, White, & Fesmire, 1999). While there is now a considerable body of work on metaphor use and management in psychotherapy, an overreliance on therapeutic lenses to view metaphors might lead one to superimpose familiar conceptual distinctions in psychotherapy research onto less familiar data, and overlook how the data might call these distinctions into question. This chapter illustrates the particular distinction between 'therapist-centred' and 'client-centred metaphor' which is common in therapeutic parlance, but may not accurately reflect the discursive complexity of metaphor use in actual therapist-client interaction. I begin by briefly reviewing existing work on the applicability of metaphor to psychotherapy practice, before focusing on the distinction between therapist and client-centred metaphor research. The therapist-centred end places greater emphasis on therapists utilising metaphor as a resource, while the client-centred end emphasises the potential of clients to contribute to their own treatment with metaphor use. Although this distinction seems sensible from the therapeutic point of view, I proceed to outline the underexplored ‘middle ground’ which embodies keywords like negotiation, co-construction, and compromise, and more accurately reflects the interactional and collaborative qualities of psychotherapy. The gist of the middle ground approach is that metaphor should be observed, analysed, and understood as a product of interaction between the perspectives and intentions of both therapist and client. I illustrate this with analyses of metaphor use in extracts of therapist-client interaction from a range of contextual circumstances, and outline some practical implications for therapists. The overarching message of this chapter is that understanding the multifaceted nature of metaphor in psychotherapy requires close attention to the contexts in which the metaphors are used (cf. McMullen, 2008).

Prof. Marwan Dwairy

Maria Milano

The Professional Counselor

Alwin E . Wagener, PhD, LPC, NCC

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• Published: 13 May 2024

Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes

• Léa Solh Dost   ORCID: orcid.org/0000-0001-5767-1305 1 , 2 ,
• Giacomo Gastaldi   ORCID: orcid.org/0000-0001-6327-7451 3 &
• Marie P. Schneider   ORCID: orcid.org/0000-0002-7557-9278 1 , 2  

BMC Health Services Research volume  24 , Article number:  620 ( 2024 ) Cite this article

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Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients’ perspectives of their medications from hospital to two months after discharge.

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

Conclusions

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients’ difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients’ needs, increase their safety, and standardize physicians’, pharmacists’, and nurses’ roles and responsibilities.

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Introduction

Continuity of patient care is characterized as the collaborative engagement between the patient and their physician-led care team in the ongoing management of healthcare, with the mutual objective of delivering high-quality and cost-effective medical care [ 1 ]. Continuity of care is under great pressure during the transition of care from hospital to outpatient care, with a risk of compromising patients’ safety [ 2 , 3 ]. The early post-discharge period is a high-risk and fragile transition: once discharged, one in five patients experience at least one adverse event during the first three weeks following discharge, and more than half of these adverse events are drug-related [ 4 , 5 ]. A retrospective study examining all discharged patients showed that adverse drug events (ADEs) account for up to 20% of 30-day hospital emergency readmissions [ 6 ]. During hospitalization, patients’ medications are generally modified, with an average of nearly four medication changes per patient [ 7 ]. Information regarding medications such as medication changes, the expected effect, side effects, and instructions for use are frequently poorly communicated to patients during hospitalization and at discharge [ 8 , 9 , 10 , 11 ]. Between 20 and 60% of discharged patients lack knowledge of their medications [ 12 , 13 ]. Consideration of patients’ needs and their active engagement in decision-making during hospitalization regarding their medications are often lacking [ 11 , 14 , 15 ]. This can lead to unsafe discharge and contribute to medication adherence difficulties, such as non-implementation of newly prescribed medications [ 16 , 17 ].

Patients with multiple comorbidities and polypharmacy are at higher risk of ADE [ 18 ]. Type 2 diabetes is one of the chronic health conditions most frequently associated with comorbidities and patients with type 2 diabetes often lack care continuum [ 19 , 20 , 21 ]. The prevalence of patients hospitalized with type 2 diabetes can exceed 40% [ 22 ] and these patients are at higher risk for readmission due to their comorbidities and their medications, such as insulin and oral hypoglycemic agents [ 23 , 24 , 25 ].

Interventions and strategies to improve patient care and safety at transition have shown mixed results worldwide in reducing cost, rehospitalization, ADE, and non-adherence [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. However, interventions that are patient-centered, with a patient follow-up and led by interprofessional healthcare teams showed promising results [ 34 , 35 , 36 ]. Most of these interventions have not been implemented routinely due to the extensive time to translate research into practice and the lack of hybrid implementation studies [ 37 , 38 , 39 , 40 , 41 ]. In addition, patient-reported outcomes and perspectives have rarely been considered, yet patients’ involvement is essential for seamless and integrated care [ 42 , 43 ]. Interprofessional collaboration in which patients are full members of the interprofessional team, is still in its infancy in outpatient care [ 44 ]. Barriers and facilitators regarding medications at the transition of care have been explored in multiple qualitative studies at one given time in a given setting (e.g., at discharge, one-month post-discharge) [ 8 , 45 , 46 , 47 , 48 ]. However, few studies have adopted a holistic methodology from the hospital to the outpatient setting to explore changes in patients’ perspectives over time [ 49 , 50 , 51 ]. Finally, little is known about whether, how, and when patients return to their daily routine following hospitalization and the impact of hospitalization weeks after discharge.

In Switzerland, continuity of care after hospital discharge is still poorly documented, both in terms of contextual analysis and interventional studies, and is mainly conducted in the hospital setting [ 31 , 35 , 52 , 53 , 54 , 55 , 56 ]. The first step of an implementation science approach is to perform a contextual analysis to set up effective interventions adapted to patients’ needs and aligned to healthcare professionals’ activities in a specific context [ 41 , 57 ]. Therefore, the main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and on their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients’ perspectives of their medications from hospital to two months after discharge.

Study design

This qualitative longitudinal study, conducted from October 2020 to July 2021, used a qualitative descriptive methodology through four consecutive in-depth semi-structured interviews per participant at three, 10-, 30- and 60-days post-discharge, as illustrated in Fig.  1 . Longitudinal qualitative research is characterized by qualitative data collection at different points in time and focuses on temporality, such as time and change [ 58 , 59 ]. Qualitative descriptive studies aim to explore and describe the depth and complexity of human experiences or phenomena [ 60 , 61 , 62 ]. We focused our qualitative study on the 60 first days after discharge as this period is considered highly vulnerable and because studies often use 30- or 60-days readmission as an outcome measure [ 5 , 63 ].

This qualitative study follows the Consolidated Criteria for Reporting Qualitative Research (COREQ). Ethics committee approval was sought and granted by the Cantonal Research Ethics Commission, Geneva (CCER) (2020 − 01779).

Recruitment took place during participants’ hospitalization in the general internal medicine divisions at the Geneva University Hospitals in the canton of Geneva (500 000 inhabitants), Switzerland. Interviews took place at participants’ homes, in a private office at the University of Geneva, by telephone or by secure video call, according to participants’ preference. Informal caregivers could also participate alongside the participants.

Study flowchart

Researcher characteristics

All the researchers were trained in qualitative studies. The diabetologist and researcher (GG) who enrolled the patients in the study was involved directly or indirectly (advice asked to the Geneva University Hospital diabetes team of which he was a part) for most participants’ care during hospitalization. LS (Ph.D. student and community pharmacist) was unknown to participants and presented herself during hospitalization as a “researcher” and not as a healthcare professional to avoid any risk of influencing participants’ answers. This study was not interventional, and the interviewer (LS) invited participants to contact a healthcare professional for any questions related to their medication or medical issues.

Population and sampling strategy

Patients with type 2 diabetes were chosen as an example population to describe polypharmacy patients as these patients usually have several health issues and polypharmacy [ 20 , 22 , 25 ]. Inclusions criteria for the study were: adult patients with type 2 diabetes, with at least two other comorbidities, hospitalized for at least three days in a general internal medicine ward, with a minimum of one medication change during hospital stay, and who self-managed their medications once discharged home. Exclusion criteria were patients not reachable by telephone following discharge, unable to give consent (patients with schizophrenia, dementia, brain damage, or drug/alcohol misuse), and who could not communicate in French. A purposive sampling methodology was applied aiming to include participants with different ages, genders, types, and numbers of health conditions by listing participants’ characteristics in a double-entry table, available in Supplementary Material 1 , until thematic saturation was reached. Thematic saturation was considered achieved when no new code or theme emerged and new data repeated previously coded information [ 64 ]. The participants were identified if they were hospitalized in the ward dedicated to diabetes care or when the diabetes team was contacted for advice. The senior ward physician (GG) screened eligible patients and the interviewer (LS) obtained written consent before hospital discharge.

Data collection and instruments

Sociodemographic (age, gender, educational level, living arrangement) and clinical characteristics (reason for hospitalization, date of admission, health conditions, diabetes diagnosis, medications before and during hospitalization) were collected by interviewing participants before their discharge and by extracting participants’ data from electronic hospital files by GG and LS. Participants’ pharmacies were contacted with the participant’s consent to obtain medication records from the last three months if information regarding medications before hospitalization was missing in the hospital files.

Semi-structured interview guides for each interview (at three, 10-, 30- and 60-days post-discharge) were developed based on different theories and components of health behavior and medication adherence: the World Health Organization’s (WHO) five dimensions for adherence, the Information-Motivation-Behavioral skills model and the Social Cognitive Theory [ 65 , 66 , 67 ]. Each interview explored participants’ itinerary in the healthcare system and their perspectives on their medications. Regarding medications, the following themes were mentioned at each interview: changes in medications, patients’ understanding and implication; information on their medications, self-management of their medications, and patients’ medication adherence. Other aspects were mentioned in specific interviews: patients’ hospitalization and experience on their return home (interview 1), motivation (interviews 2 and 4), and patient’s feedback on the past two months (interview 4). Interview guides translated from French are available in Supplementary Material 2 . The participants completed self-reported and self-administrated questionnaires at different interviews to obtain descriptive information on different factors that may affect medication management and adherence: self-report questionnaires on quality of life (EQ-5D-5 L) [ 68 ], literacy (Schooling-Opinion-Support questionnaire) [ 69 ], medication adherence (Adherence Visual Analogue Scale, A-VAS) [ 70 ] and Belief in Medication Questionnaire (BMQ) [ 71 ] were administered to each participant at the end of selected interviews to address the different factors that may affect medication management and adherence as well as to determine a trend of determinants over time. The BMQ contains two subscores: Specific-Necessity and Specific-Concerns, addressing respectively their perceived needs for their medications, and their concerns about adverse consequences associated with taking their medication [ 72 ].

Data management

Informed consent forms, including consent to obtain health data, were securely stored in a private office at the University of Geneva. The participants’ identification key was protected by a password known only by MS and LS. Confidentiality was guaranteed by pseudonymization of participants’ information and audio-recordings were destroyed once analyzed. Sociodemographic and clinical characteristics, medication changes, and answers to questionnaires were securely collected by electronic case report forms (eCRFs) on RedCap®. Interviews were double audio-recorded and field notes were taken during interviews. Recorded interviews were manually transcribed verbatim in MAXQDA® (2018.2) by research assistants and LS and transcripts were validated for accuracy by LS. A random sample of 20% of questionnaires was checked for accuracy for the transcription from the paper questionnaires to the eCRFs. Recorded sequences with no link to the discussed topics were not transcribed and this was noted in the transcripts.

Data analysis

A descriptive statistical analysis of sociodemographic, clinical characteristics and self-reported questionnaire data was carried out. A thematic analysis of transcripts was performed, as described by Braun and Clarke [ 73 ], by following six steps: raw data was read, text segments related to the study objectives were identified, text segments to create new categories were identified, similar or redundant categories were reduced and a model that integrated all significant categories was created. The analysis was conducted in parallel with patient enrolment to ensure data saturation. To ensure the validity of the coding method, transcripts were double coded independently and discussed by the research team until similar themes were obtained. The research group developed and validated an analysis grid, with which LS coded systematically the transcriptions and met regularly with the research team to discuss questions on data analysis and to ensure the quality of coding. The analysis was carried out in French, and the verbatims of interest cited in the manuscript were translated and validated by a native English-speaking researcher to preserve the meaning.

In this analysis, we used the term “healthcare professionals” when more than one profession could be involved in participants’ medication management. Otherwise, when a specific healthcare professional was involved, we used the designated profession (e.g. physicians, pharmacists).

Patient and public involvement

During the development phase of the study, interview guides and questionnaires were reviewed for clarity and validity and adapted by two patient partners, with multiple health conditions and who experienced previously a hospital discharge. They are part of the HUG Patients Partners + 3P platform for research and patient and public involvement.

Interviews and participants’ descriptions

A total of 75 interviews were conducted with 21 participants. In total, 31 patients were contacted, seven refused to participate (four at the project presentation and three at consent), two did not enter the selection criteria at discharge and one was unreachable after discharge. Among the 21 participants, 15 participated in all interviews, four in three interviews, one in two interviews, and one in one interview, due to scheduling constraints. Details regarding interviews and participants characteristics are presented in Tables  1 and 2 .

The median length of time between hospital discharge and interviews 1,2,3 and 4 was 5 (IQR: 4–7), 14 (13-20), 35 (22-38), and 63 days (61-68), respectively. On average, by comparing medications at hospital admission and discharge, a median of 7 medication changes (IQR: 6–9, range:2;17) occurred per participant during hospitalization and a median of 7 changes (5–12) during the two months following discharge. Details regarding participants’ medications are described in Table  3 .

Patient self-reported adherence over the past week for their three most challenging medications are available in Supplementary Material 3 .

Qualitative analysis

We defined care transition as the period from discharge until the first medical appointment post-discharge, and outpatient care as the period starting after the first medical appointment. Data was organized into three key themes (A. Medication management, B. Medication understanding, and C. Medication adherence) divided into subthemes at three time points (1. Hospitalization, 2. Care transition and 3. Outpatient care). Figure  2 summarizes and illustrates the themes and subthemes with their influencing factors as bullet points.

Participants’ medication management, understanding and adherence during hospitalization, care transition and outpatient care

A. Medication management

A.1 medication management during hospitalization: medication management by hospital staff.

Medications during hospitalization were mainly managed by hospital healthcare professionals (i.e. nurses and physicians) with varying degrees of patient involvement: “At the hospital, they prepared the medications for me. […] I didn’t even know what the packages looked like.” Participant 22; interview 1 (P22.1) Some participants reported having therapeutic education sessions with specialized nurses and physicians, such as the explanation and demonstration of insulin injection and glucose monitoring. A patient reported that he was given the choice of several treatments and was involved in shared decision-making. Other participants had an active role in managing and optimizing dosages, such as rapid insulin, due to prior knowledge and use of medications before hospitalization.

A.2 Medication management at transition: obtaining the medication and initiating self-management

Once discharged, some participants had difficulties obtaining their medications at the pharmacy because some medications were not stored and had to be ordered, delaying medication initiation. To counter this problem upstream, a few participants were provided a 24-to-48-hour supply of medications at discharge. It was sometimes requested by the patient or suggested by the healthcare professionals but was not systematic. The transition from medication management by hospital staff to self-management was exhausting for most participants who were faced with a large amount of new information and changes in their medications: “ When I was in the hospital, I didn’t even realize all the changes. When I came back home, I took away the old medication packages and got out the new ones. And then I thought : « my God, all this…I didn’t know I had all these changes » ” P2.1 Written documentation, such as the discharge prescription or dosage labels on medication packages, was helpful in managing their medication at home. Most participants used weekly pill organizers to manage their medications, which were either already used before hospitalization or were introduced post-discharge. The help of a family caregiver in managing and obtaining medications was reported as a facilitator.

A.3 Medication management in outpatient care: daily self-management and medication burden

A couple of days or weeks after discharge, most participants had acquired a routine so that medication management was less demanding, but the medication burden varied depending on the participants. For some, medication management became a simple action well implemented in their routine (“It has become automatic” , P23.4), while for others, the number of medications and the fact that the medications reminded them of the disease was a heavy burden to bear on a daily basis (“ During the first few days after getting out of the hospital, I thought I was going to do everything right. In the end, well [laughs] it’s complicated. I ended up not always taking the medication, not monitoring the blood sugar” P12.2) To support medication self-management, some participants had written documentation such as treatment plans, medication lists, and pictures of their medication packages on their phones. Some participants had difficulties obtaining medications weeks after discharge as discharge prescriptions were not renewable and participants did not see their physician in time. Others had to visit multiple physicians to have their prescriptions updated. A few participants were faced with prescription or dispensing errors, such as prescribing or dispensing the wrong dosage, which affected medication management and decreased trust in healthcare professionals. In most cases, according to participants, the pharmacy staff worked in an interprofessional collaboration with physicians to provide new and updated prescriptions.

B. Medication understanding

B.1 medication understanding during hospitalization: new information and instructions.

The amount of information received during hospitalization varied considerably among participants with some reporting having received too much, while others saying they received too little information regarding medication changes, the reason for changes, or for introducing new medications: “They told me I had to take this medication all my life, but they didn’t tell me what the effects were or why I was taking it.” P5.3

Hospitalization was seen by some participants as a vulnerable and tiring period during which they were less receptive to information. Information and explanations were generally given verbally, making it complicated for most participants to recall it. Some participants reported that hospital staff was attentive to their needs for information and used communication techniques such as teach-back (a way of checking understanding by asking participants to say in their own words what they need to know or do about their health or medications). Some participants were willing to be proactive in the understanding of their medications while others were more passive, had no specific needs for information, and did not see how they could be engaged more.

B.2 Medication understanding at transition: facing medication changes

At hospital discharge, the most challenging difficulty for participants was to understand the changes made regarding their medications. For newly diagnosed participants, the addition of new medications was more difficult to understand, whereas, for experienced participants, changes in known medications such as dosage modification, changes within a therapeutic class, and generic substitutions were the most difficult to understand. Not having been informed about changes caused confusion and misunderstanding. Therefore, medication reconciliation done by the patient was time-consuming, especially for participants with multiple medications: “ They didn’t tell me at all that they had changed my treatment completely. They just told me : « We’ve changed a few things. But it was the whole treatment ». ” P2.3 Written information, such as the discharge prescription, the discharge report (brief letter summarizing information about the hospitalization, given to the patient at discharge), or the label on the medication box (written by the pharmacist with instructions on dosage) helped them find or recall information about their medications and diagnoses. However, technical terms were used in hospital documentations and were not always understandable. For example, this participant said: “ On the prescription of valsartan, they wrote: ‘resume in the morning once profile…’[once hypertension profile allows]… I don’t know what that means.” P8.1 In addition, some documents were incomplete, as mentioned by a patient who did not have the insulin dosage mentioned on the hospital prescription. Some participants sought help from healthcare professionals, such as pharmacists, hospital physicians, or general practitioners a few days after discharge to review medications, answer questions, or obtain additional information.

B.3 Medication understanding in the outpatient care: concerns and knowledge

Weeks after discharge, most participants had concerns about the long-term use of their medications, their usefulness, and the possible risk of interactions or side effects. Some participants also reported having some lack of knowledge regarding indications, names, or how the medication worked: “I don’t even know what Brilique® [ticagrelor, antiplatelet agent] is for. It’s for blood pressure, isn’t it?. I don’t know.” P11.4 According to participants, the main reasons for the lack of understanding were the lack of information at the time of prescribing and the large number of medications, making it difficult to search for information and remember it. Participants sought information from different healthcare professionals or by themselves, on package inserts, through the internet, or from family and friends. Others reported having had all the information needed or were not interested in having more information. In addition, participants with low medication literacy, such as non-native speakers or elderly people, struggled more with medication understanding and sought help from family caregivers or healthcare professionals, even weeks after discharge: “ I don’t understand French very well […] [The doctor] explained it very quickly…[…] I didn’t understand everything he was saying” P16.2

C. Medication adherence

C.2 medication adherence at transition: adopting new behaviors.

Medication adherence was not mentioned as a concern during hospitalization and a few participants reported difficulties in medication initiation once back home: “I have an injection of Lantus® [insulin] in the morning, but obviously, the first day [after discharge], I forgot to do it because I was not used to it.” P23.1 Participants had to quickly adopt new behaviors in the first few days after discharge, especially for participants with few medications pre-hospitalization. The use of weekly pill organizers, alarms and specific storage space were reported as facilitators to support adherence. One patient did not initiate one of his medications because he did not understand the medication indication, and another patient took her old medications because she was used to them. Moreover, most participants experienced their hospitalization as a turning point, a time when they focused on their health, thought about the importance of their medications, and discussed any new lifestyle or dietary measures that might be implemented.

C.3 Medication adherence in outpatient care: ongoing medication adherence

More medication adherence difficulties appeared a few weeks after hospital discharge when most participants reported nonadherence behaviors, such as difficulties implementing the dosage regimen, or intentionally discontinuing the medication and modifying the medication regimen on their initiative. Determinants positively influencing medication adherence were the establishment of a routine; organizing medications in weekly pill-organizers; organizing pocket doses (medications for a short period that participants take with them when away from home); seeking support from family caregivers; using alarm clocks; and using specific storage places. Reasons for nonadherence were changes in daily routine; intake times that were not convenient for the patient; the large number of medications; and poor knowledge of the medication or side effects. Healthcare professionals’ assistance for medication management, such as the help of home nurses or pharmacists for the preparation of weekly pill-organizers, was requested by participants or offered by healthcare professionals to support medication adherence: “ I needed [a home nurse] to put my pills in the pillbox. […] I felt really weak […] and I was making mistakes. So, I’m very happy [the doctor] offered me [home care]. […] I have so many medications.” P22.3 Some participants who experienced prehospitalization non-adherence were more aware of their non-adherence and implemented strategies, such as modifying the timing of intake: “I said to my doctor : « I forget one time out of two […], can I take them in the morning? » We looked it up and yes, I can take it in the morning.” P11.2 In contrast, some participants were still struggling with adherence difficulties that they had before hospitalization. Motivations for taking medications two months after discharge were to improve health, avoid complications, reduce symptoms, reduce the number of medications in the future or out of obligation: “ I force myself to take them because I want to get to the end of my diabetes, I want to reduce the number of pills as much as possible.” P14.2 After a few weeks post-hospitalization, for some participants, health and illness were no longer the priority because of other life imperatives (e.g., family or financial situation).

This longitudinal study provided a multi-faceted representation of how patients manage, understand, and adhere to their medications from hospital discharge to two months after discharge. Our findings highlighted the varying degree of participants’ involvement in managing their medications during their hospitalization, the individualized needs for information during and after hospitalization, the complicated transition from hospital to autonomous medication management, the adaptation of daily routines around medication once back home, and the adherence difficulties that surfaced in the outpatient care, with nonadherence prior to hospitalization being an indicator of the behavior after discharge. Finally, our results confirmed the lack of continuity in care and showed the lack of patient care standardization experienced by the participants during the transition from hospital to outpatient care.

This in-depth analysis of patients’ experiences reinforces common challenges identified in the existing literature such as the lack of personalized information [ 9 , 10 , 11 ], loss of autonomy during hospitalization [ 14 , 74 , 75 ], difficulties in obtaining medication at discharge [ 11 , 45 , 76 ] and challenges in understanding treatment modifications and generics substitution [ 11 , 32 , 77 , 78 ]. Some of these studies were conducted during patients’ hospitalization [ 10 , 75 , 79 ] or up to 12 months after discharge [ 80 , 81 ], but most studies focused on the few days following hospital discharge [ 9 , 11 , 14 , 82 ]. Qualitative studies on medications at transition often focused on a specific topic, such as medication information, or a specific moment in time, and often included healthcare professionals, which muted patients’ voices [ 9 , 10 , 11 , 47 , 49 ]. Our qualitative longitudinal methodology was interested in capturing the temporal dynamics, in-depth narratives, and contextual nuances of patients’ medication experiences during transitions of care [ 59 , 83 ]. This approach provided a comprehensive understanding of how patients’ perspectives and behaviors evolved over time, offering insights into the complex interactions of medication management, understanding and adherence, and turning points within their medication journeys. A qualitative longitudinal design was used by Fylan et al. to underline patients’ resilience in medication management during and after discharge, by Brandberg et al. to show the dynamic process of self-management during the 4 weeks post-discharge and by Lawton et al. to examine how patients with type 2 diabetes perceived their care after discharge over a period of four years [ 49 , 50 , 51 ]. Our study focused on the first two months following hospitalization and future studies should focus on following discharged and at-risk patients over a longer period, as “transitions of care do not comprise linear trajectories of patients’ movements, with a starting and finishing point. Instead, they are endless loops of movements” [ 47 ].

Our results provide a particularly thorough description of how participants move from a state of total dependency during hospitalization regarding their medication management to a sudden and complete autonomy after hospital discharge impacting medication management, understanding, and adherence in the first days after discharge for some participants. Several qualitative studies have described the lack of shared decision-making and the loss of patient autonomy during hospitalization, which had an impact on self-management and created conflicts with healthcare professionals [ 75 , 81 , 84 ]. Our study also highlights nuanced patient experiences, including varying levels of patient needs, involvement, and proactivity during hospitalization and outpatient care, and our results contribute to capturing different perspectives that contrast with some literature that often portrays patients as more passive recipients of care [ 14 , 15 , 74 , 75 ]. Shared decision-making and proactive medication are key elements as they contribute to a smoother transition and better outcomes for patients post-discharge [ 85 , 86 , 87 ].

Consistent with the literature, the study identifies some challenges in medication initiation post-discharge [ 16 , 17 , 88 ] but our results also describe how daily routine rapidly takes over, either solidifying adherence behavior or generating barriers to medication adherence. Participants’ nonadherence prior to hospitalization was a factor influencing participants’ adherence post-hospitalization and this association should be further investigated, as literature showed that hospitalized patients have high scores of non-adherence [ 89 ]. Mortel et al. showed that more than 20% of discharged patients stopped their medications earlier than agreed with the physician and 25% adapted their medication intake [ 90 ]. Furthermore, patients who self-managed their medications had a lower perception of the necessity of their medication than patients who received help, which could negatively impact medication adherence [ 91 ]. Although participants in our study had high BMQ scores for necessity and lower scores for concerns, some participants expressed doubts about the need for their medications and a lack of motivation a few weeks after discharge. Targeted pharmacy interventions for newly prescribed medications have been shown to improve medication adherence, and hospital discharge is an opportune moment to implement this service [ 92 , 93 ].

Many medication changes were made during the transition of care (a median number of 7 changes during hospitalization and 7 changes during the two months after discharge), especially medication additions during hospitalization and interruptions after hospitalization. While medication changes during hospitalization are well described, the many changes following discharge are less discussed [ 7 , 94 ]. A Danish study showed that approximately 65% of changes made during hospitalization were accepted by primary healthcare professionals but only 43% of new medications initiated during hospitalization were continued after discharge [ 95 ]. The numerous changes after discharge may be caused by unnecessary intensification of medications during hospitalization, delayed discharge letters, lack of standardized procedures, miscommunication, patient self-management difficulties, or in response to an acute situation [ 96 , 97 , 98 ]. During the transition of care, in our study, both new and experienced participants were faced with difficulties in managing and understanding medication changes, either for newly prescribed medication or changes in previous medications. Such difficulties corroborate the findings of the literature [ 9 , 10 , 47 ] and our results showed that the lack of understanding during hospitalization led to participants having questions about their medications, even weeks after discharge. Particular attention should be given to patients’ understanding of medication changes jointly by physicians, nurses and pharmacists during the transition of care and in the months that follow as medications are likely to undergo as many changes as during hospitalization.

Implication for practice and future research

The patients’ perspectives in this study showed, at a system level, that there was a lack of standardization in healthcare professional practices regarding medication dispensing and follow-up. For now, in Switzerland, there are no official guidelines on medication prescription and dispensation during the transition of care although some international guidelines have been developed for outpatient healthcare professionals [ 3 , 99 , 100 , 101 , 102 ]. Here are some suggestions for improvement arising from our results. Patients should be included as partners and healthcare professionals should systematically assess (i) previous medication adherence, (ii) patients’ desired level of involvement and (iii) their needs for information during hospitalization. Hospital discharge processes should be routinely implemented to standardize hospital discharge preparation, medication prescribing, and dispensing. Discharge from the hospital should be planned with community pharmacies to ensure that all medications are available and, if necessary, doses of medications should be supplied by the hospital to bridge the gap. A partnership with outpatient healthcare professionals, such as general practitioners, community pharmacists, and homecare nurses, should be set up for effective asynchronous interprofessional collaboration to consolidate patients’ medication management, knowledge, and adherence, as well as to monitor signs of deterioration or adverse drug events.

Future research should consolidate our first attempt to develop a framework to better characterize medication at the transition of care, using Fig. 2   as a starting point. Contextualized interventions, co-designed by health professionals, patients and stakeholders, should be tested in a hybrid implementation study to test the implementation and effectiveness of the intervention for the health system [ 103 ].

Limitations

This study has some limitations. First, the transcripts were validated for accuracy by the interviewer but not by a third party, which could have increased the robustness of the transcription. Nevertheless, the interviewer followed all methodological recommendations for transcription. Second, patient inclusion took place during the COVID-19 pandemic, which may have had an impact on patient care and the availability of healthcare professionals. Third, we cannot guarantee the accuracy of some participants’ medication history before hospitalization, even though we contacted the participants’ main pharmacy, as participants could have gone to different pharmacies to obtain their medications. Fourth, our findings may not be generalizable to other populations and other healthcare systems because some issues may be specific to multimorbid patients with type 2 diabetes or to the Swiss healthcare setting. Nevertheless, issues encountered by our participants regarding their medications correlate with findings in the literature. Fifth, only 15 out of 21 participants took part in all the interviews, but most participants took part in at least three interviews and data saturation was reached. Lastly, by its qualitative and longitudinal design, it is possible that the discussion during interviews and participants’ reflections between interviews influenced participants’ management, knowledge, and adherence, even though this study was observational, and no advice or recommendations were given by the interviewer during interviews.

Discharged patients are willing to take steps to better manage, understand, and adhere to their medications, yet they are also faced with difficulties in the hospital and outpatient care. Furthermore, extensive changes in medications not only occur during hospitalization but also during the two months following hospital discharge, for which healthcare professionals should give particular attention. The different degrees of patients’ involvement, needs and resources should be carefully considered to enable them to better manage, understand and adhere to their medications. At a system level, patients’ experiences revealed a lack of standardization of medication practices during the transition of care. The healthcare system should provide the ecosystem needed for healthcare professionals responsible for or involved in the management of patients’ medications during the hospital stay, discharge, and outpatient care to standardize their practices while considering the patient as an active partner.

Data availability

The anonymized quantitative survey datasets and the qualitative codes are available in French from the corresponding author on reasonable request.

Abbreviations

adverse drug events

Adherence Visual Analogue Scale

Belief in Medication Questionnaire

Consolidated Criteria for Reporting Qualitative Research

case report form

standard deviation

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Acknowledgements

The authors would like to thank all the patients who took part in this study. We would also like to thank the Geneva University Hospitals Patients Partners + 3P platform as well as Mrs. Tourane Corbière and Mr. Joël Mermoud, patient partners, who reviewed interview guides for clarity and significance. We would like to thank Samuel Fabbi, Vitcoryavarman Koh, and Pierre Repiton for the transcriptions of the audio recordings.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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LS, GG, and MS conceptualized and designed the study. LS and GG screened and recruited participants. LS conducted the interviews. LS, GG, and MS performed data analysis and interpretation. LS drafted the manuscript and LS and MS worked on the different versions. MS and GG approved the final manuscript.

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Solh Dost, L., Gastaldi, G. & Schneider, M. Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes. BMC Health Serv Res 24 , 620 (2024). https://doi.org/10.1186/s12913-024-10784-9

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Received : 28 June 2023

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DOI : https://doi.org/10.1186/s12913-024-10784-9

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