thematic analysis in qualitative research 6 steps

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How to do a thematic analysis

What is a thematic analysis?

When is thematic analysis used, braun and clarke’s reflexive thematic analysis, the six steps of thematic analysis, 1. familiarizing, 2. generating initial codes, 3. generating themes, 4. reviewing themes, 5. defining and naming themes, 6. creating the report, the advantages and disadvantages of thematic analysis, disadvantages, frequently asked questions about thematic analysis, related articles.

Thematic analysis is a broad term that describes an approach to analyzing qualitative data . This approach can encompass diverse methods and is usually applied to a collection of texts, such as survey responses and transcriptions of interviews or focus group discussions. Learn more about different research methods.

A researcher performing a thematic analysis will study a set of data to pinpoint repeating patterns, or themes, in the topics and ideas that are expressed in the texts.

In analyzing qualitative data, thematic analysis focuses on concepts, opinions, and experiences, as opposed to pure statistics. This requires an approach to data that is complex and exploratory and can be anchored by different philosophical and conceptual foundations.

A six-step system was developed to help establish clarity and rigor around this process, and it is this system that is most commonly used when conducting a thematic analysis. The six steps are:

• Familiarization
• Generating codes
• Generating themes
• Reviewing themes
• Defining and naming themes
• Creating the report

It is important to note that even though the six steps are listed in sequence, thematic analysis is not necessarily a linear process that advances forward in a one-way, predictable fashion from step one through step six. Rather, it involves a more fluid shifting back and forth between the phases, adjusting to accommodate new insights when they arise.

And arriving at insight is a key goal of this approach. A good thematic analysis doesn’t just seek to present or summarize data. It interprets and makes a statement about it; it extracts meaning from the data.

Since thematic analysis is used to study qualitative data, it works best in cases where you’re looking to gather information about people’s views, values, opinions, experiences, and knowledge.

Some examples of research questions that thematic analysis can be used to answer are:

• What are senior citizens’ experiences of long-term care homes?
• How do women view social media sites as a tool for professional networking?
• How do non-religious people perceive the role of the church in a society?
• What are financial analysts’ ideas and opinions about cryptocurrency?

To begin answering these questions, you would need to gather data from participants who can provide relevant responses. Once you have the data, you would then analyze and interpret it.

Because you’re dealing with personal views and opinions, there is a lot of room for flexibility in terms of how you interpret the data. In this way, thematic analysis is systematic but not purely scientific.

A landmark 2006 paper by Victoria Braun and Victoria Clarke (“ Using thematic analysis in psychology ”) established parameters around thematic analysis—what it is and how to go about it in a systematic way—which had until then been widely used but poorly defined.

Since then, their work has been updated, with the name being revised, notably, to “reflexive thematic analysis.”

One common misconception that Braun and Clarke have taken pains to clarify about their work is that they do not believe that themes “emerge” from the data. To think otherwise is problematic since this suggests that meaning is somehow inherent to the data and that a researcher is merely an objective medium who identifies that meaning.

Conversely, Braun and Clarke view analysis as an interactive process in which the researcher is an active participant in constructing meaning, rather than simply identifying it.

The six stages they presented in their paper are still the benchmark for conducting a thematic analysis. They are presented below.

This step is where you take a broad, high-level view of your data, looking at it as a whole and taking note of your first impressions.

This typically involves reading through written survey responses and other texts, transcribing audio, and recording any patterns that you notice. It’s important to read through and revisit the data in its entirety several times during this stage so that you develop a thorough grasp of all your data.

After familiarizing yourself with your data, the next step is coding notable features of the data in a methodical way. This often means highlighting portions of the text and applying labels, aka codes, to them that describe the nature of their content.

In our example scenario, we’re researching the experiences of women over the age of 50 on professional networking social media sites. Interviews were conducted to gather data, with the following excerpt from one interview.

In the example interview snippet, portions have been highlighted and coded. The codes describe the idea or perception described in the text.

It pays to be exhaustive and thorough at this stage. Good practice involves scrutinizing the data several times, since new information and insight may become apparent upon further review that didn’t jump out at first glance. Multiple rounds of analysis also allow for the generation of more new codes.

Once the text is thoroughly reviewed, it’s time to collate the data into groups according to their code.

Now that we’ve created our codes, we can examine them, identify patterns within them, and begin generating themes.

Keep in mind that themes are more encompassing than codes. In general, you’ll be bundling multiple codes into a single theme.

To draw on the example we used above about women and networking through social media, codes could be combined into themes in the following way:

You’ll also be curating your codes and may elect to discard some on the basis that they are too broad or not directly relevant. You may also choose to redefine some of your codes as themes and integrate other codes into them. It all depends on the purpose and goal of your research.

This is the stage where we check that the themes we’ve generated accurately and relevantly represent the data they are based on. Once again, it’s beneficial to take a thorough, back-and-forth approach that includes review, assessment, comparison, and inquiry. The following questions can support the review:

• Has anything been overlooked?
• Are the themes definitively supported by the data?
• Is there any room for improvement?

With your final list of themes in hand, the next step is to name and define them.

In defining them, we want to nail down the meaning of each theme and, importantly, how it allows us to make sense of the data.

Once you have your themes defined, you’ll need to apply a concise and straightforward name to each one.

In our example, our “perceived lack of skills” may be adjusted to reflect that the texts expressed uncertainty about skills rather than the definitive absence of them. In this case, a more apt name for the theme might be “questions about competence.”

To finish the process, we put our findings down in writing. As with all scholarly writing, a thematic analysis should open with an introduction section that explains the research question and approach.

This is followed by a statement about the methodology that includes how data was collected and how the thematic analysis was performed.

Each theme is addressed in detail in the results section, with attention paid to the frequency and presence of the themes in the data, as well as what they mean, and with examples from the data included as supporting evidence.

The conclusion section describes how the analysis answers the research question and summarizes the key points.

In our example, the conclusion may assert that it is common for women over the age of 50 to have negative experiences on professional networking sites, and that these are often tied to interactions with other users and a sense that using these sites requires specialized skills.

Thematic analysis is useful for analyzing large data sets, and it allows a lot of flexibility in terms of designing theoretical and research frameworks. Moreover, it supports the generation and interpretation of themes that are backed by data.

There are times when thematic analysis is not the best approach to take because it can be highly subjective, and, in seeking to identify broad patterns, it can overlook nuance in the data.

What’s more, researchers must be judicious about reflecting on how their own position and perspective bears on their interpretations of the data and if they are imposing meaning that is not there or failing to pick up on meaning that is.

Thematic analysis offers a flexible and recursive way to approach qualitative data that has the potential to yield valuable insights about people’s opinions, views, and lived experience. It must be applied, however, in a conscientious fashion so as not to allow subjectivity to taint or obscure the results.

The purpose of thematic analysis is to find repeating patterns, or themes, in qualitative data. Thematic analysis can encompass diverse methods and is usually applied to a collection of texts, such as survey responses and transcriptions of interviews or focus group discussions. In analyzing qualitative data, thematic analysis focuses on concepts, opinions, and experiences, as opposed to pure statistics.

A big advantage of thematic analysis is that it allows a lot of flexibility in terms of designing theoretical and research frameworks. It also supports the generation and interpretation of themes that are backed by data.

A disadvantage of thematic analysis is that it can be highly subjective and can overlook nuance in the data. Also, researchers must be aware of how their own position and perspective influences their interpretations of the data and if they are imposing meaning that is not there or failing to pick up on meaning that is.

How many themes make sense in your thematic analysis of course depends on your topic and the material you are working with. In general, it makes sense to have no more than 6-10 broader themes, instead of having many really detailed ones. You can then identify further nuances and differences under each theme when you are diving deeper into the topic.

Since thematic analysis is used to study qualitative data, it works best in cases where you’re looking to gather information about people’s views, values, opinions, experiences, and knowledge. Therefore, it makes sense to use thematic analysis for interviews.

After familiarizing yourself with your data, the first step of a thematic analysis is coding notable features of the data in a methodical way. This often means highlighting portions of the text and applying labels, aka codes, to them that describe the nature of their content.

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• How to Do Thematic Analysis | Guide & Examples

How to Do Thematic Analysis | Guide & Examples

Published on 5 May 2022 by Jack Caulfield .

Thematic analysis is a method of analysing qualitative data . It is usually applied to a set of texts, such as an interview or transcripts . The researcher closely examines the data to identify common themes, topics, ideas and patterns of meaning that come up repeatedly.

There are various approaches to conducting thematic analysis, but the most common form follows a six-step process:

• Familiarisation
• Generating themes
• Reviewing themes
• Defining and naming themes

This process was originally developed for psychology research by Virginia Braun and Victoria Clarke . However, thematic analysis is a flexible method that can be adapted to many different kinds of research.

Table of contents

When to use thematic analysis, different approaches to thematic analysis, step 1: familiarisation, step 2: coding, step 3: generating themes, step 4: reviewing themes, step 5: defining and naming themes, step 6: writing up.

Thematic analysis is a good approach to research where you’re trying to find out something about people’s views, opinions, knowledge, experiences, or values from a set of qualitative data – for example, interview transcripts , social media profiles, or survey responses .

Some types of research questions you might use thematic analysis to answer:

• How do patients perceive doctors in a hospital setting?
• What are young women’s experiences on dating sites?
• What are non-experts’ ideas and opinions about climate change?
• How is gender constructed in secondary school history teaching?

To answer any of these questions, you would collect data from a group of relevant participants and then analyse it. Thematic analysis allows you a lot of flexibility in interpreting the data, and allows you to approach large datasets more easily by sorting them into broad themes.

However, it also involves the risk of missing nuances in the data. Thematic analysis is often quite subjective and relies on the researcher’s judgement, so you have to reflect carefully on your own choices and interpretations.

Pay close attention to the data to ensure that you’re not picking up on things that are not there – or obscuring things that are.

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Once you’ve decided to use thematic analysis, there are different approaches to consider.

There’s the distinction between inductive and deductive approaches:

• An inductive approach involves allowing the data to determine your themes.
• A deductive approach involves coming to the data with some preconceived themes you expect to find reflected there, based on theory or existing knowledge.

There’s also the distinction between a semantic and a latent approach:

• A semantic approach involves analysing the explicit content of the data.
• A latent approach involves reading into the subtext and assumptions underlying the data.

After you’ve decided thematic analysis is the right method for analysing your data, and you’ve thought about the approach you’re going to take, you can follow the six steps developed by Braun and Clarke .

The first step is to get to know our data. It’s important to get a thorough overview of all the data we collected before we start analysing individual items.

This might involve transcribing audio , reading through the text and taking initial notes, and generally looking through the data to get familiar with it.

Next up, we need to code the data. Coding means highlighting sections of our text – usually phrases or sentences – and coming up with shorthand labels or ‘codes’ to describe their content.

Let’s take a short example text. Say we’re researching perceptions of climate change among conservative voters aged 50 and up, and we have collected data through a series of interviews. An extract from one interview looks like this:

In this extract, we’ve highlighted various phrases in different colours corresponding to different codes. Each code describes the idea or feeling expressed in that part of the text.

At this stage, we want to be thorough: we go through the transcript of every interview and highlight everything that jumps out as relevant or potentially interesting. As well as highlighting all the phrases and sentences that match these codes, we can keep adding new codes as we go through the text.

After we’ve been through the text, we collate together all the data into groups identified by code. These codes allow us to gain a condensed overview of the main points and common meanings that recur throughout the data.

Next, we look over the codes we’ve created, identify patterns among them, and start coming up with themes.

Themes are generally broader than codes. Most of the time, you’ll combine several codes into a single theme. In our example, we might start combining codes into themes like this:

At this stage, we might decide that some of our codes are too vague or not relevant enough (for example, because they don’t appear very often in the data), so they can be discarded.

Other codes might become themes in their own right. In our example, we decided that the code ‘uncertainty’ made sense as a theme, with some other codes incorporated into it.

Again, what we decide will vary according to what we’re trying to find out. We want to create potential themes that tell us something helpful about the data for our purposes.

Now we have to make sure that our themes are useful and accurate representations of the data. Here, we return to the dataset and compare our themes against it. Are we missing anything? Are these themes really present in the data? What can we change to make our themes work better?

If we encounter problems with our themes, we might split them up, combine them, discard them, or create new ones: whatever makes them more useful and accurate.

For example, we might decide upon looking through the data that ‘changing terminology’ fits better under the ‘uncertainty’ theme than under ‘distrust of experts’, since the data labelled with this code involves confusion, not necessarily distrust.

Now that you have a final list of themes, it’s time to name and define each of them.

Defining themes involves formulating exactly what we mean by each theme and figuring out how it helps us understand the data.

Naming themes involves coming up with a succinct and easily understandable name for each theme.

For example, we might look at ‘distrust of experts’ and determine exactly who we mean by ‘experts’ in this theme. We might decide that a better name for the theme is ‘distrust of authority’ or ‘conspiracy thinking’.

Finally, we’ll write up our analysis of the data. Like all academic texts, writing up a thematic analysis requires an introduction to establish our research question, aims, and approach.

We should also include a methodology section, describing how we collected the data (e.g., through semi-structured interviews or open-ended survey questions ) and explaining how we conducted the thematic analysis itself.

The results or findings section usually addresses each theme in turn. We describe how often the themes come up and what they mean, including examples from the data as evidence. Finally, our conclusion explains the main takeaways and shows how the analysis has answered our research question.

In our example, we might argue that conspiracy thinking about climate change is widespread among older conservative voters, point out the uncertainty with which many voters view the issue, and discuss the role of misinformation in respondents’ perceptions.

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A Comprehensive Guide to Thematic Analysis in Qualitative Research

What is Qualitative Data?

What do all the methods above have in common? They result in loads of qualitative data. If you're not new here, you've heard us mention qualitative data many times already. Qualitative data is non-numeric data that is collected in the form of words, images, or sound bites. Qual data is often used to understand people's experiences, perspectives, and motivations, and is often collected and sorted by UX Researchers to better understand the company's users. Qualitative data is subjective and often in response to open-ended questions, and is typically analyzed through methods such as thematic analysis, content analysis, and discourse analysis. In this resource we'll be focusing specifically on how to conduct an effective thematic analysis from scratch! Qualitative data is the sister of quantitative data, which is data that is collected in the form of numbers and can be analyzed using statistical methods. Qualitative and quantitative data are often used together in mixed methods research, which combines both types of data to gain a more comprehensive understanding of a research question.

UX Research Methods

There are many different types of UX research methods that can be used to gather insights about user behavior and attitudes. Some common UX research methods include:

• Interviews: One-on-one conversations with users to gather detailed information about their experiences, needs, and preferences.
• Surveys: Online or paper-based questionnaires that can be used to gather large amounts of data from a broad group of users.
• Focus groups: Group discussions with a moderated discussion to explore user attitudes and behaviors.
• User testing: Observing users as they interact with a product or service to identify problems and gather feedback.
• Ethnographic research: Observing and interacting with users in their natural environments to gain a deep understanding of their behaviors and motivations.
• Card sorting: A technique used to understand how users categorize and organize information.
• Tree testing: A method used to evaluate the effectiveness of a website's navigation structure.
• Heuristic evaluation: A method used to identify usability issues by having experts review a product and identify potential problems.
• Expert review: Gathering feedback from industry experts on a product or service to identify potential issues and areas for improvement.

Introduction to Thematic Analysis of Qualitative Data

Thematic analysis is a popular way of analyzing qualitative data, like transcripts or interview responses, by identifying and analyzing recurring themes (hence the name!). This method often follows a six-step process, which includes getting familiar with the data, sorting and coding the data, generating your various themes, reviewing and editing these themes, defining and naming the themes, and writing up the results to present. This process can help researchers avoid confirmation bias in their analysis. Thematic analysis was developed for psychology research, but it can be used in many different types of research and is especially prevalent in the UX research profession.

When to Use Thematic Analysis

Thematic analysis is a useful method for analyzing qualitative data when you are interested in understanding the underlying themes and patterns in the data. Some situations in which thematic analysis might be appropriate include:

• When you have a large amount of qualitative data, such as transcripts from interviews or focus groups.
• When you want to understand people's experiences, perspectives, or motivations in depth.
• When you want to identify patterns or themes that emerge from the data.
• When you want to explore complex and open-ended research questions.
• When you are interested in understanding how people make sense of their experiences and the world around them.

Some UX research specific questions that could be a good fit for thematic analysis are:

• How do users think about their experiences with a particular product, service or company?
• What are the common challenges that a user might encounter when using a product or service, and how do they overcome them?
• How do users make sense of the navigation of a website or app?
• What are the key drivers of user satisfaction or dissatisfaction with a product or service?
• How do users' experiences with a product or service compare with their expectations?

It is important to keep in mind that thematic analysis is just one of many methods for analyzing qualitative data, and it may not be the most appropriate method for every research question or situation. A key part of a UX researcher's role is being aware of the most appropriate research method to use based on the problem the company is trying to solve and the constraints of the company's research practice.

Types of Thematic Analysis

There are two primary types of thematic analysis, called inductive and deductive approaches. An inductive approach involves going into the study blind, and allowing the results of the data-capture to guide and shape the analysis and theming. Think of it like induction heating-- the data heats your results! (OK, we get it, that was a bad joke. But you won't forget now!) An example of an inductive approach would be parachuting onto a client without knowing much about their website, and discovering the checkout was difficult to use by the amount of people who brought it up. An easy theme! On the flip-side, a deductive approach involves attacking the data with some preconceived notions you expect to find in the qualitative data, based on a theory. For example, if you think your company's website navigation is hard to use because the text is too small, you may find yourself looking for themes like "small text" or "difficult navigation." We don't have a joke for this one, but we tried. To get even more nitty-gritty, there are two additional types of thematic analysis called semantic and latent thematic analysis. These are more advanced, but we'll throw them here for good measure. Semantic thematic analysis involves identifying themes in the data by analyzing the exact wording of the comments made used by participants. Latent thematic analysis involves identifying themes in the data by analyzing the underlying meanings and actions that were taken, but perhaps not necessarily stated by study participants. Both of these methods can be used in user research, though latent analysis is more popular because users often say different things than what they actually do.

Steps in Conducting a Thematic Analysis

Let's jump in! As mentioned before, there are 6 steps to completing a thematic analysis.

Step One: get familiar with your data!

This might seem obvious, but sometimes it's hard to know when to start. This might take the form of listening to the audio interviews or unmoderated studies, or reading the notes taken during a moderated interview. It's important to know the overall ideas of what you're dealing with to effectively theme your study. While you're doing this, pay attention to some big picture themes you can use in step two when you code your data. Break out key ideas from each participant. This might take the form of summarized answers for each question response, or a written review of actions taken for each task given. Just make sure to standardize it across participants.

Step Two: sort & code the data.

Now that you have your standardized notes across your participants, it's time to sort and code the collected qualitative data! Think of the themes from before when you were taking your notes. Think of these codes like metaphorical buckets, and start sorting! Every comment that fits a theme in a box, put it there. Back to our navigation example: some codes could be "small text" or "hard to use." We could put a participant action of "squinting" into the bucket for "small text," or a comment from another mentioning they had trouble finding "tents" in "hard to use."

Step Three: break the codes into themes!

Try to think of each theme as a makeup of three or more codes. For the navigation example, we could put both "small text," and "hard to use" into a theme of "Difficult Navigation."

Step Four: review and name your themes.

Now is the time to clean up the data. Are all your themes relevant to the problem you're trying to solve? Are all the themes coherent and straightforward? Are you comfortable defending your theme choices to teammates? These are all great questions to ask yourself in this stage.

Step Five: Present!!

To have a cohesive presentation of your thematic analysis, you'll need to include an introduction that explains the user problem you were trying to identify and the method you took to study it. Use the terminology from beginning of this resource to identify your research method. Usually for something like this, it will be a user survey or interview. ‍ You also need to include how you analyzed your participant data (inductive, deductive, latent or semantic) to identify your codes and themes. In the meaty section of your presentation, describe each theme and give quotations and user actions from the data to support your points.

Step Six: Insights and Recommendations

Your conclusion should not stop at your presentation of your findings. The best user researchers are valuable for both their insights and recommendations. Since UX researchers spend so much time with participants, they have indispensable knowledge about the best way to do things that make life easy for the company's users. Don't keep this information to yourself! On the final 1-3 slides of your presentation, state the "Next Steps & Recommendations" that you'd like your team and leadership to follow up on. These recommendations could include things like additional qualitative or quantitative studies, UX changes to make or test, or a copy change to make the experience clearer for readers. Your ultimate job is to create the best user experience, and you made it this far-- you got this!

And there you have it! That's everything you need to complete a thematic analysis of qualitative data to identify potential solutions or key concepts for a particular user problem. But don't stop there! We recommend using these principles in the wild to conduct research of your own. Identify a question or potential problem you'd like to analyze on one of your favorite sites. Use a service like Sprig to come up with non-bias questions to ask friends and family to try and gather your own qualitative data. Next, complete and document yourself completing the 6-step analysis process. What do you discover? Be prepared to share on interviews-- hiring managers love to see initiative! Good luck.

View the UX Research Job Guide Here

Our Sources: 

Caulfield, J. (2022, November 25). How to Do Thematic Analysis | Step-by-Step Guide & Examples . Scribbr. https://www.scribbr.com/methodology/thematic-analysis/

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Thematic Analysis – A Guide with Examples

Published by Alvin Nicolas at August 16th, 2021 , Revised On August 29, 2023

Thematic analysis is one of the most important types of analysis used for qualitative data . When researchers have to analyse audio or video transcripts, they give preference to thematic analysis. A researcher needs to look keenly at the content to identify the context and the message conveyed by the speaker.

Moreover, with the help of this analysis, data can be simplified.  

Importance of Thematic Analysis

Thematic analysis has so many unique and dynamic features, some of which are given below:

Thematic analysis is used because:

• It is flexible.
• It is best for complex data sets.
• It is applied to qualitative data sets.
• It takes less complexity compared to other theories of analysis.

Intellectuals and researchers give preference to thematic analysis due to its effectiveness in the research.

How to Conduct a Thematic Analysis?

While doing any research , if your data and procedure are clear, it will be easier for your reader to understand how you concluded the results . This will add much clarity to your research.

Understand the Data

This is the first step of your thematic analysis. At this stage, you have to understand the data set. You need to read the entire data instead of reading the small portion. If you do not have the data in the textual form, you have to transcribe it.

Example: If you are visiting an adult dating website, you have to make a data corpus. You should read and re-read the data and consider several profiles. It will give you an idea of how adults represent themselves on dating sites. You may get the following results:

I am a tall, single(widowed), easy-going, honest, good listener with a good sense of humor. Being a handyperson, I keep busy working around the house, and I also like to follow my favourite hockey team on TV or spoil my two granddaughters when I get the chance!! Enjoy most music except Rap! I keep fit by jogging, walking, and bicycling (at least three times a week). I have travelled to many places and RVD the South-West U.S., but I would now like to find that special travel partner to do more travel to warm and interesting countries. I now feel it’s time to meet a nice, kind, honest woman who has some of the same interests as I do; to share the happy times, quiet times, and adventures together

I enjoy photography, lapidary & seeking collectibles in the form of classic movies & 33 1/3, 45 & 78 RPM recordings from the 1920s, ’30s & ’40s. I am retired & looking forward to travelling to Canada, the USA, the UK & Europe, China. I am unique since I do not judge a book by its cover. I accept people for who they are. I will not demand or request perfection from anyone until I am perfect, so I guess that means everyone is safe. My musical tastes range from Classical, big band era, early jazz, classic ’50s & 60’s rock & roll & country since its inception.

Development of Initial Coding:

At this stage, you have to do coding. It’s the essential step of your research . Here you have two options for coding. Either you can do the coding manually or take the help of any tool. A software named the NOVIC is considered the best tool for doing automatic coding.

For manual coding, you can follow the steps given below:

• Please write down the data in a proper format so that it can be easier to proceed.
• Use a highlighter to highlight all the essential points from data.
• Make as many points as possible.
• Take notes very carefully at this stage.
• Apply themes as much possible.
• Now check out the themes of the same pattern or concept.
• Turn all the same themes into the single one.

Example: For better understanding, the previously explained example of Step 1 is continued here. You can observe the coded profiles below:

Make Themes

At this stage, you have to make the themes. These themes should be categorised based on the codes. All the codes which have previously been generated should be turned into themes. Moreover, with the help of the codes, some themes and sub-themes can also be created. This process is usually done with the help of visuals so that a reader can take an in-depth look at first glance itself.

Extracted Data Review

Now you have to take an in-depth look at all the awarded themes again. You have to check whether all the given themes are organised properly or not. It would help if you were careful and focused because you have to note down the symmetry here. If you find that all the themes are not coherent, you can revise them. You can also reshape the data so that there will be symmetry between the themes and dataset here.

For better understanding, a mind-mapping example is given here:

Reviewing all the Themes Again

You need to review the themes after coding them. At this stage, you are allowed to play with your themes in a more detailed manner. You have to convert the bigger themes into smaller themes here. If you want to combine some similar themes into a single theme, then you can do it. This step involves two steps for better fragmentation. 

You need to observe the coded data separately so that you can have a precise view. If you find that the themes which are given are following the dataset, it’s okay. Otherwise, you may have to rearrange the data again to coherence in the coded data.

Corpus Data

Here you have to take into consideration all the corpus data again. It would help if you found how themes are arranged here. It would help if you used the visuals to check out the relationship between them. Suppose all the things are not done accordingly, so you should check out the previous steps for a refined process. Otherwise, you can move to the next step. However, make sure that all the themes are satisfactory and you are not confused.

When all the two steps are completed, you need to make a more précised mind map. An example following the previous cases has been given below:

Define all the Themes here

Now you have to define all the themes which you have given to your data set. You can recheck them carefully if you feel that some of them can fit into one concept, you can keep them, and eliminate the other irrelevant themes. Because it should be precise and clear, there should not be any ambiguity. Now you have to think about the main idea and check out that all the given themes are parallel to your main idea or not. This can change the concept for you.

The given names should be so that it can give any reader a clear idea about your findings. However, it should not oppose your thematic analysis; rather, everything should be organised accurately.

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Also, read about discourse analysis , content analysis and survey conducting . we have provided comprehensive guides.

Make a Report

You need to make the final report of all the findings you have done at this stage. You should include the dataset, findings, and every aspect of your analysis in it.

While making the final report , do not forget to consider your audience. For instance, you are writing for the Newsletter, Journal, Public awareness, etc., your report should be according to your audience. It should be concise and have some logic; it should not be repetitive. You can use the references of other relevant sources as evidence to support your discussion.  

Frequently Asked Questions

What is meant by thematic analysis.

Thematic Analysis is a qualitative research method that involves identifying, analyzing, and interpreting recurring themes or patterns in data. It aims to uncover underlying meanings, ideas, and concepts within the dataset, providing insights into participants’ perspectives and experiences.

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The authenticity of dissertation is largely influenced by the research method employed. Here we present the most notable research methods for dissertation.

A survey includes questions relevant to the research topic. The participants are selected, and the questionnaire is distributed to collect the data.

Quantitative research is associated with measurable numerical data. Qualitative research is where a researcher collects evidence to seek answers to a question.

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Most of the data in DDR will be qualitative in nature and best analyzed using a thematic approach such as Clarke and Braun’s 6-step process illustrated below:

Clarke and Braun’s (2013) Six Step Data Analysis Process

The 6-phase coding framework for thematic analysis will be used to identify themes and patterns in the data (Braun & Clarke, 2006). The phases are:

• Familiarization of data.
• Generation of codes.
• Combining codes into themes.
• Reviewing themes.
• Determine significance of themes.
• Reporting of findings.

For survey and other numeric data, descriptive statistics can be generated using EXCEL or SPSS.

Clarke, V. & Braun, V. (2013) Teaching thematic analysis: Overcoming challenges and developing strategies for effective learning. The Psychologist , 26(2), 120-123

Merriam and Tysdale (2016) is considered a seminal source for qualitative methodology. Generic design is discussed on pages 23 to 25.

Merriam, S. & Tysdale, E. (2016). Qualitative research: A guide to design and implementation(4th ed). Jossey-Bass.

Elliott and Timulak (2021) provide a current summary of descriptive design.

Elliott, R. & Timulak, L. (2021). Descriptive-interpretive qualitative research; A generic approach. American Psychological Association. https://soi.org/10.1037/0000224-000  

Kalke (2014) provides overview of generic design including the criticisms. The update, in 2018, reaffirms the 2014 source.

Kalke, R. (2014). Generic qualitative approaches: Pitfalls and benefits of methodological mixology. International Journal of Qualitative Methods, 13 , 37-52. Retrieved from https://journals.sagepub.com/doi/full/10.1177/160940691401300119

Kalke, R., (2018). Reflection/commentary on a past article” Generic qualitative approaches; Pitfalls and benefits of methodological mixology. International Journal of Qualitative Methods . https://journals.sagepub.com/doi/full/10.1177/1609406918788193  

Descriptive Design has been described in the qualitative research literature since the early 2000’s. Prior to that, it was not considered a non-categorial design lacking in rigor. The following articles address those criticisms and provide insight into how to best design a study using a descriptive approach.

Caelli, K., Ray, L., & Mill, J. (2003). Clear as mud: Towards a greater clarity in generic qualitative research. International Journal of Qualitative Methods, 2( 2), 1 – 23. https://journals.sagepub.com/doi/pdf/10.1177/160940690300200201

Percy, W., Kostere, K., & Kostere, S. (2015). Generic qualitative research in psychology. The Qualitative Report, 20 (2), 76-85. https://nsuworks.nova.edu/tqr/vol20/iss2/7/

Sandelowski, M. (2000). Focus on research methods-Whatever happened to qualitative description? Research in Nursing and Health, 23 (4), 334-340. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.461.4974&rep=rep1&type=pdf

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A worked example of Braun and Clarke’s approach to reflexive thematic analysis

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• Published: 26 June 2021
• Volume 56 , pages 1391–1412, ( 2022 )

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• David Byrne   ORCID: orcid.org/0000-0002-0587-4677 1  

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Since the publication of their inaugural paper on the topic in 2006, Braun and Clarke’s approach has arguably become one of the most thoroughly delineated methods of conducting thematic analysis (TA). However, confusion persists as to how to implement this specific approach to TA appropriately. The authors themselves have identified that many researchers who purport to adhere to this approach—and who reference their work as such—fail to adhere fully to the principles of ‘reflexive thematic analysis’ (RTA). Over the course of numerous publications, Braun and Clarke have elaborated significantly upon the constitution of RTA and attempted to clarify numerous misconceptions that they have found in the literature. This paper will offer a worked example of Braun and Clarke’s contemporary approach to reflexive thematic analysis with the aim of helping to dispel some of the confusion regarding the position of RTA among the numerous existing typologies of TA. While the data used in the worked example has been garnered from health and wellbeing education research and was examined to ascertain educators’ attitudes regarding such, the example offered of how to implement the RTA would be easily transferable to many other contexts and research topics.

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1 Introduction

Although the lineage of thematic analysis (TA) can be traced back as far as the early twentieth century (Joffe 2012 ), it has up until recently been a relatively poorly demarcated and poorly understood method of qualitative analysis. Much of the credit for the recent enlightenment and subsequent increase in interest in TA can arguably be afforded to Braun and Clarke’s ( 2006 ) inaugural publication on the topic of thematic analysis in the field of psychology. These authors have since published several articles and book chapters, as well as their own book, all of which make considerable contributions to further delineating their approach to TA (see, for example, Braun and Clarke 2012 , 2013 , 2014 , 2019 , 2020 ; Braun et al. 2016 ; Terry et al. 2017 ). However, on numerous occasions Braun and Clarke have identified a tendency for scholars to cite their 2006 article, but fail to fully adhere to their contemporary approach to RTA (see Braun and Clarke 2013 , 2019 , 2020 ). Commendably, they have acknowledged that their 2006 paper left several aspect of their approach incompletely defined and open to interpretation. Indeed, the term ‘reflexive thematic analysis’ only recently came about in response to these misconceptions (Braun and Clarke 2019 ). Much of their subsequent body of literature in this area addresses these issues and attempts to correct some of the misconceptions in the wider literature regarding their approach. Braun and Clarke have repeatedly iterated that researchers who chose to adopt their approach should interrogate their relevant publications beyond their 2006 article and adhere to their contemporary approach (Braun and Clarke 2019 , 2020 ). The purpose of this paper is to contribute to dispelling some of the confusion and misconceptions regarding Braun and Clarke’s approach by providing a worked example of their contemporary approach to reflexive thematic analysis. The worked example will be presented in relation to the author’s own research, which examined the attitudes of post-primary educators’ regarding the promotion of student wellbeing. This paper is intended to be a supplementary resource for any prospective proponents of RTA, but may be of particular interest to scholars conducting attitudinal studies in an educational context. While this paper is aimed at all scholars regardless of research experience, it may be most useful to research students and their supervisors. Ultimately, the provided example of how to implement the six-phase analysis is easily transferable to many contexts and research topics.

2 What is reflexive thematic analysis?

Reflexive thematic analysis is an easily accessible and theoretically flexible interpretative approach to qualitative data analysis that facilitates the identification and analysis of patterns or themes in a given data set (Braun and Clarke 2012 ). RTA sits among a number of varied approaches to conducting thematic analysis. Braun and Clarke have noted that very often, researchers who purport to have adopted RTA have failed to fully delineate their implementation of RTA, of have confused RTA with other approaches to thematic analysis. The over-riding tendency in this regard is for scholars to mislabel their analysis as RTA, or to draw from a number of different approaches to TA, some of which may not be compatible with each other (Braun and Clarke 2012 , 2013 , 2019 ; Terry et al. 2017 ). In an attempt to resolve this confusion, Braun and Clarke have demarcated the position of RTA among the other forms of thematic analysis by differentiating between three principal approaches to TA: (1) coding reliability TA; (2) codebook approaches to TA, and; (3) the reflexive approach to TA (Braun et al. 2019 ).

Coding reliability approaches, such as those espoused by Boyatzis ( 1998 ) and Joffe ( 2012 ), accentuate the measurement of accuracy or reliability when coding data, often involving the use of a structured codebook. The researcher would also seek a degree of consensus among multiple coders, which can be measured using Cohen’s Kappa (Braun and Clarke 2013 ). When adopting a coding reliability approach, themes tend to be developed very early in the analytical process. Themes can be hypothesised based on theory prior to data collection, with evidence to support these hypotheses then gathered from the data in the form of codes. Alternatively, themes can be hypothesised following a degree of familiarisation with the data (Terry et al. 2017 ). Themes are typically understood to constitute ‘domain summaries’, or “summaries of what participants said in relation to a particular topic or data collection question” (Braun et al. 2019 , p. 5), and are likely to be discussed as residing within the data in a positivistic sense.

Codebook approaches, such as framework analysis (Smith and Firth 2011 ) or template analysis (King and Brooks 2017 ), can be understood to be something of a mid-point between coding reliability approaches and the reflexive approach. Like coding reliability approaches, codebook approaches adopt the use of a structured codebook and share the conceptualisation of themes as domain summaries. However, codebook approaches are more akin to the reflexive approach in terms of the prioritisation of a qualitative philosophy with regard to coding. Proponents of codebook approaches would typically forgo positivistic conceptions of coding reliability, instead recognising the interpretive nature of data coding (Braun et al. 2019 ).

The reflexive approach to TA highlights the researcher’s active role in knowledge production (Braun and Clarke 2019 ). Codes are understood to represent the researcher’s interpretations of patterns of meaning across the dataset. Reflexive thematic analysis is considered a reflection of the researcher’s interpretive analysis of the data conducted at the intersection of: (1) the dataset; (2) the theoretical assumptions of the analysis, and; (3) the analytical skills/resources of the researcher (Braun and Clarke 2019 ). It is fully appreciated—even expected—that no two researchers will intersect this tripartite of criteria in the same way. As such, there should be no expectation that codes or themes interpreted by one researcher may be reproduced by another (although, this is of course possible). Prospective proponents of RTA are discouraged from attempting to provide accounts of ‘accurate’ or ‘reliable’ coding, or pursuing consensus among multiple coders or using Cohen’s Kappa values. Rather, RTA is about “the researcher’s reflective and thoughtful engagement with their data and their reflexive and thoughtful engagement with the analytic process” (Braun and Clarke 2019 , p. 594). Multiple coders may, however, be beneficial in a reflexive manner (e.g. to sense-check ideas, or to explore multiple assumptions or interpretations of the data). If analysis does involve more than one researcher, the approach should be collaborative and reflexive, aiming to achieve richer interpretations of meaning, rather than attempting to achieve consensus of meaning. Indeed, in this sense it would be beneficial for proponents of RTA to remain cognisant that qualitative analysis as a whole does not contend to provide a single or ‘correct’ answer (Braun and Clarke 2013 ).

The process of coding (and theme development) is flexible and organic, and very often will evolve throughout the analytical process (Braun et al. 2019 ). Progression through the analysis will tend to facilitate further familiarity with the data, which may in turn result in the interpretation of new patterns of meaning. This is converse to the use of codebooks, which can often predefine themes before coding. Through the reflexive approach, themes are not predefined in order to ‘find’ codes. Rather, themes are produced by organising codes around a relative core commonality, or ‘central organising concept’, that the researcher interprets from the data (Braun and Clarke 2019 ).

In their 2006 paper, Braun and Clarke ( 2006 ) originally conceptualised RTA as a paradigmatically flexible analytical method, suitable for use within a wide range of ontological and epistemological considerations. In recent publications, the authors have moved away from this view, instead defining RTA as a purely qualitative approach. This pushes the use RTA into exclusivity under appropriate qualitative paradigms (e.g. constructionism) (Braun and Clarke 2019 , 2020 ). As opposed to other forms of qualitative analysis such as content analysis (Vaismoradi et al. 2013 ), and even other forms of TA such as Boyatzis’ ( 1998 ) approach, RTA eschews any positivistic notions of data interpretation. Braun and Clarke ( 2019 ) encourage the researcher to embrace reflexivity, subjectivity and creativity as assets in knowledge production, where they argue some scholars, such as Boyatzis ( 1998 ), may otherwise construe these assets as threats.

3 A worked example of reflexive thematic analysis

The data used in the following example is taken from the qualitative phase of a mixed methods study I conducted, which examined mental health in an educational context. This study set out to understand the attitudes and opinions of Irish post-primary educators with regard to the promotion of students’ social and emotional wellbeing, with the intention to feed this information back to key governmental and non-governmental stakeholders such as the National Council for Curriculum and Assessment and the Department of Education. The research questions for this study aimed to examine educators’ general attitudes toward the promotion of student wellbeing and towards a set of ‘wellbeing guidelines’ that had recently been introduced in Irish post-primary schools. I also wanted to identify any potential barriers to wellbeing promotion and to solicit educators’ opinions as to what might constitute apposite remedial measures in this regard.

The qualitative phase of this study, from which the data for this example is garnered, involved eleven semi-structured interviews, which lasted approximately 25–30 min each. Participants consisted of core-curriculum teachers, wellbeing curriculum teachers, pastoral care team-members and senior management members. Participants were questioned on their attitudes regarding the promotion of student wellbeing, the wellbeing curriculum, the wellbeing guidelines and their perceptions of their own wellbeing. When conducting these interviews, I loosely adhered to an interview agenda to ensure each of these four key topics were addressed. However, discussions were typically guided by what I interpreted to be meaningful to the interviewee, and would often weave in and out of these different topics.

The research questions for this study were addressed within a paradigmatic framework of interpretivism and constructivism. A key principle I adopted for this study was to reflect educators’ own accounts of their attitudes, opinions and experiences as faithfully as was possible, while also accounting for the reflexive influence of my own interpretations as the researcher. I felt RTA was highly appropriate in the context of the underlying theoretical and paradigmatic assumptions of my study and would allow me to ensure qualitative data was collected and analysed in a manner that respected and expressed the subjectivity of participants’ accounts of their attitudes, while also acknowledging and embracing the reflexive influence of my interpretations as the researcher.

In the next section, I will outline the theoretical assumptions of the RTA conducted in my original study in more detail. It should be noted that outlining these theoretical assumptions is not a task specific to reflexive thematic analysis. Rather, these assumptions should be addressed prior to implementing any form of thematic analysis (Braun and Clarke 2012 , 2019 , 2020 ; Braun et al. 2016 ). The six-phase process for conducting reflexive thematic analysis will then be appropriately detailed and punctuated with examples from my study.

3.1 Addressing underlying theoretical assumptions

Across several publications, Braun and Clarke ( 2012 , 2014 , 2020 ) have identified a number of theoretical assumptions that should be addressed when conducting RTA, or indeed any form of thematic analysis. These assumptions are conceptualised as a series of continua as follows: essentialist versus constructionist epistemologies; experiential versus critical orientation to data; inductive versus deductive analyses, and; semantic versus latent coding of data. The aim is not just for the researcher to identify where their analysis is situated on each of these continua, but why the analysis is situated as it is and why this conceptualisation is appropriate to answering the research question(s).

3.1.1 Essentialist versus constructionist epistemologies

Ontological and epistemological considerations would usually be determined when a study is first being conceptualised. However, these considerations may become salient again when data analysis becomes the research focus, particularly with regard to mixed methods. The purpose of addressing this continuum is to conceptualise theoretically how the researcher understands their data and the way in which the reader should interpret the findings (Braun and Clarke 2013 , 2014 ). By adhering to essentialism, the researcher adopts a unidirectional understanding of the relationship between language and communicated experience, in that it is assumed that language is a simple reflection of our articulated meanings and experiences (Widdicombe and Wooffiitt 1995 ). The meanings and systems inherent in constructing these meanings are largely uninterrogated, with the interpretive potential of TA largely unutilised (Braun et al. 2016 ).

Conversely, researchers of a constructionist persuasion would tend to adopt a bidirectional understanding of the language/experience relationship, viewing language as implicit in the social production and reproduction of both meaning and experience (Burr 1995 ; Schwandt 1998 ). A constructionist epistemology has particular implications with regard to thematic analysis, namely that in addition to the recurrence of perceptibly important information, meaningfulness is highly influential in the development and interpretation of codes and themes. The criteria for a theme to be considered noteworthy via recurrence is simply that the theme should present repeatedly within the data. However, what is common is not necessarily meaningful or important to the analysis. Braun and Clarke ( 2012 , p. 37) offer this example:

…in researching white-collar workers’ experiences of sociality at work, a researcher might interview people about their work environment and start with questions about their typical workday. If most or all reported that they started work at around 9:00 a.m., this would be a pattern in the data, but it would not necessarily be a meaningful or important one.

Furthermore, there may be varying degrees of conviction in respondents’ expression when addressing different issues that may facilitate in identifying the salience of a prospective theme. Therefore, meaningfulness can be conceptualised, firstly on the part of the researcher, with regard to the necessity to identify themes that are relevant to answering the research questions, and secondly on the part of the respondent, as the expression of varying degrees of importance with regard to the issues being addressed. By adopting a constructionist epistemology, the researcher acknowledges the importance of recurrence, but appreciates meaning and meaningfulness as the central criteria in the coding process.

In keeping with the qualitative philosophy of RTA, epistemological consideration regarding the example data were constructionist. As such, meaning and experience was interpreted to be socially produced and reproduced via an interplay of subjective and inter-subjective construction. Footnote 1

3.1.2 Experiential versus critical orientation

An experiential orientation to understanding data typically prioritises the examination of how a given phenomenon may be experienced by the participant. This involves investigating the meaning ascribed to the phenomenon by the respondent, as well as the meaningfulness of the phenomenon to the respondent. However, although these thoughts, feelings and experiences are subjectively and inter-subjectively (re)produced, the researcher would cede to the meaning and meaningfulness ascribed by the participant (Braun and Clarke 2014 ). Adopting an experiential orientation requires an appreciation that the thoughts, feelings and experiences of participants are a reflection of personal states held internally by the participant. Conversely, a critical orientation appreciates and analyses discourse as if it were constitutive, rather than reflective, of respondents’ personal states (Braun and Clarke 2014 ). As such, a critical perspective seeks to interrogate patterns and themes of meaning with a theoretical understanding that language can create, rather than merely reflect, a given social reality (Terry et al. 2017 ). A critical perspective can examine the mechanisms that inform the construction of systems of meaning, and therefore offer interpretations of meaning further to those explicitly communicated by participants. It is then also possible to examine how the wider social context may facilitate or impugn these systems of meaning (Braun and Clarke 2012 ). In short, the researcher uses this continuum to clarify their intention to reflect the experience of a social reality (experiential orientation) or examine the constitution of a social reality (critical orientation).

In the present example, an experiential orientation to data interpretation was adopted in order to emphasise meaning and meaningfulness as ascribed by participants. Adopting this approach meant that this analysis did not seek to make claims about the social construction of the research topic (which would more so necessitate a critical perspective), but rather acknowledged the socially constructed nature of the research topic when examining the subjective ‘personal states’ of participants. An experiential orientation was most appropriate as the aim of the study was to prioritise educators’ own accounts of their attitudes, opinions. More importantly, the research questions aimed to examine educators’ attitudes regarding their experience of promoting student wellbeing—or the ‘meanings made’—and not, for example, the socio-cultural factors that may underlie the development of these attitudes—or the ‘meaning making’.

3.1.3 Inductive versus deductive analysis

A researcher who adopts a deductive or ‘theory-driven’ approach may wish to produce codes relative to a pre-specified conceptual framework or codebook. In this case, the analysis would tend to be ‘analyst-driven’, predicated on the theoretically informed interpretation of the researcher. Conversely, a researcher who adopts an inductive or ‘data-driven’ approach may wish to produce codes that are solely reflective of the content of the data, free from any pre-conceived theory or conceptual framework. In this case, data are not coded to fit a pre-existing coding frame, but instead ‘open-coded’ in order to best represent meaning as communicated by the participants (Braun and Clarke 2013 ). Data analysed and coded deductively can often provide a less rich description of the overall dataset, instead focusing on providing a detailed analysis of a particular aspect of the dataset interpreted through a particular theoretical lens (Braun and Clarke 2020 ). Deductive analysis has typically been associated with positivistic/essentialist approaches (e.g. Boyatzis 1998 ), while inductive analysis tends to be aligned with constructivist approaches (e.g. Frith and Gleeson 2004 ). That being said, inductive/deductive approaches to analysis are by no means exclusively or intrinsically linked to a particular epistemology.

Coding and analysis rarely fall cleanly into one of these approaches and, more often than not, use a combination of both (Braun and Clarke 2013 , 2019 , 2020 ). It is arguably not possible to conduct an exclusively deductive analysis, as an appreciation for the relationship between different items of information in the data set is necessary in order to identify recurring commonalities with regard to a pre-specified theory or conceptual framework. Equally, it is arguably not possible to conduct an exclusively inductive analysis, as the researcher would require some form of criteria to identify whether or not a piece of information may be conducive to addressing the research question(s), and therefore worth coding. When addressing this issue, Braun and Clarke ( 2012 ) clarify that one approach does tend to predominate over the other, and that the predominance of the deductive or inductive approach can indicate an overall orientation towards prioritising either researcher/theory-based meaning or respondent/data-based meaning, respectively.

A predominantly inductive approach was adopted in this example, meaning data was open-coded and respondent/data-based meanings were emphasised. A degree of deductive analysis was, however, employed to ensure that the open-coding contributed to producing themes that were meaningful to the research questions, and to ensure that the respondent/data-based meanings that were emphasised were relevant to the research questions.

3.1.4 Semantic versus latent coding

Semantic codes are identified through the explicit or surface meanings of the data. The researcher does not examine beyond what a respondent has said or written. The production of semantic codes can be described as a descriptive analysis of the data, aimed solely at presenting the content of the data as communicated by the respondent. Latent coding goes beyond the descriptive level of the data and attempts to identify hidden meanings or underlying assumptions, ideas, or ideologies that may shape or inform the descriptive or semantic content of the data. When coding is latent, the analysis becomes much more interpretive, requiring a more creative and active role on the part of the researcher. Indeed, Braun and Clarke ( 2012 , 2013 , 2020 ) have repeatedly presented the argument that codes and themes do not ‘emerge’ from the data or that they may be residing in the data, waiting to be found. Rather, the researcher plays an active role in interpreting codes and themes, and identifying which are relevant to the research question(s). Analyses that use latent coding can often overlap with aspects of thematic discourse analysis in that the language used by the respondent can be used to interpret deeper levels of meaning and meaningfulness (Braun and Clarke 2006 ).

In this example, both semantic and latent coding were utilised. No attempt was made to prioritise semantic coding over latent coding or vice-versa. Rather, semantic codes were produced when meaningful semantic information was interpreted, and latent codes were produced when meaningful latent information was interpreted. As such, any item of information could be double-coded in accordance with the semantic meaning communicated by the respondent, and the latent meaning interpreted by the researcher (Patton 1990 ). This was reflective of the underlying theoretical assumptions of the analysis, as the constructive and interpretive epistemology and ontology were addressed by affording due consideration to both the meaning constructed and communicated by the participant and my interpretation of this meaning as the researcher.

3.2 The six-phase analytical process

Braun and Clarke ( 2012 , 2013 , 2014 , 2020 ) have proposed a six-phase process, which can facilitate the analysis and help the researcher identify and attend to the important aspects of a thematic analysis. In this sense, Braun and Clarke ( 2012 ) have identified the six-phase process as an approach to doing TA, as well as learning how to do TA. While the six phases are organised in a logical sequential order, the researcher should be cognisant that the analysis is not a linear process of moving forward through the phases. Rather, the analysis is recursive and iterative, requiring the researcher to move back and forth through the phases as necessary (Braun and Clarke 2020 ). TA is a time consuming process that evolves as the researcher navigates the different phases. This can lead to new interpretations of the data, which may in turn require further iterations of earlier phases. As such, it is important to appreciate the six-phase process as a set of guidelines, rather than rules, that should be applied in a flexible manner to fit the data and the research question(s) (Braun and Clarke 2013 , 2020 ).

3.2.1 Phase one: familiarisation with the data

The ‘familiarisation’ phase is prevalent in many forms of qualitative analysis. Familiarisation entails the reading and re-reading of the entire dataset in order to become intimately familiar with the data. This is necessary to be able to identify appropriate information that may be relevant to the research question(s). Manual transcription of data can be a very useful activity for the researcher in this regard, and can greatly facilitate a deep immersion into the data. Data should be transcribed orthographically, noting inflections, breaks, pauses, tones, etc. on the part of both the interviewer and the participant (Braun and Clarke 2013 ). Often times, data may not have been gathered or transcribed by the researcher, in which case, it would be beneficial for the researcher to watch/listen to video or audio recordings to achieve a greater contextual understanding of the data. This phase can be quite time consuming and requires a degree of patience. However, it is important to afford equal consideration across the entire depth and breadth of the dataset, and to avoid the temptation of being selective of what to read, or even ‘skipping over’ this phase completely (Braun and Clarke 2006 ).

At this phase, I set about familiarising myself with the data by firstly listening to each interview recording once before transcribing that particular recording. This first playback of each interview recording required ‘active listening’ and, as such, I did not take any notes at this point. I performed this active-listen in order to develop an understanding of the primary areas addressed in each interview prior to transcription. This also provided me an opportunity, unburdened by tasks such as note taking, to recall gestures and mannerisms that may or may not have been documented in interview notes. I manually transcribed each interview immediately after the active-listen playback. When transcription of all interviews was complete, I read each transcripts numerous times. At this point, I took note of casual observations of initial trends in the data and potentially interesting passages in the transcripts. I also documented my thoughts and feelings regarding both the data and the analytical process (in terms of transparency, it would be beneficial to adhere to this practice throughout the entire analysis). Some preliminary notes made during the early iterations of familiarisation with the data can be seen in Box 1. It will be seen later that some of these notes would go on to inform the interpretation of the finalised thematic framework.

Example of preliminary notes taken during phase one

3.2.2 Phase two: generating initial codes

Codes are the fundamental building blocks of what will later become themes. The process of coding is undertaken to produce succinct, shorthand descriptive or interpretive labels for pieces of information that may be of relevance to the research question(s). It is recommended that the researcher work systematically through the entire dataset, attending to each data item with equal consideration, and identifying aspects of data items that are interesting and may be informative in developing themes. Codes should be brief, but offer sufficient detail to be able to stand alone and inform of the underlying commonality among constituent data items in relation to the subject of the research (Braun and Clarke 2012 ; Braun et al. 2016 ).

A brief excerpt of the preliminary coding process of one participant’s interview transcript is presented in Box 2. The preliminary iteration of coding was conducted using the ‘comments’ function in Microsoft Word (2016). This allowed codes to be noted in the side margin, while also highlighting the area of text assigned to each respective code. This is a relatively straightforward example with no double-codes or overlap in data informing different codes, as new codes begin where previous codes end. The code C5 offers an exemplar of the provision of sufficient detail to explain what I interpreted from the related data item. A poor example of this code would be to say “the wellbeing guidelines are not relatable” or “not relatable for students”. Each of these examples lack context. Understanding codes written in this way would be contingent upon knowledge of the underlying data extract. The code C8 exemplifies this issue. It is unclear if the positivity mentioned relates to the particular participant, their colleagues, or their students. This code was subsequently redefined in later iterations of coding. It can also be seen in this short example that the same code has been produced for both C4 and C9. This code was prevalent throughout the entire dataset and would subsequently be informative in the development of a theme.

Extract of preliminary coding

Any item of data that might be useful in addressing the research question(s) should be coded. Through repeated iterations of coding and further familiarisation, the researcher can identify which codes are conducive to interpreting themes and which can be discarded. I would recommend that the researcher document their progression through iterations of coding to track the evolution of codes and indeed prospective themes. RTA is a recursive process and it is rare that a researcher would follow a linear path through the six phases (Braun and Clarke 2014 ). It is very common for the researcher to follow a particular train of thought when coding, only to encounter an impasse where several different interpretations of the data come to light. It may be necessary to explore each of these prospective options to identify the most appropriate path to follow. Tracking the evolution of codes will not only aid transparency, but will afford the researcher signposts and waypoints to which they may return should a particular approach to coding prove unfruitful. I tracked the evolution of my coding process in a spreadsheet, with data items documented in the first column and iterations of codes in each successive column. I found it useful to highlight which codes were changed in each successive iteration. Table 1 provides an excerpt of a Microsoft Excel (2016) spreadsheet that was established to track iterations of coding and document the overall analytical process. All codes developed during the first iteration of coding were transferred into this spreadsheet along with a label identifying the respective participant. Subsequent iterations of coding were documented in this spreadsheet. The original transcripts were still regularly consulted to assess existing codes and examine for the interpretation of new codes as further familiarity with the data developed. Column one presents a reference number for the data item that was coded, while column two indicates the participant who provided each data item. Column three presents the data item that was coded. Columns four and five indicate the iteration of the coding process to be the third and fourth iteration, respectively. Codes revised between iterations three and four are highlighted.

With regard to data item one, I initially considered that a narrative might develop exploring a potential discrepancy in levels of training received by wellbeing educators and non-wellbeing educators. In early iterations of coding, I adopted a convention of coding training-related information with reference to the wellbeing or non-wellbeing status of the participant. While this discrepancy in levels of training remained evident throughout the dataset, I eventually deemed it unnecessary to pursue interpretation of the data in this way. This coding convention was abandoned at iteration four in favour of the pre-existing generalised code “insufficient training in wellbeing curriculum”. With data item three, I realised that the code was descriptive at a semantic level, but not very informative. Upon re-evaluating this data item, I found the pre-existing code “lack of clarity in assessing student wellbeing” to be much more appropriate and representative of what the participant seemed to be communicating. Finally, I realised that the code for data item five was too specific to this particular data item. No other data item shared this code, which would preclude this code (and data item) from consideration when construction themes. I decided that this item would be subsumed under the pre-existing code “more training is needed for wellbeing promotion”.

The process of generating codes is non-prescriptive regarding how data is segmented and itemised for coding, and how many codes or what type of codes (semantic or latent) are interpreted from an item of data. The same data item can be coded both semantically and latently if deemed necessary. For example, when discussing how able they felt to attend to their students’ wellbeing needs, one participant stated “…if someone’s struggling a bit with their schoolwork and it’s getting them down a bit, it’s common sense that determines what we say to them or how we approach them. And it might help to talk, but I don’t know that it has a lasting effect” [2B]. Here, I understood that the participant was explicitly sharing the way in which they address their students’ wellbeing concerns, but also that the participant was implying that this commonsense approach might not be sufficient. As such, this data item was coded both semantically as “educators rely on common sense when attending to wellbeing issues”, and latently as “common sense inadequate for wellbeing promotion”. Both codes were revised later in the analysis. However, this example illustrates the way in which any data item can be coded in multiple ways and for multiple meanings. There is also no upper or lower limit regarding how many codes should be interpreted. What is important is that, when the dataset is fully coded and codes are collated, sufficient depth exists to examine the patterns within the data and the diversity of the positions held by participants. It is, however, necessary to ensure that codes pertain to more than one data item (Braun and Clarke 2012 ).

3.2.3 Phase three: generating themes

This phase begins when all relevant data items have been coded. The focus shifts from the interpretation of individual data items within the dataset, to the interpretation of aggregated meaning and meaningfulness across the dataset. The coded data is reviewed and analysed as to how different codes may be combined according to shared meanings so that they may form themes or sub-themes. This will often involve collapsing multiple codes that share a similar underlying concept or feature of the data into one single code. Equally, one particular code may turn out to be representative of an over-arching narrative within the data and be promoted as a sub-theme or even a theme (Braun and Clarke 2012 ). It is important to re-emphasise that themes do not reside in the data waiting to be found. Rather, the researcher must actively construe the relationship among the different codes and examine how this relationship may inform the narrative of a given theme. Construing the importance or salience of a theme is not contingent upon the number of codes or data items that inform a particular theme. What is important is that the pattern of codes and data items communicates something meaningful that helps answer the research question(s) (Braun and Clarke 2013 ).

Themes should be distinctive and may even be contradictory to other themes, but should tie together to produce a coherent and lucid picture of the dataset. The researcher must be able and willing to let go of codes or prospective themes that may not fit within the overall analysis. It may be beneficial to construct a miscellaneous theme (or category) to contain all the codes that do not appear to fit in among any prospective themes. This miscellaneous theme may end up becoming a theme in its own right, or may simple be removed from the analysis during a later phase (Braun and Clarke 2012 ). Much the same as with codes, there is no correct amount of themes. However, with too many themes the analysis may become unwieldy and incoherent, whereas too few themes can result in the analysis failing to explore fully the depth and breadth of the data. At the end of this stage, the researcher should be able to produce a thematic map (e.g. a mind map or affinity map) or table that collates codes and data items relative to their respective themes (Braun and Clarke 2012 , 2020 ).

At this point in the analysis, I assembled codes into initial candidate themes. A thematic map of the initial candidate themes can be seen in Fig.  1 . The theme “best practice in wellbeing promotion” was clearly definable, with constituent coded data presenting two concurrent narratives. These narratives were constructed as two separate sub-themes, which emphasised the involvement of the entire school staff and the active pursuit of practical measures in promoting student wellbeing, respectively. The theme “recognising student wellbeing” was similarly clear. Again, I interpreted a dichotomy of narratives. However, in this case, the two narratives seemed to be even more synergetic. The two sub-themes for “best practice…” highlighted two independently informative factors in best practice. Here, the sub-themes are much more closely related, with one sub-theme identifying factors that may inhibit the development of student wellbeing, while the second sub-theme discusses factors that may improve student wellbeing. At this early stage in the analysis, I was considering that this sub-theme structure might also be used to delineate the theme “recognising educator wellbeing”. Finally, the theme “factors influencing wellbeing promotion” collated coded data items that addressed inhibitive factors with regard to wellbeing promotion. These factors were conceptualised as four separate sub-themes reflecting a lack of training, a lack of time, a lack of appropriate value for wellbeing promotion, and a lack of knowledge of supporting wellbeing-related documents. While it was useful to bring all of this information together under one theme, even at this early stage it was evident that this particular theme was very dense and unwieldy, and would likely require further revision.

Initial thematic map indicating four candidate themes

3.2.4 Phase four: reviewing potential themes

This phase requires the researcher to conduct a recursive review of the candidate themes in relation to the coded data items and the entire dataset (Braun and Clarke 2012 , 2020 ). At this phase, it is not uncommon to find that some candidate themes may not function well as meaningful interpretations of the data, or may not provide information that addresses the research question(s). It may also come to light that some of the constituent codes and/or data items that inform these themes may be incongruent and require revision. Braun and Clarke ( 2012 , p. 65) proposed a series of key questions that the researcher should address when reviewing potential themes. They are:

Is this a theme (it could be just a code)?

If it is a theme, what is the quality of this theme (does it tell me something useful about the data set and my research question)?

What are the boundaries of this theme (what does it include and exclude)?

Are there enough (meaningful) data to support this theme (is the theme thin or thick)?

Are the data too diverse and wide ranging (does the theme lack coherence)?

The analysis conducted at this phase involves two levels of review. Level one is a review of the relationships among the data items and codes that inform each theme and sub-theme. If the items/codes form a coherent pattern, it can be assumed that the candidate theme/sub-theme makes a logical argument and may contribute to the overall narrative of the data. At level two, the candidate themes are reviewed in relation to the data set. Themes are assessed as to how well they provide the most apt interpretation of the data in relation to the research question(s). Braun and Clarke have proposed that, when addressing these key questions, it may be useful to observe Patton’s ( 1990 ) ‘dual criteria for judging categories’ (i.e. internal homogeneity and external heterogeneity). The aim of Patton’s dual criteria would be to observe internal homogeneity within themes at the level one review, while observing external heterogeneity among themes at the level two review. Essentially, these two levels of review function to demonstrate that items and codes are appropriate to inform a theme, and that a theme is appropriate to inform the interpretation of the dataset (Braun and Clarke 2006 ). The outcome of this dual-level review is often that some sub-themes or themes may need to be restructured by adding or removing codes, or indeed adding or removing themes/sub-themes. The finalised thematic framework that resulted from the review of the candidate themes can be seen in Fig.  2 .

Finalised thematic map demonstrating five themes

During the level one review, inspection of the prospective sub-theme “sources of negative affect” in relation to the theme “recognising educator wellbeing” resulted in a new interpretation of the constituent coded data items. Participants communicated numerous pre-existing work-related factors that they felt had a negative impact upon their wellbeing. However, it was also evident that participants felt the introduction of the new wellbeing curriculum and the newly mandated task of formally attending to student wellbeing had compounded these pre-existing issues. While pre-existing issues and wellbeing-related issues were both informative of educators’ negative affect, the new interpretation of this data informed the realisation of two concurrent narratives, with wellbeing-related issues being a compounding factor in relation to pre-existing issues. This resulted in the “sources of negative affect” sub-theme being split into two new sub-themes; “work-related negative affect” and “the influence of wellbeing promotion”. The “actions to improve educator wellbeing” sub-theme was folded into these sub-themes, with remedial measures for each issue being discussed in respective sub-themes.

During the level two review, my concerns regarding the theme “factors inhibiting wellbeing promotion” were addressed. With regard to Braun and Clarke’s key questions, it was quite difficult to identify the boundaries of this theme. It was also particularly dense (or too thick) and somewhat incoherent. At this point, I concluded that this theme did not constitute an appropriate representation of the data. Earlier phases of the analysis were reiterated and new interpretations of the data were developed. This candidate theme was subsequently broken down into three separate themes. While the sub-themes of this candidate theme were, to a degree, informative in the development of the new themes, the way in which the constituent data was understood was fundamentally reconceptualised. The new theme, entitled “the influence of time”, moves past merely describing time constraints as an inhibitive factor in wellbeing promotion. A more thorough account of the bi-directional nature of time constraints was realised, which acknowledged that previously existing time constraints affected wellbeing promotion, while wellbeing promotion compounded previously existing time constraints. This added an analysis of the way in which the introduction of wellbeing promotion also produced time constraints in relation to core curricular activities.

The candidate sub-themes “lack of training” and “knowledge of necessary documents” were re-evaluated and considered to be topical rather than thematic aspects of the data. Upon further inspection, I felt that the constituent coded data items of these two sub-themes were informative of a single narrative of participants attending to their students’ wellbeing in an atheoretical manner. As such, these two candidate sub-themes were folded into each other to produce the theme “incompletely theorised agreements”. Finally, the level two review led me to the conclusion that the full potential of the data that informed the candidate sub-theme “lack of value of wellbeing promotion” was not realised. I found that a much richer understanding of this data was possible, which was obscured by the initial, relatively simplistic, descriptive account offered. An important distinction was made, in that participants held differing perceptions of the value attributed to wellbeing promotion by educators and by students. Further, I realised that educators’ perceptions of wellbeing promotion were not necessarily negative and should not be exclusively presented as an inhibitive factor in wellbeing promotion. A new theme, named “the axiology of wellbeing” and informed by the sub-themes “students’ valuation of wellbeing promotion” and “educators’ valuation of wellbeing promotion”, was developed to delineate this multifaceted understanding of participants’ accounts of the value of wellbeing promotion.

It is quite typical at this phase that codes, as well as themes, may be revised or removed to facilitate the most meaningful interpretation of the data. As such, it may be necessary to reiterate some of the activities undertaken during phases two and three of the analysis. It may be necessary to recode some data items, collapse some codes into one, remove some codes, or promote some codes as sub-themes or themes. For example, when re-examining the data items that informed the narrative of the value ascribed to wellbeing promotion, I observed that participants offered very different perceptions of the value ascribed by educators and by students. To pursue this line of analysis, numerous codes were reconceptualised to reflect the two different perspectives. Codes such as “positivity regarding the wellbeing curriculum” were split into the more specified codes “student positivity regarding the wellbeing curriculum” and “educator positivity regarding the wellbeing curriculum”. Amending codes in this way ultimately contributed to the reinterpretation of the data and the development of the finalised thematic map.

As with all other phases, it is very important to track and document all of these changes. With regard to some of the more significant changes (removing a theme, for example), I would recommend making notes on why it might be necessary to take this action. The aim of this phase is to produce a revised thematic map or table that captures the most important elements of the data in relation to the research question(s).

3.2.5 Phase five: defining and naming theme

At this phase, the researcher is tasked with presenting a detailed analysis of the thematic framework. Each individual theme and sub-theme is to be expressed in relation to both the dataset and the research question(s). As per Patton’s ( 1990 ) dual criteria, each theme should provide a coherent and internally consistent account of the data that cannot be told by the other themes. However, all themes should come together to create a lucid narrative that is consistent with the content of the dataset and informative in relation to the research question(s). The names of the themes are also subject to a final revision (if necessary) at this point.

Defining themes requires a deep analysis of the underlying data items. There will likely be many data items underlying each theme. It is at this point that the researcher is required to identify which data items to use as extracts when writing up the results of the analysis. The chosen extracts should provide a vivid and compelling account of the arguments being made by a respective theme. Multiple extracts should be used from the entire pool of data items that inform a theme in order to convey the diversity of expressions of meaning across these data items, and to demonstrate the cohesion of the theme’s constituent data items. Furthermore, each of the reported data extracts should be subject to a deep analysis, going beyond merely reporting what a participant may have said. Each extract should be interpreted in relation to its constitutive theme, as well as the broader context of the research question(s), creating an analytic narrative that informs the reader what is interesting about this extract and why (Braun and Clarke 2012 ).

Data extracts can be presented either illustratively, providing a surface-level description of what participants said, or analytically, interrogating what has been interpreted to be important about what participants said and contextualising this interpretation in relation to the available literature. If the researcher were aiming to produce a more illustrative write-up of the analysis, relating the results to the available literature would tend to be held until the ‘discussion’ section of the report. If the researcher were aiming to produce an analytical write-up, extracts would tend to be contextualised in relation to the literature as and when they are reported in the ‘results’ section (Braun and Clarke 2013 ; Terry et al. 2017 ). While an illustrative write-up of RTA results is completely acceptable, the researcher should remain cognisant that the narrative of the write-up should communicate the complexities of the data, while remaining “embedded in the scholarly field” (Braun and Clarke 2012 , p. 69). RTA is an interpretive approach to analysis and, as such, the overall report should go beyond describing the data, providing theoretically informed arguments as to how the data addresses the research question(s). To this end, a relatively straightforward test can reveal a researcher’s potential proclivity towards one particular reporting convention: If an extract can be removed and the write-up still makes sense, the reporting style is illustrative; if an extract is removed and the write-up no longer makes sense, the reporting style is analytical (Terry et al. 2017 ).

The example in Box 3 contains a brief excerpt from the sub-theme “the whole-school approach”, which demonstrates the way in which a data extract may be reported in an illustrative manner. Here, the narrative discussed the necessity of having an ‘appropriate educator’ deliver the different aspects of the wellbeing curriculum. One participant provided a particularly useful real-world example of the potential negative implications of having ‘the wrong person’ for this job in relation to physical education (one of the aspects of the wellbeing curriculum). This data extract very much informed the narrative and illustrated participants’ arguments regarding the importance of choosing an appropriate educator for the job.

Example of data extract reported illustratively

In Box 4, an example is offered of how a data extract may be reported in an analytical manner. This excerpt is also taken from the sub-theme “the whole-school approach”, and also informs the ‘appropriate educator for the job’ narrative. Here, however, sufficient evidence has already been established to illustrate the perspectives of the participants. The report turns to a deeper analysis of what has been said and how it has been said. Specifically, the way in which participants seemed to construe an ‘appropriate educator’ was examined and related to existing literature. The analytical interpretation of this data extract (and others) proposes interesting implications regarding the way in which participants constructed their schema of an ‘appropriate educator’.

Example of data extract reported analytically

The names of themes are also subject to a final review (if necessary) at this point. Naming themes may seem trivial and might subsequently receive less attention than it actually requires. However, naming themes is a very important task. Theme names are the first indication to the reader of what has been captured from the data. Names should be concise, informative, and memorable. The overriding tendency may be to create names that are descriptors of the theme. Braun and Clarke ( 2013 , 2014 , 2020 ) encourage creativity and advocate the use of catchy names that may more immediately capture the attention of the reader, while also communicating an important aspect of the theme. To this end, they suggest that it may be useful to examine data items for a short extract that could be used to punctuate the theme name.

3.2.6 Phase six: producing the report

The separation between phases five and six can often be blurry. Further, this ‘final’ phase would rarely only occur at the end of the analysis. As opposed to practices typical of quantitative research that would see the researcher conduct and then write up the analysis, the write-up of qualitative research is very much interwoven into the entire process of the analysis (Braun and Clarke 2012 ). Again, as with previous phases, this will likely require a recursive approach to report writing. As codes and themes change and evolve over the course of the analysis, so too can the write-up. Changes should be well documented by this phase and reflected in informal notes and memos, as well as a research journal that should be kept over the entire course of the research. Phase six then, can be seen as the completion and final inspection of the report that the researcher would most likely have begun writing before even undertaking their thematic analysis (e.g. a journal article or thesis/dissertation).

A useful task to address at this point would be to establish the order in which themes are reported. Themes should connect in a logical and meaningful manner, building a cogent narrative of the data. Where relevant, themes should build upon previously reported themes, while remaining internally consistent and capable of communicating their own individual narrative if isolated from other themes (Braun and Clarke 2012 ). I reported the theme “best practice in wellbeing promotion” first, as I felt it established the positivity that seemed to underlie the accounts provided by all of my participants. This theme was also strongly influence by semantic codes, with participants being very capable of describing what they felt would constitute ‘best practice’. I saw this as an easily digestible first theme to ease the reader into the wider analysis. It made sense to report “the axiology of wellbeing promotion” next. This theme introduced the reality that, despite an underlying degree of positivity, participants did indeed have numerous concerns regarding wellbeing promotion, and that participants’ attitudes were generally positive with a significant ‘but’. This theme provided good sign-posting for the next two themes that would be reported, which were “the influence of time” and “incompletely theorised agreements”, respectively. I reported “the influence of time” first, as this theme established how time constraints could negatively affect educator training, contributing to a context in which educators were inadvertently pushed towards adopting incompletely theorised agreements when promoting student wellbeing. The last theme to be reported was “recognising educator wellbeing”. As the purpose of the analysis was to ascertain the attitudes of educators regarding wellbeing promotion, it felt appropriate to offer the closing commentary of the analysis to educators’ accounts of their own wellbeing. This became particularly pertinent when the sub-themes were revised to reflect the influence of pre-existing work-related issues and the subsequent influence of wellbeing promotion.

An issue proponents of RTA may realise when writing up their analysis is the potential for incongruence between traditional conventions for report writing and the appropriate style for reporting RTA—particularly when adopting an analytical approach to reporting on data. The document structure for academic journal articles and Masters or PhD theses typically subscribe to the convention of reporting results of analyses in a ‘results’ section and then synthesising and contextualising the results of analyses in a ‘discussion’ section. Conversely, Braun and Clarke recommend synthesising and contextualising data as and when they are reported in the ‘results’ section (Braun and Clarke 2013 ; Terry et al. 2017 ). This is a significant departure from the traditional reporting convention, which researchers—particularly post-graduate students—may find difficult to reconcile. While Braun and Clarke do not explicitly address this potential issue, it is implicitly evident that they would advocate that researchers prioritise the appropriate reporting style for RTA and not cede to the traditional reporting convention.

4 Conclusion

Although Braun and Clarke are widely published on the topic of reflexive thematic analysis, confusion persists in the wider literature regarding the appropriate implementation of this approach. The aim of this paper has been to contribute to dispelling some of this confusion by provide a worked example of Braun and Clarke’s contemporary approach to reflexive thematic analysis. To this end, this paper provided instruction in how to address the theoretical underpinnings of RTA by operationalising the theoretical assumptions of the example data in relation to the study from which the data was taken. Clear instruction was also provided in how to conduct a reflexive thematic analysis. This was achieved by providing a detailed step-by-step guide to Braun and Clarke’s six-phase process, and by providing numerous examples of the implementation of each phase based on my own research. Braun and Clarke have made (and continue to make) an extremely valuable contribution to the discourse regarding qualitative analysis. I strongly recommended that any prospective proponents of RTA who may read this paper thoroughly examine Braun and Clarke’s full body of literature in this area, and aim to achieve an understanding of RTA’s nuanced position among the numerous different approaches to thematic analysis.

While the reconceptualisation of RTA as falling within the remit of a purely qualitative paradigm precipitates that the research fall on the constructionist end of this continuum, it is nevertheless good practice to explicate this theoretical position.

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Byrne, D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant 56 , 1391–1412 (2022). https://doi.org/10.1007/s11135-021-01182-y

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Original research

Silver linings of adhd: a thematic analysis of adults’ positive experiences with living with adhd, emilie s. nordby.

1 Division of Psychiatry, Haukeland University Hospital, Bergen, Norway

2 Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway

Frode Guribye

3 Department of Information Science and Media Studies, University of Bergen, Bergen, Norway

Tine Nordgreen

4 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway

Astri J. Lundervold

Associated data.

Data are available upon reasonable request. The data is available from the corresponding author upon reasonable request.

To identify and explore positive aspects of attention deficit hyperactivity disorder (ADHD) as reported by adults with the diagnosis.

The current study used a qualitative survey design including the written responses to an open-ended question on positive aspects of ADHD. The participants’ responses were analysed using thematic analysis.

The participants took part in trial of a self-guided internet-delivered intervention in Norway. As part of the intervention, the participants were asked to describe positive aspects of having ADHD.

Participants

The study included 50 help-seeking adults with an ADHD diagnosis.

The participants described a variety of positive aspects related to having ADHD. The participants’ experiences were conceptualised and thematically organised into four main themes: (1) the dual impact of ADHD characteristics; (2) the unconventional mind; (3) the pursuit of new experiences and (4) resilience and growth.

Conclusions

Having ADHD was experienced as both challenging and beneficial, depending on the context and one’s sociocultural environment. The findings provide arguments for putting a stronger emphasis on positive aspects of ADHD, alongside the challenges, in treatment settings.

Trial registration number

{"type":"clinical-trial","attrs":{"text":"NCT04511169","term_id":"NCT04511169"}} NCT04511169

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The current study is one of few studies that focuses on positive aspects of attention deficit hyperactivity disorder (ADHD).
• With the current study design, we could only explore the participants’ experiences with positive aspects of ADHD. Future studies are needed to examine the generalisability of these positive aspects.
• The large majority of the sample were women, which makes the findings less transferable to men.
• The sample is restricted to including participants who responded to a question regarding positive traits.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with prevalence estimates of approximately 5% of children and 2.6% of adults. 1 2 Recently, the number of individuals being diagnosed with ADHD in adulthood has increased, with women being at particular risk for receiving a diagnosis later in life. 3 4 The diagnosis of ADHD is characterised by three cardinal symptoms: inattention, hyperactivity and impulsivity. 5 Adults with ADHD also tend to face additional challenges related to emotion dysregulation, poor working memory, planning and organisation skills. 6 7 These symptoms and challenges are known to interfere with many activities of daily living, with impact on occupational, educational, interpersonal and financial domains. 5 Pharmacological treatment is the primary treatment for adults with ADHD, but many seek additional psychological treatment. 8 9

Research on ADHD has traditionally focused on the impairments and negative outcomes associated with the diagnosis. When portraying a primarily deficit-oriented view on the diagnosis, it may add to the burden of living with ADHD. For instance, it is well known that individuals with ADHD are prone to experience public stigma, prejudice and criticism based on their diagnosis, which can negatively impact self-esteem, self-efficacy and well-being. 10 11 Moreover, a deficit-oriented view of ADHD may overlook strengths of persons with the diagnosis. An alternative approach would be to adopt a more ability-oriented view of ADHD, emphasising the individuals’ resources, abilities and skills. 12 This perspective aligns with beliefs of the neurodiversity movement, which has gained considerable recognition with the rise of social media platforms like TikTok and Instagram. 13 Unlike the biological-medical perspective of ADHD, the neurodiversity movement advocates that ADHD and similar conditions should be denoted as neurological differences rather than being conceptualised as deficits. 14 15 From this perspective, the neurological differences associated with ADHD are considered to be of societal benefit as they contribute to valuable diversity within the population. 15

The majority of available studies on psychological treatment interventions for adults with ADHD also tend to have a deficit-oriented focus, with most studies defining successful treatment as reduction in core ADHD symptoms. 16 Among 23 studies on cognitive behavioural therapy for adults with ADHD included in a recent systematic review, only one study examined an intervention with an explicit focus on strengths associated with having ADHD. 17 18 This particular intervention was found to improve the participants’ knowledge about ADHD and life satisfaction, giving support for incorporation of a strength-based approach in psychological treatment for adults with ADHD. 17 Findings from qualitative research further indicate that public mental healthcare is perceived as too deficit centred and symptom centred by adults with ADHD, leading some to seek alternative treatments that are perceived as more strength-based, even if not reimbursed by healthcare insurances. 19 The willingness to pay out-of-pocket for these treatments could suggest that the current treatment options do not fully meet the needs of adults with ADHD. 19

Taken together, the scientific literature on the strengths associated with ADHD is still scarce. 20 Moreover, most studies on ADHD have included clinical samples of children, and less research has focused on adults’ experiences with the diagnosis. However, there are a few recent qualitative studies that have explored the positive experiences of adults with ADHD. A review on qualitative research examining the lived experience of adults with ADHD indicates that certain aspects of ADHD can be experienced as positive. 21 Within these studies, attributes like energy, creativity, determination, hyperfocus, adventurousness, curiosity and resilience were emphasised. 22–25 However, these studies have largely included small samples of high-functioning adults with ADHD. One exception is the study by Schippers et al, 26 which applied both qualitative and quantitative methods to examine perceived positive characteristics with ADHD in a large sample of 206 adults with ADHD. 26 Almost all of the participants in the study reported positive aspects related to ADHD, with core themes being creativity, being dynamic, flexibility, socioaffective skills and higher order cognitive skills. There are also a few quantitative studies that have focused on positive aspects of ADHD, in particular, creativity. A review of the link between creativity and ADHD has also shown that creative abilities and achievements were high among individuals with both clinical and subclinical symptoms of ADHD. 20 In line with this, some studies have found ADHD to be associated with entrepreneurial intentions and initiation of entrepreneurial actions. 27 28 As such, these studies highlight that despite the well-known challenges associated with ADHD, there are also several strengths that may be linked to having the diagnosis.

The current study employs a qualitative design to identify and explore positive aspects of having ADHD. By including a fairly large group of adults with ADHD seeking psychological help (n=50), the study further aims to shed light on how these positive aspects of the diagnosis can be used as part of psychological interventions for this group of adults. In this regard, the current study follows up on findings from previous qualitative studies that explored positive experiences with having the diagnosis. It also resonates with studies, indicating that adults with ADHD advocate for treatment options that are less deficit-oriented. We, thus, believe that an investigation into the positive experiences of help-seeking adults with ADHD would contribute to fill an important gap in the research field. A two-folded focus on both the strengths and challenges related to ADHD may further have a countereffect on the public stigmatisation associated with the diagnosis and help to empower individuals with the diagnosis.

Study design

The current study is a qualitative investigation including written responses from adults with ADHD to an open-ended question about self-perceived positive aspects of having ADHD. The empirical material was analysed using thematic analysis with hermeneutic phenomenological framework. 29 30

Study context

The data used in the current study originate from a larger clinical trial of a self-guided internet-delivered intervention for adults with ADHD. 31 The clinical trial was a multiple randomised controlled trial, including 109 adults with ADHD aiming to examine whether SMS reminders would improve treatment adherence. The self-guided intervention was accessed online and included seven modules targeting common themes and challenges related to ADHD. The first module was an introduction module, whereas the second to sixth module focused on inattention, inhibitory control, emotion dysregulation, planning and organisation and self-acceptance, and included instructions to various coping strategies. The seventh and last module was a summary module of the entire programme (see Kenter et al 32 for a more detailed description of the intervention). The majority of the participants who responded to the postassessment reported to be satisfied with the intervention. The participants received a gift card of 400 NOK (38 EUR) for their participation in the clinical trial, regardless of whether they answered the question assessing positive aspects of ADHD.

The original study protocol planned to use both qualitative and quantitative methods for data analysis, but it was not planned to examine positive aspects of ADHD. However, when reviewing the data, we were struck by its richness and the number of answers given to this open and non-obligatory question on positive aspects of ADHD, which inspired us to conduct a more in-depth examination of the empirical material.

Recruitment and inclusion criteria

Participants who were eligible to participate in the clinical trial were adults with ADHD living in Norway. The participants were recruited through the Norwegian ADHD patient association, via the associations’ Facebook page and email listings. Their members received a link to our project website, where they could read about the study and complete a prescreening survey to confirm their eligibility. The participants who were eligible were invited to a telephone screening interview performed by a clinical psychologist or a psychiatric nurse. In the telephone screening, the participants had to confirm a diagnosis of ADHD, give information about the name of the diagnosing physician, the diagnosing institution and the date of diagnostic decision. They were also asked about current ADHD symptoms, everyday functioning and treatment. Comorbid psychiatric disorders, including depression, suicidality, psychosis, bipolar disorder and substance abuse, were assessed through the Mini-International Neuropsychiatric Interview (MINI) 33 as part of the telephone screening. This was done to ensure that participants in need of other treatment interventions were not included in the trial. Moreover, all participants had to give their national identity number, which was used to confirm their identity and secure safe login to the online intervention portal. Following inclusion, the participants gave their informed consent to participate and completed the preintervention assessment, including the Adult ADHD Self-Report Scale, used to assess core ADHD symptoms.

The inclusion criteria for the clinical trial were: (a) age 18 years or older; (b) a diagnosis of ADHD; (c) access to a computer or smartphone with internet access, (d) the ability to read and write the Norwegian language. The exclusion criteria were: (a) severe mental illness, such as major depression, suicidality, bipolar disorder, psychosis or substance abuse disorder; (b) currently participating in another psychological treatment. All participants who responded to the question assessing positive aspects of ADHD were included in the current study.

Data collection

The data were collected between June and October 2020. The data material consisted of the participants’ written responses to the question: ‘What do you experience as positive aspects of having ADHD?’. Along with the question, the participants were given some additional guiding questions that could help them write their response: (a) ‘is there any positive aspects related to having ADHD? (b) has ADHD given you any useful knowledge or experiences? (c) has ADHD helped you get in contact with someone you appreciate? These guiding questions were included as examples to help the participants remind themselves of experiences of positive aspects related to having ADHD. The module page also gave some examples of positive characteristics that adults with ADHD may experience, based on previous studies, including being creative, accepting of others, fun, active, explorative, spontaneous and open minded. Considering that the question was text based and, therefore, without the opportunity to ask follow-up questions, we found it necessary to include those examples to provide a context for the participants when answering the question. The participant could write their response to the question in an open-text field on the module page. The mean number of words in the participants’ responses was 72.5, ranging from 1 to 261 words. There were no instructions on number of words or formatting and the question was not obligatory to answer to continue with the module or the intervention. The question was included in the sixth module of intervention, which was named ‘acceptance’ and had an overall focus on self-acceptance and self-compassion, that is, accepting what you cannot change and being kind to yourself. The module included psychoeducation, videos, tasks as well as text and audio instructions to acceptance and self-compassion strategies.

Data analysis

Qualitative analysis.

The data were analysed using thematic analysis, employing a hermeneutic phenomenological framework. Thematic analysis is a well-known qualitative method for identifying and analysing themes or patterns across the data. 29 Unlike some other methods for qualitative data analysis, thematic analysis does not have a pre-existing theoretical framework and it can, therefore, be applied within different frameworks. In line with the framework we have chosen, we acknowledge that the analytic work is an interpretative and inherently subjective activity. To ensure credibility, we have carefully followed the guidelines prescribed for thematic analysis. The thematic analysis followed the six phases described by Braun and Clarke 29 : (1) familiarisation with data, (2) generation of codes, (3) search for themes, (4) reviewing themes, (5) finalise and naming of themes and (6) producing the report.

Following these steps, the first author began the analytic work by reading through the data material and taking notes. This included transferring the data material from the online intervention platform to the research server and reading carefully through each of participants’ responses while taking notes on preliminary thoughts and ideas. As a next step, the first author generated codes in line with the analytic focus of the study: ‘what do adults with ADHD experience as positive aspects with the diagnosis’. To safeguard interpretive credibility, the coding was conducted in a ‘low-inference’ manner, where the codes were phrased closely to the participants original accounts. The data material was coded using NVivo software. 34 See figure 1 for an overview of all the codes and their frequency. Following the coding, the first author created a visual map where the codes that shared similarities were grouped together. The creation of the visual map was intended to provide an overview of the codes and to obtain preliminary ideas regarding categories and themes. All authors were then given an overview of the codes. The first author also presented the codes with illustrative examples of excerpts from the data to the second author to discuss how the quotes were interpreted. The first and second author continued with the third step in the analysis, namely searching for themes. The initial search for themes resulted in a thematic structure of ten themes. All authors were given an overview of these ten initial themes to provide their input and feedback. As a fourth step, the thematic structure was reviewed in more detail by the first and second author. In this analysis, it became clear that certain themes shared some commonalities, for instance, the initial themes ‘energy’ and ‘hyperfocus’ shared overlapping features, and where, thus, merged into one theme. A new thematic structure was identified, resulting in four core themes (shown in figure 1 ). These four themes were then finalised and named by the first and second author (step 5) and the final report was produced by all authors (step 6).

Overview of core themes, subthemes and codes. Note. Core themes are shown within the upper boxes, whereas subthemes are shown the boxes beneath. Codes are shown as bullet points and code frequency is shown in parenthesis.

Quantitative analysis

In addition to the thematic analysis, differences in participant characteristics and ADHD severity scores were examined using independent t-tests and χ 2 . SPSS was used for quantitative analyses.

Reflexivity

We have strived to maintain reflexivity throughout the research process by consistently examining our pre-existing understanding and assumptions. During both data analysis and interpretation of results, the authors have actively engaged in self-reflection and peer discussions to identify our own preconceptions. For instance, ESN, being a clinical psychologist, has generally been taught that symptoms of ADHD and other psychiatric diagnoses are inherently negative attributes and have been less exposed to the potential positive aspects related to ADHD during her clinical training. To address potential biases, the authors revisited the raw data after creation of the themes to ensure that the participants’ perspectives were accurately represented and to validate their own interpretations.

Patient and public involvement

The user involvement in the larger project (INTROMAT), from which the data are derived, has been extensive. Throughout the 5-year project period, there have been arranged several user meetings with adults with ADHD to examine their needs and preferences to psychological interventions for ADHD. Adults with ADHD have also been involved in the development of content and videos to the intervention as well as evaluating the intervention. In these user meetings, we did not address the research question or research design for the current study; however, the focus of the current study was informed by previous qualitative studies involving adults with ADHD who have expressed a wish for both research and treatment interventions for ADHD to have a stronger focus on positive aspects related to ADHD. The results from the current study will be published on the project website where study participants can be informed. We will also present the findings at meetings for the ADHD patient association, which contributed to the recruitment of participants to the current study.

Among the 109 participants of the intervention study, 62 participants accessed the module, which included the question on positive aspects of ADHD, and 50 gave their response. The remaining 47 participants did not access the module and, consequently, did not have the opportunity to view and respond to the question. None of these 47 participants accessed the following module either and was thereby considered to be dropouts. When comparing the responders (N=50) to the non-responders (N=59), there were no significant differences in age, medication status, age when diagnosed, gender, education, employment status or ADHD severity scores.

The final sample included 50 participants, with a large majority being women. All but one were diagnosed with ADHD in adulthood, with 4.8 years being the mean time since being diagnosed. A total of 37 (72.5%) participants were full-time employed or students and 30 (58.8%) participants had higher education. When comparing men and women in the final sample, the men were significantly older than the women (see table 1 ).

Participant characteristics, gender differences and ADHD severity scores

*p < .05.

ADHD, attention deficit hyperactivity disorder; ASRS, Adult ADHD Self-Report Scale; n, number of participants.

Thematic analysis

The participants reported that they experienced a variety of benefits and advantages related to having ADHD, where all but two participants reported that they experienced ADHD to have positive aspects. With regards to ADHD medication, there were two participants who specifically reported that medications contributed to their positive experiences with ADHD, with one participant reporting that the positive aspects of ADHD were only experienced when taking medication. In the thematic analysis, the participants’ positive experiences associated with having ADHD were arranged within four core themes: (1) the dual impact of ADHD characteristics, (2) the unconventional mind, (3) the pursuit of new experiences and (4) resilience and growth (See table 2 ).

Overview of core themes

ADHD, attention deficit hyperactivity disorder.

Theme 1: the dual impact of ADHD characteristics

Many of the participants stated that even core characteristics of ADHD, such as hyperactivity and impulsivity, could be experienced as positive features. Although these core characteristics could be troublesome, they could also be advantageous and beneficial in some situations.

High levels of energy and drive were reported to be useful in many contexts, such as during physical labour, sports, social events or home renovation. One participant stated: I am active. I am often able to do a lot in a short amount of time, and then I get to experience more (woman, 30 years). However, although there were positive aspects to having high energy levels, there could also be downsides: I have understood that my energy can be used for a lot of good, and that if I use it wrong, it can make things challenging (woman, 26 years). The participants also reported that they did not tire as easily as others: If it is something I really like, I have better endurance than others. I can work on something I enjoy forever without stopping (woman, 26 years).

Several participants also reported spontaneity and risk taking, which may be categorised as impulsive traits, as positive aspects associated with ADHD: I am spontaneous/impulsive. I can easily just ‘jump into it’ and that has given me a lot of great experiences (woman, 30 years). It was also mentioned that spontaneity contributed to memorable experiences and learning. However, some emphasised that spontaneity could be challenging as well: I am not really that fond of that spontaneous side of myself because I experience losing control, but at the same time it has given me unique friendships, relations and possibilities (woman, 28 years).

Hyperfocusing, the ability to have an intense focus on an activity for a longer period of time, was commonly mentioned as an advantage of having ADHD. The participants stated that if they were really interested in a topic, they could maintain focus for a long time without being distracted. Hyperfocus was mentioned to be a contributing factor for completing demanding educational courses, school exams and job assignments. One participant stated that hyperfocusing served as a compensatory strategy: I think my ADHD has helped me throughout the exam periods. If it had not been for a kind of hyperfocus, it would not have worked. But then again, I might not have postponed the reading for so long if I did not have ADHD (woman, 23 years). Another participant emphasised that the hyperfocus on useful task for it to be considered as a positive aspect of ADHD: The only positive is hyperfocus on tasks that are really exciting, but for ADHD to be considered positive in this setting, the task has to be something useful, such as school or work (man, 31 years). Most of the participants did not report inattention be positive, however, one participant explicitly mentioned inattention to also have upsides: Inattention can be nice when I actually need to change focus, if something happens while I am driving etc. It is also nice because I have observed some amusing conversations and such when I am actually supposed to be doing something else (woman, 26 years).

Theme 2: the unconventional mind

Many participants reported that they experienced unconventional thinking and behaviour as positive aspects of having ADHD. This included characteristics such as being creative, having novel ideas, seeing things from a different perspective than others and being good at finding solutions. At the same time, it was also emphasised that the social context and expectations present in one’s sociocultural environment could sometimes be an obstacle for utilising these strengths.

Creativity was emphasised to be a positive aspect of ADHD by many participants: Creativity and being able to think outside the norm is something I really appreciate (woman, 26 years).

Creativity was reported to help one to start new projects and find good solutions at work as well as make everyday life more exciting: I am creative and solution-oriented and very passionate about the things that I am interested in (man, 32 years). Creativity was also mentioned to be a good quality when it came to parenting as it facilitated playfulness with one’s children. Although creativity was viewed as a positive trait by many participants, some emphasised a complexity: From my experience in a work-related context, thinking outside the box is not as accepted in all contexts, despite good results’ (woman, 27 years). With this, the participant underscores that whether a quality is deemed as ‘good’ or ‘bad’ is also dependent on one’s social context.

There were also participants who described that they could be socially unconventional and go outside the norm: I do not care that much about what other think (woman, 41 years). Some reported that they could be quite straightforward, unafraid and uninhibited in social situations: I am pretty forward, and I am not afraid to take up space when I need a bit of attention. I know a lot of people and that is probably because I am not scared to say hi to new people (woman, 23 years).

Theme 3: the pursuit of new experiences

There were several participants who reported that they experienced adventurousness and novelty-seeking as positive aspects of ADHD. Being explorative also appeared to be connected to being both curious and courageous, with some participants describing that they were curious of the unknown and not afraid to embark on new ventures.

Many emphasised that they were curious and enjoyed trying new things and seeking new experiences. The participants also reported that they enjoyed learning new things: I seek new environments where I can learn new things (woman, 29 years). Because they enjoyed learning, they also acquired knowledge about various topics. In line with this, one participant also underlined that they would not give up easily when attempting to learn something new: I enjoy trying new things, and if I do not get it right the first time, I will examine the possibility of trying a simpler method. (woman, 30 years). To enjoy novelty was also reported to be of significance to one’s choice of occupation: I enjoy trying new things and changes. This is the reason why I have the job that I have (woman, 42 years).

There were also reports about being courageous and unafraid, which could push one to seek new experiences: I have experienced things that only would have happened by taking a risk (man, 62 years). Moreover, being impulsive could make one more daring: I dare more than when I sit down and think about it (woman, 29 years).

Theme 4: resilience and growth

The final theme centres around the participants’ experiences of growth and insight after facing adversity. The participants underscored that although ADHD indeed could be challenging, especially the process towards being diagnosed with ADHD, coping with these challenges could also foster resilience and growth.

Some of the participants reported to have a better understanding and acceptance for themselves because of ADHD: Being diagnosed with ADHD made me learn a lot about myself. Things I perhaps have been annoyed about, I can now accept and think that it is not ‘my fault’ in a way (woman, 30 years). Although the process of getting diagnosed could be tough, it could also give valuable insight: The road to my final ADHD diagnosis has been so long and cruel, but I would not have been without all the pain and unbearable years, and all that experience made me know myself in a completely unique way, and I have gotten a very valued quality when it comes to being able to reflect over situations both I and others are in (woman, 25 years).

The participants also expressed resilience after coping with previous challenges: ’ am better at handling resistance or challenges now, because I have learned to handle such challenges, it is part of life to have ups and down s (woman, 51 years). Likewise, coping with challenges could also make one more persistent: I have learned to not give up in the face of resistance. Maybe I must take some detours, do things differently than others, find out what works for me and trust myself, but the point is, I can make it if I want to (woman, 28 years).

The experience of receiving the diagnosis appeared to be especially important: To get the diagnosis was a relief because it gave me an explanation for why I did things I did not understand earlier, such as why I was not able to shut up, but talk without thinking, and why my emotions fluctuate so much, and often without me understanding why. It has given me more understanding and acceptance for myself (woman, 57 years). When the participants learned about the diagnosis, it allowed them to be more kind towards themselves: I discovered that I have ADHD in adulthood, so I lived most of my life in the belief that I am like everyone else. I have had high expectations to myself, compared myself to others, and achieved a lot (…) So when I found out about my challenges, it all became like a piece of cake. I could with good reasons lower the expectations to myself and finally rest with a clear conscience (woman, 37 years).

The participants also reported that they were non-judgemental and accepting of other people: Since I am such a “fool” I don’t judge others for being it (woman, 24 years). The participants also reported to be more empathic and understanding of others’ point of view. Several participants had jobs that involved working with people with disabilities, where having ADHD themselves could help them to connect with their students or patients: As a teacher, ADHD helps me to understand students that have a learning disability (man, 31 years). Another participant stated: I understand a part of the youth on a different level than my colleagu|es, and I therefore experience that I am able to get a better connection with the students others find it difficult to get close to (woman, 44 years). Another participant also shared similar experiences: I notice that I can meet children with ADHD with more understanding, so they feel safe with me quickly, and I know I can help them in challenging situations, or prepare them a bit extra, so that they are able to get through their school day (woman, 30 years).

The current study aimed to identify and explore positive aspects of having ADHD from the perspective of help-seeking adults with the diagnosis. The participants’ accounts of positive experiences of having ADHD could be arranged within the following four themes: (1) the dual impact of ADHD characteristics, (2) the unconventional mind, (3) the pursuit of new experiences and (4) resilience and growth. Through the discussion, we further seek to highlight how positive experiences with the diagnosis can be used in treatment interventions.

The characteristics of ADHD could be experienced as a double-edged sword, where the traits could be seen as both challenging and beneficial. This is in accordance with findings in several studies included in the review by Ginapp et al 21 and Schippers et al 26 . The direction of this relationship further seemed to be dependent on context and the norms in one’s sociocultural environment, where certain qualities could be deemed as beneficial in some situations, but undesirable in other situations. Although one’s environment appeared to be central in the participants’ experience of duality related to ADHD characteristics, individual factors are still important to take into consideration; one person might find a certain characteristic as beneficial, while another might not share the same perspective. As such, whether a characteristic is seen as positive or negative is likely dependent on a variety of factors, including individual factors, environmental factors and the interaction between the two.

From the perspective of the participants, it appeared that even core diagnostic characteristics of ADHD could be experienced as advantageous. For instance, the high energy associated with hyperactivity could be considered as an advantage in certain social settings and within sports, whereas hyperfocus could be beneficial during school exams or at work. These findings are in line with results reported in previous qualitative studies. 22 23 As such, the analytic findings support the notion that some of the characteristics associated with ADHD can be reframed in a more positive manner. Given the high persistence of ADHD symptoms into adulthood, helping adults to explore potential advantages of their symptoms in a treatment setting could perhaps have favourable outcomes for treatment and improve life satisfaction 17

On the other hand, the present findings resonate with results from several other previous studies showing that ADHD characteristics are associated with problems that affect daily-life functioning. 35–37 Based on the current reports, it appeared that the participants had to figure out the ways to make ADHD work for them, with certain traits, such as hyperfocus and high energy, only being considered beneficial under the right circumstances. This reasoning can imply that a key step in psychological interventions for ADHD would be to not only identify the participants’ strengths but also to examine in what contexts these strengths are useful and potential pitfalls or obstacles for utilising them.

Interestingly, only one of the participants reported inattention to be beneficial. In relation to this, a study on ADHD and identity among youth with ADHD found that while several participants experienced positive sides to hyperactivity and impulsivity and integrated these as part of their identity, inattentive symptoms were not associated with such positive experiences. 38 The experience of living with inattentive versus hyperactive/impulsive traits should be an interesting topic for future studies.

The findings further show that creativity seems to be experienced as a core positive aspect of having ADHD. These findings are in line with results from previous studies, which have associated ADHD symptoms with certain qualities of creativity. 39 40 Distractibility has, for example, been associated with creative achievements. 41 As such, it may be that distractibility makes one notice more so-called ‘irrelevant’ information in one’s environment, which later may be helpful in generating more original ideas. 41 Given that creativity may be a strength of ADHD, it should be possible to take advantage of this quality in treatment settings, for example, by including more creative tasks in psychosocial interventions to facilitate engagement and adherence.

The current accounts further show that traits such as adventurousness, exploration and courage may be seen as strengths of ADHD. Such strengths have also been reported by adults with ADHD in previous studies. 23 25 42 In their study, Newark et al 42 found courage to be a resource among adults with ADHD and they further linked this trait to self-efficacy and self-esteem. The authors further emphasised that courage could be a valuable skill in therapy, a situation where clients indeed are faced with both challenges and novel experiences. 36

Lastly, it appeared like coping with the challenges associated with ADHD could lead to resilience and growth for some participants. There were reports about understanding oneself and others in a more nuanced manner, and successful coping was seen as making them more fit to cope with future challenges. This is in line with findings from a previous study including women with ADHD, where the participants identified positive learning from the challenges they had faced. 25 When people are faced with adversity, they often underestimate their abilities to cope with the emotional distress and overestimate the intensity and impact of the particular event. 43 In line with this, some participants seemed to cope with the challenges related to ADHD in a resilient manner and perhaps even experience growth during times of adversity. These findings may be understood within Dombrowski’s theory of positive disintegration, which posits that emotional difficulty and turmoil are necessary for human growth and development. 44 It has further been suggested that resilience is linked to impulsivity, where impulsive traits may help adults to faster move on from their problems, which may be useful in therapy settings. 45

Implications

The clinical implications of the findings may be to incorporate a stronger focus on strengths and resources in both the assessment and treatment of ADHD in adulthood. There is a consensus within psychotherapy that treatment should not only focus on the absence of symptoms but also on recovery, coping, well-being and growth. 46 However, adults with ADHD still report current treatment options to be too deficit oriented. 19 By putting an emphasis on the full range of experiences related to ADHD, both good and bad, one might be able to offer treatment interventions more in line with the needs of adults with ADHD, which may be favourable for treatment engagement and clinical outcomes. For instance, therapist could help adults with ADHD to identify strengths, which may be beneficial for self-esteem and self-efficacy. Within cognitive-behavioural therapy, one could also use positive experiences with ADHD to reframe negative automatic thoughts or maladaptive cognitions. These speculations should indeed provide interesting topics for further studies. A focus on positive sides to ADHD within research may also have societal implications by changing social perception around ADHD and by this reducing stigma related to the diagnosis.

Strengths and limitations

The current study is one of few studies that focus on positive aspects of ADHD, and one of few with a fairly large sample size. Moreover, this study is the only study investigating positive aspects in a sample of help-seeking adults with ADHD. Still, several limitations should be noted. With the current study design and analysis, we can only explore the participants’ experiences with positive aspects of ADHD and give a thematic structure of these experiences. However, future studies combining qualitative and quantitative analyses are needed to further evaluate the generalisability of the positive aspects of ADHD reported in this and previous studies. The sample of the present study was restricted to only include participants who responded to a question regarding positive traits, which only was about half of the participants in the clinical trial. The lower response rate is likely due to the question being asked at the end of the intervention and several participants had been lost to drop-out and thus never accessed the question on positive aspects of ADHD. The impact of being participants in a psychological intervention should also be commented on. For example, it is possible that taking part in the intervention increased the participants’ positive beliefs about themselves and ADHD. The participants did also receive some examples of positive aspects with ADHD in the intervention, which may have influenced their answers. We found it necessary to include these examples since the data collection was conducted online without the guidance of a researcher. As such, when conducting the data analysis and creating the themes, we were careful to examine depth and richness in the participants’ answers and not only frequency. The examples were reported 47 times in the data material, with creativity being the trait most frequently referred to in the data material (27 references). However, creativity was also the most frequently mentioned positive aspect of ADHD in Schippers et al ’ s study. Moreover, we found it reassuring that the participants’ answers went beyond the examples given. The participants of the study mainly consisted of high-functioning women in their 20s and 30s who were diagnosed with ADHD as adults and were seeking psychological help for ADHD. The sample did therefore include more females than males, which makes the findings less transferable to males since the clinical expression of ADHD is known to vary with gender. 47 It may also be seen as a limitation that the ADHD diagnosis was based on self-report. To ensure validity of the diagnosis, it could have been beneficial to conduct a clinical re-examination to confirm that the participants met the diagnostic criteria. However, all participants were asked to report the date, venue and diagnosing healthcare professional for the diagnosis as well as their national identity number. We, therefore, have trust in the participants’ reports. In addition, because participants with ongoing severe mental illness were excluded from the study, the participants are most likely individuals within the less severe end of the ADHD symptom spectrum.

Future directions

The findings from this study need to be validated by future studies. These studies should not only investigate characteristics of strengths related to ADHD but also in what contexts these strengths are useful and beneficial. Moreover, future studies should investigate the impact of strength-based treatments on both treatment engagement and clinical outcomes. Future research should aim for the development of a valid procedure to assess strengths and positive qualities of adults with ADHD. Moreover, it would also be interesting for future studies to include other observers’ impressions of positive aspects related to ADHD, for instance, family members and clinicians.

The aim of the current study was to identify and explore positive aspects of having ADHD from the perspective of help-seeking adults with the diagnosis. From the perspective of the participants, the characteristics of ADHD could be both beneficial and challenging, depending on the individuals’ contextual environment. For clinicians, it may be important to examine the individual’s positive experiences of ADHD, as this should be capitalised on within treatment. A stronger focus on positive aspects of ADHD in treatment interventions, alongside the challenges, may also help to contribute to support a more ability-oriented view of ADHD.

Supplementary Material

Contributors: ESN contributed to the recruitment of participants for the clinical trial, was responsible for the thematic analysis, interpretation of the results, and drafting of the manuscript. FG contributed substantially to the thematic analysis and interpretation of the results, and with comments and input to different versions of the manuscript. TN was responsible for the clinical trial (PI) and contributed with comments and input to the manuscript. AL was responsible for the idea of the current study and contributed substantially with comments and input on different drafts of the manuscript. All authors have read and accepted the final draft of the manuscript. ESN acts as the guarantor for the work.

Funding: The data used in the current study are from the INTROMAT project, funded by The Research Council of Norway (grant: 259293). ESN received funding from the Western Norway Regional Health Authorities (Helse Vest) for her doctoral thesis (grant: F-11016).

Competing interests: None declared.

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

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by Regional Committees for Medical and Health Research, Region West Reference ID: 90483. Participants gave informed consent to participate in the study before taking part.

• Open access
• Published: 31 May 2024

Exploring presence practices: a study of unit managers in a selected Provincial Hospital in Free State Province

• Bernardine Smith 1 ,
• Precious Chibuike Chukwuere 1 &
• Leepile Alfred Sehularo 2  

BMC Nursing volume  23 , Article number:  367 ( 2024 ) Cite this article

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Nursing presence depends on an individual’s belief system, truths, sensory experience, professional skills, and active listening. Thus, one may assume that presence occurs when nurses care for patients in a kind and compassionate way. This study aimed to explore and describe presence practices amongst unit managers in a selected provincial hospital in Free State Province.

A qualitative research approach with an exploratory descriptive contextual research design was employed in this study. A purposive nonprobability sampling technique was utilised to select participants. Data were collected through semi-structured interviews and analysed using the six steps of thematic qualitative data analysis. The study’s trustworthiness was ensured through ascertaining credibility, dependability, confirmability, transferability, and authenticity. Approval to conduct the study was obtained from the North-West University Health Research Ethics Committee (NWU-HREC), DoH in the Free State Province, and the CEO (the gatekeeper) of the selected hospital.

Four themes were generated, namely, presence practices amongst unit managers in a selected provincial hospital in Free State, the impact of presence practices on hospital dynamics in a selected provincial hospital in Free State, unit managers’ practices of relational care and human connectedness in the unit, and the perceptions of unit managers on barriers to presence practices in a selected provincial hospital in Free State. Each of these themes presents categories and sub-categories. Unit managers actively foster supportive work cultures, effective management, human connectedness and relational care, and effective communication to yield team cohesion and positive impacts on patient care. Unit managers also display resilience and highlight the need for ongoing support from colleagues and top management.

Unit managers exhibit diverse presence practices which emphasise their commitment through visibility and accessibility despite staff shortages and resource constraints.

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Introduction

Nursing presence is described as an aspect of the art of nursing [ 1 ]. Nursing presence depends on an individual’s belief system, truths, sensory experience, professional skills, and active listening [ 2 ]. Thus, one may assume that presence occurs when nurses care for patients in a kind and compassionate way [ 3 ]. Furthermore, when true presence is practised by nurses, they identify what patients perceive as important through merely listening and observing a patient’s verbal and non-verbal behaviour [ 4 ]. Hence, it is important that effective communication occurs between the patient and the nurse to maintain and ensure a mutual relationship that is healthy and therapeutic [ 5 ]. Hansbrough and Georges describe nursing presence as occurring when nurses utilise practices to intentionally enter a positive and mutual relationship with their patients [ 6 ]. In essence, presence practices aim to facilitate human connectedness, relational care, and the attuning of care to the needs of patients [ 7 , 8 ]. In healthcare, human connection or interactions nurture robust relationships and enhance nurse-patient engagement which could improve patient outcomes and experiences [ 1 ]. Therefore, presence practices are pivotal in ensuring quality nursing care.

Practising nursing presence can be beneficial to both nurses and patients. Patients may feel more comfortable in communicating their signs, symptoms, or concerns to nurses when there is a human connectedness and positive therapeutic relationship between the nurse and the patient [ 5 ]. This is essential as it aids the healing process of patients. Nurses also benefit both on a professional and a personal level when practising presence [ 9 ]. Moreover, the employer also benefits when presence is practised because there are less complaints from patients and their families and there is an improved organisational culture. Therefore, leaders should ensure team cohesion, listen to nurses, and provide the necessary information and a safe environment [ 10 ]. Similarly, the workplace culture would improve when all nurses feel enriched by practising presence whilst taking care of their patients in the hospital or care centres [ 11 ]. Nurses, who believe that their profession is perceived as positive, do a better job, engage more, listen more to patients, and in general achieve better results [ 12 ].

Unfortunately, presence is not always practised by nurses. Contributory factors were identified as possible causes that may lead to a lack of nurses practising presence. These include burnout and exhaustion, lack of professional nursing skills, and lack of resources [ 13 ]. Nurses, therefore, owe it to themselves to continuously develop professionally in order to keep up to date with new knowledge and skills that will enable them to provide better care to patients. To this end, society considers it vital, almost a prerequisite, that nurses possess high technical skills. This perpetuates the classical view of healthcare, nursing care, the nursing profession, and the recipient of care [ 14 ]. Thus, the creation of a nurturing environment, characterized by health, support, and compassion, is essential for enhancing the experiences of patients, their families, nursing staff, and unit managers [ 15 ]. Toxic leadership may impact negatively on nursing performance and adversely affect organisational culture [ 16 ]. Nurses also reported that the lack of respect from patients and the public demotivates them and has a major influence on their ability to practice presence [ 12 ].

Interestingly, the unit manager’s key role is to lead his or her subordinates in his or her perspective unit [ 17 ]. Therefore, a unit manager must be in possession of leadership skills, communication skills, and resilience in order to guide the team in the right direction [ 18 ]. Unit managers must be able to manage conflict situations and ensure team cohesion [ 19 ]. According to Beukes and Botha, employee engagement and staff performance will increase when there is effective communication which is essential to achieve quality patient care [ 20 ]. Mtise and Yako further mention that the unit manager’s roles encompass staff performance management, coaching and mentoring, budgeting, effective communication, human resource management, and equipment and stock management [ 21 ]. Abou Zeid and colleagues suggest that nursing leaders should be in possession of spiritual competencies which would aid their followers’ psychological capital as well [ 22 ]. Importantly, nursing leaders must acknowledge the capability of nurses to act in their positions and be the role models that they require [ 23 ].

However, there are insufficient published studies regarding presence practices amongst unit managers specifically in a selected provincial hospital in the Free State in South Africa. Shopo and Tau highlight the importance of an in-depth understanding of presence in South Africa [ 24 ]. Furthermore, Oukouomi-Noutchie heighten the concern over the lack of presence practices by South African nurses [ 25 ]. Thus, the focus of this study was to narrow the gap regarding this phenomenon. Owing to the vital roles of nursing unit managers and the importance of presence practices in nursing, the objective of this study was to unpack the presence practices amongst unit managers in a selected study area in the Free State in South Africa through a qualitative research approach. The study was founded on the core principles of presence practices, relational care, human connectedness, and the attuning of care [ 7 , 8 , 26 ].

Research design

A qualitative research approach and an exploratory descriptive contextual research design were followed [ 27 , 28 , 29 ]. The research approach and design were followed to explore, describe, and contextualize the perspectives of the unit managers on presence practice and how they practise relational care and human connectedness in the unit at a selected hospital in Free State Province. Therefore, owing to the vital roles of nursing unit managers and the importance of presence practices in nursing, the objective of this study was to unpack the presence practices among unit managers in a selected study area in the Free State in South Africa through a qualitative research approach.

Study setting

There are four provincial hospitals in the Free State. The study was conducted in one of the main public provincial hospitals in Free State. This selected hospital was the ideal setting to conduct the research because it was a government institution with a variety of units that had large numbers of nursing staff. Additionally, the researcher believed that this selected hospital was ideal because of its high value in research and the fact that it is a referral hospital with an emergency unit.

Population and sampling

A research population includes the entire group or units that constitute the research focus such as the unit managers working in a selected provincial hospital [ 28 ]. The population includes the unit managers working at the main provincial hospital in Free State. A non-probability purposive sampling technique was used in this study. The researcher purposefully selected this sample because the participants have all of the characteristics needed to take part in the study. The unit managers at the provincial hospital in Free State were the participants of the study. They were the most suitable candidates/participants to answer the research questions because of their roles. A total of 12 registered nurses participated in this study (10 female and 2 male participants). The sample size was determined through data saturation.

Inclusion and exclusion criteria were clearly defined for participant selection. Professional nurses registered with the South African Nursing Council (SANC) and employed as unit managers at the main provincial hospital in Free State for at least one year were invited to participate in the study. This criterion was chosen to ensure that participants held administrative and leadership roles, thus capable of providing in-depth insights into the research questions. Additionally, only unit managers who had been in their positions for a minimum of one full year were included. Interviews were conducted in English with all eligible participants. All other nursing staff categories, including registered nurses, enrolled nurses, and registered nursing assistants, were excluded from the study. Furthermore, the nursing manager (Matron) was also excluded.

An administrative officer assisted the researcher in distributing pamphlets at all strategic work areas within the selected hospital, including but not limited to nursing stations, waiting rooms, administrative offices, and staff break areas. The nursing manager encouraged the participants to partake in the study. The study participants who were interested in participating in the study contacted the researcher. A time was scheduled to obtain informed consent first. An independent person not directly involved in the research facilitated the signing of consent forms. The independent person was a master’s student from the primary researcher’s institution who had undertaken a course on research methodology and, hence was knowledgeable about facilitating the signing of informed consent forms. The researcher endeavored to educate the independent person about this study and the expected roles. The independent person was not directly involved in the study. The independent person ensured that participants understood their rights regarding participation in the study, gave them the opportunity to answer pressing questions regarding the study, and further allowed them to make informed decisions regarding participation in the study before signing the consent forms.

Data collection method

Semi-structured interviews were used in this study to collect data from the study participants. Data collection commenced after the necessary ethical clearance was obtained from the relevant authorities. Semi-structured interviews were conducted with the participants who were interested in the study [ 29 ]. Data were collected from the participants who signed the consent form. Data were collected in a secured venue in the selected hospital which was clearly marked with ‘ Do not disturb ’. The participant was the only person allowed in the room with the interviewer when the data were collected. Data were collected using semi-structured interviews and in the English language. The interviews were conducted during working hours to avoid burdening the participants by requiring them to stay extra hours after work. Prior to each interview, the researcher introduced herself and confirmed that the participant had signed the consent form. During the semi-structured interviews, the researchers used a few communication techniques such as paraphrasing, probing, clarifying, and reflection. The interview sessions were audio-recorded with permission from the participants prior to recording. The interview sessions lasted for 45 min to one hour to enable the researcher to probe the questions for in-depth and broad data collection. The researcher took reflective field notes during the interview sessions whilst asking the research questions and probing questions and also maintained full control of the interview sessions.

The following research questions were addressed:

What are the presence practices amongst unit managers in a selected provincial hospital in Free State?

What are the perceptions of unit managers on presence practices in a selected provincial hospital in Free State?

How does one practise relational care and human connectedness towards one’s subordinates in the unit?

Data analysis

The data that were generated from the semi-structured interviews were analysed by the researcher and an independent co-coder using thematic analysis (TA). The analysts used ATLAS.ti to analyse the data [ 29 ]. Braun and Clarke’s six steps of thematic qualitative data analysis were used in the study [ 30 ]. These six steps are presented below:

Step one – The researcher transcribed the data verbatim from the tape recorder, read through the data, and reflected on what the participants said. Data were shared with a co-coder who read through the data and reflected on the findings.

Step two – Codes were generated from the collected data (phrases or categories were then coded) and were written down in a book to assist with the interpretation of the data [ 30 ]. The researcher and the co-coder independently conducted this step.

Step three – The researcher searched for themes and categories which gave meaning to the data set [ 30 ]. This step was conducted independently by the researcher and the co-coder and then consensus was determined.

Step four – All potential themes and categories were reviewed for quality purposes, coherence, and suitability [ 30 ].

Step five – Themes and categories were named and defined by clearly stating the uniqueness of these themes and categories to provide structure for the analysis process [ 30 ].

Step six – The researcher validated the generated themes and categories and reflected on them to ensure that they reflected the participants’ authentic responses [ 30 ].

Trustworthiness

A qualitative researcher should be open and flexible at all times to ensure that the methods of data collection foster thoroughness and authenticity [ 28 ]. Polit and Beck mention that a framework for qualitative criteria was created by Lincoln and Guba in 1985 which suggested four criteria to ensure trustworthiness in qualitative research, namely: credibility, dependability, confirmability, and transferability [ 29 , 31 ] In this study, trustworthiness was ensured through ascertaining the study’s credibility, dependability, confirmability, transferability, and authenticity. The researcher ensured that the research methods used in this study provided data that were analysed and interpreted truthfully [ 29 ]. The researcher ensured the portrayal of the truth whilst the collected data were interpreted. Credibility was ensured in this study through the application of techniques such as prolonged engagement with participants by spending time with the participants during data collection. This enabled them to consider and answer the research questions critically and thoroughly. Additionally, peer debriefing occurred through the consultation with peers to confirm the validity of the data. Finally, member checking occurred through summarising the participants’ answers during the interviews and confirming with them whether the information was correct. Dependability refers to the condition of the data over time as well as the reliability or stability of the data collected during the interviews [ 29 ]. This study ensured dependability as the findings of this research would remain the same if the study were to be repeated in the same context and with the same participants. In this study, dependability was ensured through means of an audit trail as detailed records were kept of the study from the beginning to the end of the study. The data of this research are representative of the information provided by the participants and not the researcher’s own inventions [ 29 ].

To ascertain the confirmability, one considers the objectivity, meaning, and relevance of the collected data in this research and confirms the findings. Objectivity was ensured by employing an independent co-coder. The study supervisors served as independent checkers throughout the study. The findings of this research are the true reflection of the participants’ own voices regarding their influences as unit managers on their subordinates. As noted by Lincoln and Guba, rich data that is descriptive in nature should be provided by the investigator [ 29 , 31 ] Therefore, transferability was ensured by providing an in-depth description of the adopted research methods. Amidst the implementation and data collection of this research, authenticity was evident in the report on the findings by revealing a range of realities [ 29 ]. Authenticity in this research was ascertained through active listening to the participants during the data collection, which fostered the collection of in-depth and broad data that reflected the views of the participants.

Demographic characteristics of participants

Twelve registered nurses participated in this study, which included ten female participants and two male participants. The ages of the participants ranged between 44 and 59 years of age. These registered nurses are unit managers with years of experience in their current field which ranges between one and 20 years. Each of the direct quotes were supported by participant’s distinct characteristics which are participant number, gender, age and years of experience.

Organisation of the themes

Four themes were extracted from the data analysis and are presented in Table  1 below.

Theme 1: Presence practices among unit managers in a selected provincial hospital in Free State

The above theme represents the presence practices among unit managers in the selected provincial hospital in the Free State. The theme demonstrates that participants practise presence in various ways. The participants’ responses provided insight into the discussion of presence practice in patient care. A few categories emerged, which are presented below and supported by direct quotes.

Category 1.1: Leadership presence and accessibility

Participants in the study underscored their commitment to practising presence through leadership presence and accessibility. This emphasis on leadership presence and accessibility illuminates the integral role that managerial figures play in fostering a culture of presence within healthcare settings. For instance, a few of the direct quotes from the participants revealed the following:

For, my patients as well. My patients usually I will start with them, because we are here for the patients. I’ll start with them in the morning after taking the report, we go bed by bed with them. I go with my staff, the matron is also there, myself going bed to bed seeing that every, you know, patients are being taking care of accordingly [Part 1, F-59, 2 yrs exp].

But for me definitely I think it is part of being here being visibly here, having an open door-policy,. But for the staff these days you have to be more present emotionally. You have to be seen physically as well, otherwise it is like oh, this matron is just in the office the whole day long [Part 2, F-51, 20 yrs exp].

A number of the participants further confirmed that they practise presence as managers through being there at all times and being visible in the unit for their staff. The participants’ direct quotes are presented below:

The presence means, okay on my side I understand it as I must be there all the time when my staff needs me, when there is something about my patient, I need to be there for that patient … [Part 12, F-54, 18 mnths exp].

What I understand when you said practice presence, according to me, I think I must be present on the patient at all times [Part 7, M-56, 1 year exp].

For, me presence means being visible with your team. Seeing that things or processes are running and everything. So, my presence being visible … [Part 6, F-54, 8 year exp].

Furthermore, certain participants explained how they, as unit managers, establish a conducive workplace environment for their subordinates. The participants’ responses are presented as the direct quotes below:

But if I can make the environment where you work, where a patient maybe sees his last minutes here, maybe before they die and I can make it positive, then I’ve done my job the day [Part 3, F-51, 6yrs exp].

… you don’t know how emotionally the person is heard but in the meantime on my side I have to start to make the environment of the theatre to be calm so that everybody is covered … [Part 12, F-54, 1 year.6 months exp].

Category 1.2: supportive work culture

Participants highlighted their ability to create a supportive work culture for both the subordinates and their patients by conducting personal interviews with staff and patients before referring them for specific assistance when needed. This supportive work culture also includes fostering positive and helpful attitudes towards staff members and recognising the diversity of their subordinates. In this instance, a few of the direct quotes from the participants revealed:

So I’m coming with her we are doing this thing like this and this and then if she, you see she is struggling you help. That’s why I said to you I carry them along because there are those you say nna cannot afford this I don’t think I can manage you come with them, that’s what I mean sitting with them, supporting them, supporting them that’s the main thing [Part 1, F-59, 2 yrs exp].

To say, but we, we are supporting you don’t resign or don’t drink. Because a lot of things came out yesterday, she’s not in a good state. Just to find out, she’s not drinking. We said OK we’ll take her out of that place, we are putting in another clinic, but whilst we’re doing that, we support you and motivate [Part 6, F-54, 8yrs exp].

The support that I give them is I’ll be there for them. They know even if I’m off during the week there is a problem, they called me and I come and help them. For there’s nothing I can do. There’s no way I can get other people somewhere else. So I’ll be there even if I’m home, they know they call me, matron come and help, I come and help [Part 9, F-50, 6yrs exp].

Category 1.3: effective management and development

Furthermore, in the participants’ attempts to explain their presence practices, it was established that they practise presence through effective management and development. As leaders, they verbalised the need for problem-solving and conflict management skills to ensure the smooth operation of the unit. The participants also highlighted how they motivate and encourage the subordinates to empower themselves through education and the provision of regular in-service training. In this instance, a few of the direct quotes from the participants revealed:

So, then they will come to me that I follow up with their doctors, so we solve the problems normally very quickly and there’s no further complaints on on issues like that, that small things normally [Part 3, F-51, 6yrs exp].

One of the responsibilities is to ensure that all the conflicts are resolved so that the key environment is very friendly to all of us. So, it’s very it’s very it’s very it’s very straining to try to keep to try to keep up with their fight, is very straining to to try to keep up to say let’s have a team because somebody have done something to and they take it personal [Part 6, F-54, 8yrs exp].

I will listen to the patient or the patient relative what is the problem, then I will go to the my staff and ask what was really happening just to investigate the matter. And then if we maybe the thing need to be solved, because at times it will be misunderstanding between the patient and the nurse, you know, miscommunication then we resolve it in my office like asking apologies and all those stuff [Part 7, M-56, 1 year exp].

Participants also mentioned the importance of clinical governance to ensure continuous improvement which contributes to high-quality nursing care and participative leadership in the workplace. Moreover, unit managers should plan their daily schedules actively whilst implementing effective time and resource management in order to ensure sufficient staff and resources to complete the daily activities in the units. Additionally, one of the participants mentioned how they respond to complaints and provide feedback to the patients, which included corrective interventions. A selection of the direct quotes from the participants are presented below:

… definitely just involving them will also increase your practice in presence in a leadership situation…actually participative management. So at least if you practice that type of management. I think people will also feel responsible for the unite and take ownership for the unit … [Part 2, F-51, 20yrs exp].

Now with clinical governance, we are accountable for, for whatever that we are doing to our patients, we are accountable [Part 4, F-44yrs, 2yrs exp].

And then do follow ups and sometimes maybe sometimes if the problem you know when you are working in an environment and then I’m working with you maybe I’ve got issues with you, like I’ll try to find out what is the problem, then I will separate them like in a shift maybe the other one will go to the other shift and the other one to the so to prevent the mis understanding [Part 8, F-50, 15yrs exp].

Theme 2: Impact of presence practices on hospital dynamics in a selected provincial hospital in Free State

The second theme delineates the impact of presence practices on the hospital dynamics in a selected provincial hospital in the Free State. According to the participants, practising presence can have both positive as well as negative effects on hospital dynamics. The categories which emerged are presented below and supported by direct quotes from the participants.

Category 2.1: positive impact on patient care and staff management

Participants communicated the positive impact on patient care and staff management when practising presence in a selected provincial hospital in the Free State. Participants explained how nursing presence improves patient satisfaction and positively affects staff management which contributes to harmony, teamwork, and collaboration in the team. The resulting environment has a calming and healing effect on patients and their families whilst preventing adverse events from occurring. The following direct quotes from the participants were selected to support this category:

Maybe the manager would say but we’ve got shortage in maternity, in ICU, wherever and then she place you there and she wasn’t actually for that. So, make the place friendly for her, ja. Obviously, she will be anxious, but I didn’t like this, though I’m a nurse, I didn’t like this. So I like making the work place friendly for them, ja by sitting around with them and then saying but this is not complicated [P1, F-59, 2yrs exp].

But if the environment is positive, I can’t fix the things at home for you? But if I can make the environment where you work, where a patient maybe see his last minutes here, maybe before they die and I can make it positive, then I I’ve done my job for the day neh. So, for me it’s very important that patients are happy and and that my staff is happy because if you if you can get that part, you will work harder. Everyone will give a extra more of themselves. If your environment is positive and what you call it? Conducive [P3, F-51, 6yrs exp].

If your personnel they are satisfied, happy and you always support them, even if you are having like, we having shortage of staff like in South Africa, even if there’s a shortage, they will always be willing to help, you see because they know that our matron is always there for us, so they will support you [P8, F-50, 15yrs exp].

All the support that you are giving them, they become relaxed, they they they tend to learn how to care for their babies and you won’t even struggle with milk production [P4, F-44, 2 yrs exp].

It’s all about like patient being like healed going out of the hospital being like healed you know going back to his family his or her family so that makes us very good as a team yes [P7, M-56, 1 year exp].

If my staff practice presence the advantages is that the stay of the patients in the hospital will be short and then one other thing, they would have too much burden of work if they do what they are supposed to do [P11, M-53, 1.7 yrs exp].

To make them feel relaxed that whichever way I’ll be taken into theatre, I will be operated that’s it, the most important thing is for our patients to know that is the most important thing, I mean the advantage of knowing is you are calming them, you are making them relaxed, you are making them believe that whichever way I’ll be done today [P12, F-54, 1.6 yrs exp].

Category 2.2: challenges and negative outcomes

Participants expressed their concerns regarding the challenges and negative outcomes associated with a lack of presence practice amongst unit managers and staff in a selected provincial hospital in the Free State. These negative outcomes and challenges mentioned by the participants may lead to patient dissatisfaction and a decline in the quality of nursing care. Subsequently, the healing process of the patients and their families could be affected negatively. These concerns are expressed in a selection of direct quotes from the participants:

So many things can go wrong, so many things can go wrong if really they are not happy, they are not coming to work because who will nurse the patients you know [P1, F-59, 2yrs exp].

There will be more death, the death rate will be higher. So, mortality will increase as it is at the moment we don’t have a high care so, my ward is also a high care. So, if we are not present, we will really have a bad mortality rate here and it will really increase [P4, F-44, 2yrs exp].

Yeah, the mothers well if we don’t practice presence. They are also not supported. They don’t support their babies and they feel frustrated. They don’t know who to talk to. Therefore, you’ll be having this, this, I don’t want to say bitter mothers that you will behave in these mothers that are not active in their babies care that are not participating whenever you need them to participate, and that also indirectly affects the baby. Because they need their moms to be there for them [P4, F-44, 2yrs exp].

One patient will complicate, two you won’t identify the problems on time [P5, F-48, 2yrs exp].

The disadvantage, the anxiety with our patients they are lying there not knowing. I’m being collected from my ward but I’m lying here, you understand, so it’s the anxiety that I think that can go through [P12, F-54, 1.6 yrs exp].

I would think, depending on whether your patient is a minor or not. Or even a geriatric patient, or a patient cannot speak for him or herself. They will also be feeling negative about the very institution where the patient is being nursed. They might feel unhappy with the care that the patient is getting [P2, F-51, 20 yrs exp].

Furthermore, some of the participants observed that the image of the of the hospital could be affected negatively when unit managers do not practise presence. Simultaneously, it could affect negatively the patients’ and their families’ healing. It is important to acknowledge the public or community trust in the nursing profession and the crucial roles of the unit managers in managing the units. For instance, participants maintained the following:

Even our image as a hospital, you know will be at the bad side you know to the community, they won’t even trust our hospital, yes [P7, M-56, 1 year exp].

If I don’t practice presence the disadvantages is that there will be no smooth running of the department, there’s gonna be chaotic, and then its gonna, there’s gonna be lot of complaints that the patients are not cared for. And then even that will lead to the long stay of the patients [P11, M-53, 1.7 yrs exp].

The patient will die, definitely the patient will die. That is the only thing the patient will suffer, there’s nothing. If you don’t do anything the best to the patient that you are here for, who’s suffering, that helpless patient, if you don’t do anything if you don’t do wound dressing on daily basis the patient will end up being septic, if you don’t clean the wound of the patient the patient will be septic [P10, F-55, 3 yrs exp].

Theme 3: unit managers’ practices of relational care and human connectedness in the unit

The third theme demonstrates how unit managers practise relational care and human connectedness in the units with their staff and their patients. This theme explores the different strategies employed by these unit managers to attune relational care and human connectedness in their units. A few categories emerged which are presented below and supported by direct quotes from the participants.

Category 3.1: unit managers’ practices of relational care

The ability of unit managers to practise relational care to patients and staff was expressed by the participants. This category recognises the participants’ use of supportive practices towards staff members as well as patients and their families. Communication was highlighted as integral to practising presence whilst establishing trustworthy and professional relationships as well as rapport in the work environment. The direct quotes from the participants reveal this category:

The relationship, the relation I’m building with my staff, listen to their concerns and then if maybe I see they are not on the line I discipline them and then I try to motivate them to do what they are supposed to do [P11, M-53, 1.7 yrs exp].

So, I’m always around and helping all over the hospital, and that’s also something that I say to them, remember it don’t help we keep our knowledge for ourselves, so even if we need to go to other departments and share our knowledge, use it like that [P3, F-51, 6yrs exp].

Like when you are a manager mos you must communicate with your staff. So, like every morning when during report taking I’m there with them so that I can know what is going on in the unit and then to understand if there is any challenges like staff shortages or equipment [P8, F-50, 15yrs exp].

Supporting everybody. Where they need support, knowing your staff, seeing when they are having an off day or not feeling well, asking them about them [P2, F-51, 20 yrs exp].

Category 3.2: practices to facilitate human connectedness

In this category, participants verbalised their practices to facilitate human connectedness by reaching out to others and engaging the team in team building activities. They described the importance of unit managers having empathy with staff and providing the others with the necessary support. Direct quotes from the participants reveal their perceptions:

Well, sometimes, for instance, when they are busy and there are a few people, I will assist but if I can’t assist, I will do just give them a little something like for instance a cappuccino sachet that they can enjoy on teatime or something like that and they do appreciate those little gestures [P2, F-51, 20 yrs exp].

If somebody have done and everything correctly I will buy some a cup just to say you have done well good for this, you understand. Others are depending being depressed neh because of some other social problem that I have but what I usually do I will let the staff to contribute whatever they have to buy something, it can be a slipper or whatever or a present or whatever, just to say [P12, F-54, 1.6 yrs exp].

Ja, is to my staff and we do some things in the ward just for team building, mustn’t be work, work, work all the time. So sometimes I’m there doing somethings cheering us up [P1, F-59, 2yrs exp].

Human connectedness to my staff, sometimes we hold the small, the small parties together and go out to be together in our free time so that we can have time to know each other well even outside our workplace [P11, M-53, 1.7 yrs exp].

Theme 4: The perceptions of unit managers on barriers to presence practices in a selected provincial hospital in Free State

The final theme depicts the perceptions of the participants on barriers to presence practices in a selected provincial hospital in the Free State. This theme also identifies different types of barriers that could hinder the practising of presence. A few categories emerged which are presented below and supported by direct quotes from the participants.

Category 4.1: managers and staff-related barriers to presence practices

Participants identified the managers as well as staff-related barriers that may impact presence practices. They highlighted a few factors such as fatigue and burnout as barriers to presence practice. Participants also highlighted other contributing factors, such as staff attitude as well as staff members with personal disequilibrium, as barriers to presence practices. The following direct quotes from the participants address this category:

The unit manager, operational manager. Name it what you want to is actually emotionally and psychologically drained she cannot support the rest of the people, neither the patients, neither the staff, neither the family members, nobody [P2, F-51, 20 yrs exp].

They don’t want to be confronted, you know, they feel that if you are wanting things to be done as they’re supposed to be done, you’re on them, on their case. So, that’s what I’m saying people are just on the edge. If you say a thing, no matter how in what context they’re just on fire day [P6, F-54, 8yrs exp].

The challenges sometimes the nursing staff others especially at night mos they would be rude maybe they are tired so like when the patient is asking for something they would be like rude to the patient or ignorant [P8, F-50, 15 yrs exp].

Others will be abusing substances. There are those that are abusing substances. There are those that are that are going through divorce [P4, F-44, 2 yrs exp].

Category 4.2: work-related barriers to presence practices

Barriers that are work-related were identified by the participants. These include, but are not limited to, insufficient resources, work overload, multiple expectations, staff shortages, inadequate support, and the lack of acknowledgement. A few direct quotes from the participants may elaborate:

It’s not always to say that we can physically change the situation or. Say for instance, you don’t have a certain kind of consumable. Doctors, sisters, everybody will get frustrated and highly frustrated. And then you have to be the sound board for that [P2, F-51, 20 yrs exp].

Shortage of resources, cos sometimes they are the one next to the patient. If maybe there is no resources, they become frustrated. So, they have to leave the patient in the ICU to go and ask around you know, so those things like frustrate them and then their interpersonal relationship also like people they are not the same so those things [P4, F-44, 2yrs exp].

Presently, it’s so challenging because like, some of the things that, I can’t even, not a problem, for example there’s a shortage of staff, there’s not enough personnel as I indicated, shortage of what you call it, equipment and also absenteeism also affect the things that we manage, some of the things that affects me, yes [P7, M-56, 1 year exp].

Sometimes we are so exhausted even the nurses I see sometimes really they are so exhausted but we keep on working, we keep on working because even if there is no someone, I have to call them come to do overtime, come to help us [P9, F-50, 6 yrs exp].

Category 4.3: managers coping with barriers to presence practices

Participants shared their coping mechanisms for the barriers to presence practice. Evidently, as managers, they are faced with several challenges. Consequently, they are forced to resort to various courses of action in. order to cope with these barriers which could affect practising presence. Some of the participants indicated that they rely on others for support. Additionally, they have to result to improvisation, self-sacrifice, emotion-focused coping, and problem-focused coping. This is illustrated by several direct quotes from the participants:

…and I must say that, sometimes you get more support than other times in the sense of not only just nursing management, but also your doctors that actually works with you or the ones that’s in charge of your units [P2, F-51, 20 yrs exp].

Even me, I need sometimes to just go and rebrief with my manager or with one of the doctors, you know, because we need because of the death rate [P3, F-51, 6yrs exp].

I do get support from the two ladies that I’ve mentioned my assistant manager and my nurse manager, recently just they’ve supported me fully. I don’t want to lie [P5, F-48, 2 yrs exp].

Fortunately with me I’m a very, very, calm person, even if I see that I can’t manage, I’m a very, very, calm person, I wouldn’t even show you that now I’m so much overwhelmed. I’ll take them one by one, one by one until I finish what I’m supposed to be doing for that day [P12, F-54, 1.6 yrs exp].

So, we’ll be improvising, improvising and then at end when the families came here then they gonna log the complaints? [P11, M-53, 1.7 yrs exp].

Presence practice exists amongst unit managers, but it is practised differently. In this study, the unit managers practise presence merely by being visible, available, and accessible to the staff and the patients. Mohammadipour et al. explain that “nursing presence” refers to being there for patients and that it is the essence of interaction between nurses and patients [ 32 ]. Unit managers attempt to provide the staff with a conducive working environment to the best of their ability. The supportive work cultures also were evident because the unit managers conducted personal interviews with the staff and patients regarding problems that were identified. Subsequently, the unit managers referred them to the relevant persons for assistance when necessary. Moreover, the unit managers also attempted to manage their staff effectively through participative leadership, clinical governance, problem-solving, and conflict management. These are critical skills and knowledge that are essential traits for unit managers to facilitate evidence-based nursing and effective management of their units. In addition, unit managers encourage and motivate their staff by providing staff development opportunities and empowering them to grow professionally. Even though not all staff members may be interested in furthering their academic studies, the unit managers frequently provide in-service training or on-the-job training which similarly empower their staff in the units. Lovinck et al. refer to “a leader who fosters and reinforces changes for improvement” [ 11 ].

To ascertain the perceptions of the unit managers on presence practice, the study identified positive impacts as well as negative impacts on hospital dynamics. When nurses practise presence, it prevents adverse events whilst having a healing and calming effect on patients and their families. When unit managers practise presence, it has a positive impact on staff management. Staff work together in harmony when there is collaboration and team cohesion. Additionally, Du Plessis highlights the importance of staff supervision and direction to improve staff work performance, motivation, and morale [ 33 ]. Consequently, the unit managers should receive training to improve their competencies and skills [ 17 ]. Despite the positive impact, challenges and negative outcomes were verbalised when unit managers did not practise presence in their units. This could have a negative effect on the patients’ healing process, lead to patient and family dissatisfaction, and hamper the quality of patient care. Paturra et al. state that “nurse leaders both indirectly and directly influence their subordinates’ performance” which could impact the quality of nursing care [ 17 ].

Additionally, unit managers attempt to practise relational care in their units. They establish rapport, they attempt to build trusting relationships through effective communication, and establish professional relationships with others by means of supportive practices. Shandu emphasises the importance of two-way communication to assist in strategies that enhance hospital dynamics [ 34 ]. Simultaneously, unit managers attempt to facilitate human connectedness by showing empathy, reaching out to others, supporting others, and even planning extra curriculum activities such as teambuilding activities after hours. Du Plessis further adds that “presence is about connecting to the other and attuning to their needs” [ 33 ]. An added benefit to an institution could be if a leader is also a spiritual leader who can revolutionise the nursing environments and provide adequate guidance and support [ 22 ].

Finally, the study revealed the participants’ perceptions of the barriers to presence practices in a selected provincial hospital in Free State. The study revealed that staff-related barriers to presence practices were issues such as staff attitude, staff with personal issues, and staff burnout or fatigue. Blackman et al. allude to the reasons for nursing care to be neglected as a lack of adequate staffing and inadequate resources which could result in staff burnout and attitude issues [ 35 ]. A few other barriers to presence practice that were highlighted are insufficient resources and work overload due to a shortage of staff. In essence, these were factors outside of the unit manager’s control. Interestingly, a study conducted by Blackman et al. states that staff shortage is not the primary cause of missed patient care, even though it does contribute to it [ 35 ]. Sarkhosh et al. also emphasise in their study how resource constraints impact on patient safety [ 36 ]. At times, the unit manager lacks the provision of support and fails to acknowledge staff performance. These unit managers are also under tremendous stress. At times, they need to find ways to cope with certain barriers to practise presence. Some of the participants expressed the lack of support whilst others indicated that they were fully supported from top management and their fellow colleagues. According to Quenon et al., top managers are under immense pressure as they are held responsible for positive and negative results as well as ensuring that their facilities run smoothly [ 10 ].

In conclusion, this study unveils the perceptions and practices of unit managers regarding presence in a Free State hospital. Unit managers exhibit diverse presence practices by emphasising their commitment to visibility despite resource constraints and staff shortages. They actively foster supportive work cultures and effective management in order to have positive impacts on patient care and team cohesion. Conversely, challenges arise when managers lack presence, which affects patient healing and nursing care quality. The study underscores the importance of relational care, effective communication, and coping mechanisms. Unit managers display resilience by navigating obstacles and emphasising the need for ongoing support from top management and colleagues.

Availability of data and materials

To access the data in this study, kindly contact the corresponding author. The interview (data) used in this study was developed for this study and has previously not been published elsewhere. The data was uploaded as a supplementary file.

Abbreviations

Computer-Assisted Qualitative Data Analysis Software

North-West University

South African National Blood Services

South African Nursing Council

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Acknowledgements

Firstly, I would like to give praise to my ALMIGHTY FATHER, for his grace and favour bestowed upon my life. Secondly, I would like to acknowledge my supervisors (Dr. Precious and Prof Sehularo), especially Dr. Precious who moulded me, supported and guided me during difficult times that I wanted to give up. Then I want to acknowledge the management of the hospital for their willingness to grant me access to their institution. Thank you very much for everything. I also want extend my appreciation to NWU-HREC for the approval of the study. I’m eternally grateful to North-West University (NWU) and South African National Blood Services (SANBS) for the financial assistance they provided to me in the form of bursaries during my studies. In addition, I would also like to thank the co-coder and the language editor for their diligent work in co-coding and language editing of this study. Lastly, I would like to acknowledge my family that supported me during this journey, there were difficult days but they always encouraged me as they felt my absence.

Open access funding provided by North-West University. The study was funded by the NWU and SANBS research and development department.

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B.S conducted the study in fulfilment of requirements for a Master of Nursing Science (MNSc) degree, Dr P.C.C and Professor L.A.S supervised the study from the conception of ideas to its completion.

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I, Bernardine Chrisanda Smith, hereby declare that this study “Presence Practices Amongst Unit Managers in a Selected Provincial Hospital in the Free State Province” is my original work, and the sources used throughout the study have been fully acknowledged. Ethical approval was obtained from the North-West University Health Research Ethics Committee (NWU-HREC). Additionally, approval was obtained from the Free State DoH.

The study was approved by the North-West University Health Research Ethics Committee (NWU-HREC) (HREC-Ethics number- NWU-00076-23-A1). Approval was further obtained from the DoH in the Free State Province. Additionally, approval was obtained from the CEO (the gatekeeper) of the selected hospital. An informed consent to participate was obtained from all of the participants in the study.

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Smith, B., Chukwuere, P.C. & Sehularo, L.A. Exploring presence practices: a study of unit managers in a selected Provincial Hospital in Free State Province. BMC Nurs 23 , 367 (2024). https://doi.org/10.1186/s12912-024-02023-7

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Women’s experiences of disrespect and abuse in Swiss facilities during the COVID-19 pandemic: a qualitative analysis of an open-ended question in the IMAgiNE EURO study

• Alessia Abderhalden-Zellweger 1 ,
• Claire de Labrusse 1 ,
• Michael Gemperle 2 ,
• Susanne Grylka-Baeschlin 2 ,
• Anouck Pfund 1 ,
• Antonia N. Mueller 2 ,
• Ilaria Mariani 3 ,
• Emanuelle Pessa Valente 3 &
• Marzia Lazzerini 3  

BMC Pregnancy and Childbirth volume  24 , Article number:  402 ( 2024 ) Cite this article

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The COVID-19 pandemic has challenged the provision of maternal care. The IMAgiNE EURO study investigates the Quality of Maternal and Newborn Care during the pandemic in over 20 countries, including Switzerland.

This study aims to understand women’s experiences of disrespect and abuse in Swiss health facilities during the COVID-19 pandemic.

Data were collected via an anonymous online survey on REDCap®. Women who gave birth between March 2020 and March 2022 and answered an open-ended question in the IMAgiNE EURO questionnaire were included in the study. A qualitative thematic analysis of the women’s comments was conducted using the International Confederation of Midwives’ RESPECT toolkit as a framework for analysis.

The data source for this study consisted of 199 comments provided by women in response to the open-ended question in the IMAgiNE EURO questionnaire. Analysis of these comments revealed clear patterns of disrespect and abuse in health facilities during the COVID-19 pandemic. These patterns include non-consensual care, with disregard for women’s choices and birth preferences; undignified care, characterised by disrespectful attitudes and a lack of empathy from healthcare professionals; and feelings of abandonment and neglect, including denial of companionship during childbirth and separation from newborns. Insufficient organisational and human resources in health facilities were identified as contributing factors to disrespectful care. Empathic relationships with healthcare professionals were reported to be the cornerstone of positive experiences.

Swiss healthcare facilities showed shortcomings related to disrespect and abuse in maternal care. The pandemic context may have brought new challenges that compromised certain aspects of respectful care. The COVID-19 crisis also acted as a magnifying glass, potentially revealing and exacerbating pre-existing gaps and structural weaknesses within the healthcare system, including understaffing.

Conclusions

These findings should guide advocacy efforts, urging policy makers and health facilities to allocate adequate resources to ensure respectful and high-quality maternal care during pandemics and beyond.

Peer Review reports

The consequences of the COVID-19 pandemic have been unpredictable and devastating for individuals, families, societies, and economic systems around the world [ 1 ]. Healthcare systems, including maternity care services, have been severely affected by the pandemic, as clinical guidelines and safety procedures have had to be rapidly revised and updated to contain the spread of the virus [ 2 ]. Approximately 85 000 births are observed each year in Switzerland, with the vast majority (98.3%) taking place in hospitals [ 3 ]. The rate of caesarean sections is about 32.2% [ 3 ] (17.8% elective [ 4 ]), which is higher than the European average of 25.7% [ 5 ]. Before the pandemic, Switzerland had a fertility rate of 1.48 births per woman, slightly below the EU average of 1.53 [ 6 ]. During the pandemic, fertility declined by 14.1% in European countries (5.4% in Switzerland) [ 7 ].

Because of the medical emergency caused by the pandemic, some essential aspects of maternal and newborn care have been deprioritised in health facilities [ 8 ]. Studies in various national settings have shown that during the early stages of the pandemic, women’s companions were not allowed to remain with them during labour to limit potential sources of infection. Additionally, obstetric interventions, such as caesarean sections, were performed without clear clinical indication, and women and their newborns were separated after birth if the mother tested positive for SARS-CoV-2 [ 9 , 10 , 11 ]. In Switzerland, specific measures and national recommendations targeting maternity services were issued, including restricting hospital visits, and limiting the presence of partners during and after childbirth [ 12 , 13 ]. While these measures were implemented to control COVID-19 infection, some of them do not align with the recommendations of quality and respectful maternal care [ 14 , 15 , 16 ]. For instance, excluding partners and separating newborns from their mothers are particularly unrecommended practices according to the rights-based approach to maternity care [ 8 , 17 , 18 ]. These actions are deemed as deviations from established practice without supporting evidence [ 8 ]. Violations of respectful maternity care and disrespectful and abusive practices were observed during COVID-19, both directly and indirectly related to the pandemic context.

In 2010, seven categories of disrespect and abuse in maternity care were defined by Bowser et al. [ 19 ]. These categories include: physical abuse; non-consented care; non-confidential care; non-dignified care (including verbal abuse); discrimination based on specific attributes; abandonment or denial of care; and detention in facilities. These categories were documented by the White Ribbons Alliance [ 20 ], which sought to broaden the scope of ‘safe motherhood’ by acknowledging the importance of the relationship between caregivers and women. Building on this, the International Confederation of Midwives (ICM) subsequently used the same categories to develop the RESPECT Toolkit [ 21 ], to promote respectful maternity care for all women around the time of childbirth.

Although the focus of this paper is on disrespect and abuse in maternity care, it is important to note the corresponding rights that are designed to counteract the manifestations of these mistreatments, as outlined by Bowser et al. [ 19 ]. Figure  1 shows the categories of respectful maternity care identified by Jolivet et al. [ 22 ] in their systematic scoping review. These categories were identified by comparing two frameworks: the Respectful Maternity Care Charter developed by the White Ribbon Alliance (2011, updated 2019) [ 20 ] and the International Human Rights and the Mistreatment of Women during Childbirth by Khosla et al. [ 23 ].

Categories of respectful care during childbirth identified by Jolivet et al. [ 22 ]). Legend : Abbreviation: RMC = Respectful Maternity Care

Respectful maternity care is not only a fundamental human right, but it also plays a crucial role in shaping the well-being of both mothers and newborns. Negative experiences around the time of childbirth, such as disrespect or neglect of women’s wishes, discrimination, or verbal or physical abuse, can lead to poorer physical and mental health outcomes for mothers and their newborns [ 24 ]. Renfrew et al. [ 25 ] stressed the importance for maternity and neonatal services to provide pregnant women and new mothers with quality care, even in the face of unforeseen events.

Since 2020, the IMAgiNE EURO study, based on the WHO Standards for improving Quality of Maternal and Newborn Care (QMNC) [ 26 ], has been documenting QMNC during the COVID-19 pandemic in the European Region. Several studies resulting from this international project reported limitations in the QMNC provided during the COVID-19 pandemic [ 27 , 28 , 29 , 30 ]. Quantitative data from the IMAgiNE EURO study among 1′175 women who gave birth in Switzerland from March 2020 to February 2022, indicate that about 28% of women reported limitations in the QMNC during the pandemic [ 27 ]. However, little is known qualitatively about women’s experiences of care around the time of childbirth, and their experiences of disrespect and abuse during the COVID-19 pandemic.

This study aims to provide valuable insights into the experiences of women who gave birth in Swiss facilities during the COVID-19 pandemic, using the categories of disrespect and abuse defined in the ICM RESPECT Toolkit [ 21 ] as a framework for analysis. The results of this study will help improve maternity care provision and advocate for respectful maternal and newborn care in general, including during health crises [ 25 ].

Study design

This study reports qualitative data collected through the IMAgiNE EURO study “Improving Maternal Newborn Care in the European Region”. Led by the WHO Collaborating Center for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy [ 31 ] and based on the WHO Standards [ 26 ], the IMAgiNE EURO study documents QMNC during the COVID-19 pandemic in more than 20 European countries, including Switzerland (ClinicalTrials.gov NCT04847336).

The Standards for Reporting Qualitative Research (SRQR) [ 32 ] were used to report this study (see Supplementary Information 1).

Data collection

Data were collected using an online survey hosted in REDCap® as part of the IMAgiNE EURO study. The validated questionnaire was developed based on the 40 key Quality Measures of the WHO Standards for improving QMNC in health facilities [ 33 ]. Women who had given birth in Switzerland were recruited using multiple strategies, including targeted outreach to specific groups of mothers on social media, and distribution of flyers through hospitals and by independent midwives. Participants accessed the online survey via a link or QR code and could choose their preferred language from 24 available.

The data collection period covers the first 2 years of the IMAgiNE EURO study. It is important to note that, on 1 April 2022 the emergency measures related to the COVID-19 pandemic were lifted in Switzerland [ 34 ]. Women aged 18 years and older, who gave birth in Swiss’ hospitals and clinics between 1 March 2020 and 14 March 2022 and gave their consent to participate were eligible for this study. At the end of the questionnaire, a non-mandatory open-ended question allows women to provide comments for improve the QMNC: “Do you have any suggestions to improve the quality of care at the facility where you gave birth or to improve the questionnaire?”. However, many respondents did not provide specific suggestions, but rather gave general comments about their experience of care at the hospital where they gave birth. Although the question does not explicitly address disrespect and abuse, several women shared comments that reflected negative instances of disrespect and abuse. The use of a tailored framework was deemed necessary to accurately report the prevalence of such experiences among the women who responded to the open-ended question. This highlights the importance of using the ICM RESPECT Toolkit [ 21 ] as a framework for analysis.

Table 4 outlines the specific recommendations for improving QMNC provided by participants, which are also discussed in a separate section of the results.

The qualitative analysis for this study was limited to women who responded to the open-ended question in one of the languages known to the authors (French, German, Italian, English) (Fig.  2 ). Table 1 summarises the socio-demographic data collected for these women.

Women participating in the IMAgiNE EURO study and answering to the open-ended question in French, German, Italian or English. Legend : 1 Women who did not answer to the question “Do you have any suggestions to improve the quality of care in the facility where you gave birth or to improve the questionnaire?”; 2 Women who answered by simply indicate: “-”; “no”; “I have no comments”

Data analysis

Women’s comments on the open-ended question were exported to an Excel spreadsheet and then imported into the MAXQDA-20 software, regardless of the language used. This software is suitable for systematically processing the excerpts related to the different themes. Women who answered ‘no’, ‘yes’ or ‘I have no comments’ were excluded from further analysis. Initially, the first author independently coded participants’ comments using MAXQDA-20, along with reflective and analytical notes explaining the decision-making process and choices. The themes sought to summarise women’s experiences of disrespect and abuse in maternity care. For this purpose, women’s comments were analysed thematically, using the categories of disrespect and abuse reported by the ICM [ 21 ] as a framework for analysis (i.e., physical abuse; non-consented care; non-confidential care; non-dignified care; discrimination based on specific attributes; abandonment or denial of care; and detention in facilities), following a deductive approach. When necessary, the categories related to disrespect and abuse were operationalised with reference to the systematic review by Sando et al. [ 35 ]. If a woman’s statement pertained to two or more categories established in the ICM’s RESPECT Toolkit, the comment was added to both themes. For each language chosen for analysis (i.e., French, German, Italian, English), a second author (CdL, MGE, or SBG) independently coded the same selection of comments, which were compared and discussed. If needed, a third researcher was consulted to reach a consensus. Where themes in the women’s comments were not related to the ICM’s RESPECT Toolkit [ 21 ], a reflexive thematic analysis was undertaken following the steps recommended by Braun and Clarke [ 36 , 37 ], using an inductive approach. Following the iterative process of coding, conceptual sub-themes and other inductive themes were generated. The final list of codes was agreed on during team meetings with experienced maternal and newborn health researchers and all authors of this paper. As part of this publication, all women’s comments were translated into English. The reliability of the translated comments was ensured by double-checking the translation with at least two authors.

Ethical aspects

The study protocol was approved by the Institutional Review Board of the IRCCS Burlo Garofolo. As this was a voluntary, anonymous survey of maternal views on QMNC, the Ethics Committee of the Canton of Vaud considered that this study did not fall under the Human Research Act (art. 2) and therefore did not require any further ethical approval in Switzerland (CER-VD, information on July 9th, 2021). Data were stored in Italy. Data transmission and storage were secured by encryption. When accessing the link and before participating, women were informed about the aims and methods of the study, including their right to refuse to participate or to withdraw at any time. Informed consent was obtained before answering the questionnaire, and a full privacy statement was available for download if requested.

Of the 1′205 women who gave birth in Switzerland and participated in the IMAgiNE study, 199 responded to the non-mandatory open-ended question and met the inclusion criteria (Fig.  2 ). The comments provided by these 199 women were analysed.

In the IMAgiNE EURO questionnaire, participants were asked if they had experienced limitations in QMNC due to the COVID-19 pandemic. Of the 199 women who responded to the open-ended question, 43.2% reported experiencing limitations in the QMNC received due to COVID-19, either ‘always/nearly always’ or ‘sometimes’.

Characteristics of the study population

The characteristics of the 199 women who responded to the open-ended question are presented in Table  1 . Most women (67.8%) were born in Switzerland and responded in French (55.3%). The majority were aged between 31 and 35 years, and 95.5% had completed at least high school. Half of the participants (50.3%) were primiparous, and the vast majority (80.4%) gave birth in a public hospital.

Categories of disrespect and abuse identified through deductive thematic analysis using the RESPECT toolkit

Table 2 shows the categories of disrespect and abuse according to the RESPECT toolkit and the sub-categories identified.

Overall, five out of the seven categories of disrespect and abuse as defined by the ICM [ 21 ] were observed. None of the comments made by women fell into the categories ‘Detention in facilities’ and ‘Discrimination based on specific attributes’.

Non-consented care

Comments related to the category of ‘non-consented care’ highlighted instances where HCP failed to respect women’s choices and preferences.

“Respect the ‘preferences’ for childbirth […], and if medically not feasible, explain in a humane manner and show more understanding” (comment in German, age ≥ 40, private hospital/clinic).

Some women also felt that the HCP prioritised protocols over women’s individuality.

“We are all lumped into the same group, on the assumption that each of us will give birth, feel, and experience identical emotions” (comment in French, age 31–35, private hospital/clinic).

It is also worth noting that 11.6% of women reported not knowing the HCP attending their birth because they did not introduce themselves (Table  1 ). This also highlights an issue related to non-consented care.

Non-dignified care (including verbal abuse)

Women reported experiencing various forms of non-dignified care, including a lack of empathy and emotional support from HCP. These elements are crucial, especially during the COVID-19 pandemic and the associated climate of uncertainty.

“Be more attentive to the needs of mothers despite COVID-19! Be much more empathetic because emotionally it was horrible, and I still haven’t come to terms with this terrible childbirth experience! I feel like my last childbirth was stolen from me ” (comment in French, age 31–35, private hospital/clinic).

Some women also perceived disrespectful attitudes and inappropriate behaviour on the part of HCP.

“The anaesthetists should be more respectful and take the time instead of adopting inappropriate attitudes and gestures under the pretext of an operation at 7:20 a.m.” (comment in French, age 25–30, public hospital).

Some women pointed out that HCP often transmitted their own stress to the women in their care.

“ Sometimes, we are faced with exhausted employees who have no filters or who pass on their ‘stress’ to us. In my opinion, this should change ” (comment in French, age 31–35, public hospital).

Finally, women reported emotional pressure from HCP such as being blamed during labour and being shamed for wanting painkillers during childbirth.

“ Shaming for wanting painkillers during labour should not exist—everyone has different pain tolerance and it’s not like there is a medal for suffering ” (comment in English, age 31–35, public hospital).

Abandonment/neglect of care

Participants stated that being denied companionship during childbirth constitutes a significant violation of their right to respectful care.

“ The emotional experience of the mother not knowing whether her partner can be present at the birth. […], this was the greatest and most stressful burden. Having a child is not only the mother’s business and leaving the hospital as a father 24 h after the birth or not being able to be there at all is not appropriate ” (comment in German, age 36–39, public hospital).

Being separated from their newborn after birth was also perceived by women as a significant failure in providing respectful care.

“ I gave birth on the day of the second wave of COVID, and my daughter was in the neonatal unit for over three weeks. My partner and I were denied access to the neonatal unit and we had to fight to get into the hospital. It was a nightmare. […] I am being treated for depression because of this. They did not support us during this difficult time due to COVID ” (comment in French, age 25–30, public hospital).

Some women felt left alone and abandoned during maternity care.

“ When mothers give birth without birthing partners they should not be left alone so much, […]. I was given a drug to speed up labour and then left alone. By the time the midwife came back, the baby was crowning, and I was alone. I had to ring an alarm to get them to come back. I heard the midwife say to the other midwife ‘I shouldn’t have left her’, but no one said anything to me ” (comment in English, age ≥ 40, public hospital).

Other testimonies revealed shortcomings in the care provided, mostly due to the lack of available staff, which can be partly attributed to the pandemic context.

“ I experienced 3 bladder hematomas after my caesarean section and felt a pain I had never felt before. […]. During the pain, I thought I was going to die […]. The postpartum service called a doctor, who was busy with a REAL emergency, and never came. Not even the next day. I understand that staff shortages are a reality and solutions must be found ” (comment in French, age 31–35, private hospital/clinic).

Non-confidential care

Only six comments were related to the category of ‘non-confidential care’. The most common complaints were about the lack of privacy due to the layout of the rooms in the maternity wards during the COVID-19 pandemic.

“ The only drawback is with regards to the rooms, the separation curtain between the beds is too small and doesn’t provide enough privacy” (comment in French, age 25–30, public hospital).

The reconfiguration of maternity care in response to the COVID-19 pandemic may have contributed to this problem.

Physical abuse

Finally, a few women wrote comments that fall into the category of physical abuse. Some of them reported aggressive behaviour by HCP, particularly midwives.

“The post-delivery treatment was very difficult for me. The midwives were aggressive, implying that I wasn’t trying hard enough to walk the day after the operation” (comment in French, age ≥ 40, public hospital).

It should be noted that the woman’s experience may refer to criticism from the midwives rather than physical aggression. The other two comments in this category were testimonies of forced use of instruments during childbirth and pulling of the cord to remove the placenta, which the woman perceived as a direct cause of her subsequent haemorrhage.

Categories of disrespect and abuse identified through the inductive reflexive thematic analysis

Table 3 presents further categories of disrespect and abuse identified through the reflexive thematic analysis.

The inductive thematic analysis of women’s comments allowed for the identification of additional themes, most of which were specifically related to the uniqueness of the pandemic context and structural weaknesses within health facilities.

Lack of sufficient/adequate resources

Several women emphasized the lack of sufficient and appropriate resources to ensure respectful maternity care, particularly regarding the number of HCP or other material resources such as an adequate number of rooms.

“ The biggest problem was the limited number of staff. When I gave birth, the midwife who was assisting me worked for 13 h without a break, attending to both me and another woman, as well as the mothers in the other rooms. […], we were told to call the midwives only in emergencies, because there were too few of them ” (comment in Italian, age 25–30, private hospital/clinic).

No clear information from HCP regarding COVID-19

Some women perceived unclear, contradictory, or insufficient information about protective measures in relation to COVID-19.

“ The guidelines on the viral load at which a Covid  +  mother can visit her child(ren) were not uniformly regulated between the postpartum ward and the NICU; the postpartum ward wanted to keep me in isolation, while the neonatology unit allowed me to visit. This resulted in me not being able to see my children for 5 days after giving birth” (comment in German, age 36–39, public hospital) .

Inappropriate use of protective equipment by HCP

A few women also reported inappropriate use of personal protective equipment by HCP.

“ And despite being a private hospital the midwives had to use a disposable mask for the whole shifts (instead of changing every 4 h as recommended) ” (comment in English, age 31–35, private hospital/clinic).

Positive experience

Finally, several women reported very positive experiences with the maternity care they received.

“My experience of childbirth was very positive. I had a very patient and understanding midwife who gave me all the possible choices that could be made at that moment, but this is not the case for everyone, and it shouldn’t be left to chance ” (comment in Italian, age 25–30, private hospital/clinic).

Positive experiences were mainly attributed to a good relationship with HCP, characterised by empathy, effective communication, and the respect of women’s choices during childbirth. These factors were considered essential by women.

“Excellent communication and empathy from midwives […]. The birth plan was respected, even by the doctors” (comment in French, age 31–35, public hospital).

Suggestions to improve QMNC during the pandemic

Table 4 presents specific suggestions for improving QMNC during the pandemic, as identified by participants.

Allow partners to stay during labour and birth

As mentioned above, the presence of a partner during labour and birth was perceived as essential for women to have a positive childbirth experience. Thus, even during the pandemic, women are advocating for their partners to be allowed to be present during this crucial time.

“ The partner must be allowed to be present during childbirth. It was terrible that the father could only be there at the end and was only allowed to hold the baby briefly before he left and could not come back ” (comment in German, age 31–35, public hospital).

No restrictions on partner and family after childbirth (including older children)

Respondents clearly stated that visits from partners and close family members should not have been denied or restricted.

“ Due to the pandemic, the hospital had very strict restrictions regarding the presence of fathers. After the two hours of postnatal observation, the father had to leave the hospital and could not return until the mother and baby were discharged. These rules were very difficult to deal with (loneliness and exhaustion for the mother who had to manage the first few days alone because the staff was overwhelmed, trauma for both parents, […]). These restrictions must be reviewed urgently as they are INHUMANE!” (comment in French, age 31–35, public hospital).

Limit the number of visits from other family members

Several women expressed satisfaction that visits from family members other than their partner were limited. This allowed the women and newborns to rest, and bond.

“ I appreciated the policy of not allowing relatives to visit the postnatal ward. It gave me a chance to rest and bond with my baby. I recommend that this policy be continued” (comment in German, age 36–39, public hospital).

No restrictions on NICU visits for parents

Finally, when a newborn requires admission to the NICU, parents should not be restricted from visiting their child because of the pandemic, as suggested by women.

“ And what about those mothers who have given birth and must have a health pass to see their baby? What kind of world are we living in? It’s a shame” (comment in French, age 31–35, public hospital).

This study investigated women’s experiences of disrespect and abuse in maternity care during the COVID-19 pandemic in Switzerland. Using the ICM’s RESPECT Toolkit [ 21 ] as a framework for analysis, the findings highlighted shortcomings in Swiss health facilities related to disrespect and abuse in maternal care during the pandemic. Women frequently reported mistreatment related to non-consented care, abandonment, neglect, and non-dignified care. Additionally, they feel that HCP often dismiss their wishes and needs with little empathy. Some of the COVID-19 pandemic-related measures, such as denying companionship during childbirth, caused feelings of isolation and loneliness, and some participants conveyed the inhumanity associated with such practices. In times of crisis, certain rights may be restricted in favour of security, safety, or emergency resource management [ 8 ]. However, compromising the principles of quality and respectful care poses a significant risk to women and newborns. Negative experiences during pregnancy and the stress generated by the COVID-19 pandemic can have far-reaching consequences for maternal and newborn health, as well as for mother-infant bonding [ 17 , 38 , 39 , 40 ].

The positive experiences reported by some women also provide encouraging findings. These results underline the importance for HCP, institutions, and policy-makers to recognise that essential elements of respectful maternity care, such as respect, dignity, empathy, and emotional support during childbirth, should be an integral part of care provision and not treated as optional or superfluous in times of health crisis.

Disrespect and abuse around the time of childbirth

Women’s comments have drawn attention to several complaints of abuse and disrespect in Swiss’ health facilities during the COVID-19 pandemic. These elements are presented in detail in the following sections.

Firstly, healthcare facilities appear to face difficulties to consider women’s choices and preferences during childbirth, yet these elements have been identified as crucial in achieving a positive childbirth experience [ 41 , 42 ]. Issues related to non-consented care are consistent with the quantitative data collected in the Netherlands by van der Pijl et al. [ 43 ] among 12′239 women, where almost 40% of the interviewed women reported a lack of choice during labour and birth (e.g., concerning the position to give birth). More specifically in the context of the pandemic, data from a cross-sectional study in Luxembourg show that 42.9% of women were not asked for their consent before instrumental vaginal birth (IVB) [ 44 ]. In the present study, women reported that protocols were too often prioritised over their individual needs, which is contrary to the central tenet of patient-centred care [ 31 ] and a crucial aspect of high-quality perinatal care as outlined by the WHO [ 9 , 26 ]. Similar findings were reported in a mixed methods study conducted in Switzerland, where several women reported that their wishes and needs were easily dismissed by HCP, and that interventions were carried out without addressing their concerns [ 45 ]. These outcomes suggest that this phenomenon goes beyond the exclusive context of the pandemic, as it appears to be present in healthcare settings regardless of the pandemic context. Nevertheless, it is plausible that the pandemic, with its constantly changing protocols and pressures on HCP [ 46 ], may have exacerbated instances of disrespectful care provision, such as non-consented care.

Secondly, during the COVID-19 pandemic, women reported experiencing abandonment and lack of support around the time of childbirth. This was mainly due to pandemic-related measures that restricted the presence and visitation of close family members. These findings corroborate previous studies indicating that hospital-imposed restrictions on partner presence and visiting hours during the COVID-19 pandemic had a negative impact on the experience of pregnancy, childbirth, and the postpartum period, leading to pronounced feelings of sadness and anxiety among women [ 47 ] and their partners [ 48 , 49 ]. Diamond et al. [ 50 ] conducted a quantitative study of the impact of perinatal health policy changes resulting from COVID-19 on post-traumatic stress disorder (PTSD) following childbirth. Based on a sample of 269 women in the United States, they found that higher rates of PTSD were significantly associated with limited length of stay ( p  = 0.001) and having only one support person during labour and childbirth ( p  = 0.003) [ 50 ]. When suggesting ways to improve QMNC, many women in this study emphasised the importance of not restricting the presence of birth partners and postnatal visits. Interestingly, women were also positive about limiting visits from other family members and friends, which is consistent with existing literature [ 9 , 51 ]. Healthcare facilities should prioritise flexibility in visitation policies to accommodate parents’ needs during normal times and health crises [ 17 ]. It is unclear whether restricting visiting hours has more advantages than disadvantages, and future studies should address this issue. Another major concern expressed by women is the separation from their newborns after childbirth, and many participants argued against restrictions on newborn visitation in the NICU. A global cross-sectional study among 424 HCP [ 11 ] found that over a quarter of suspected COVID-19 cases resulted in the separation of mothers from their newborns at birth. This practice, intended for the safety of the baby, has been criticised by Jolivet et al. [ 8 ] and Bergman [ 52 ], as it can have long-lasting consequences such as impaired attachment, and postnatal depression that persist for months or even years after childbirth, as reported by participants in our study.

Thirdly, health facilities seem to have difficulties in providing dignified care, as women have reported disrespectful attitudes, inappropriate gestures (e.g. pulling on the cord to remove the placenta, slanderous remarks) and a lack of empathy on the part of health professionals. Experiencing such attitudes and emotional pressure from HCP resulted in some women having negative perceptions of their birth experience. Lack of support from HCP has also been found to negatively affect the birth experience in previous research and outside the pandemic context [ 43 ]. However, as mentioned by the authors, this type of mistreatment is mostly related to emotional pressure and a lack of empathy, which is more subtle compared to physical abuse or other violent behaviour [ 43 ]. Mistreatment of this type seems to be more common in high-income countries (such as Switzerland), where HCP may exhibit abusive and coercive behaviour in a more subtle manner [ 53 ]. Nevertheless, it is important to avoid blaming HCP alone, as their behaviour is often influenced by systemic and structural factors [ 54 ]. In the pandemic context, a survey among 1′127 health workers from 71 countries [ 10 ] found that compromised standards of care, overwhelmed staff coping with rapidly evolving guidelines, and increased infection prevention measures were among the major barriers to providing respectful maternity care.

Fourthly, the issue of compromised privacy in the category of non-confidential care was primarily attributed by women to room layout factors such as the number of patients per room and inadequate space between beds. It is plausible to hypothesise that the pandemic had a negative impact on the provision of confidential care during childbirth in Switzerland, as evidenced by the reconfiguration and closure of maternity wards that occurred amidst the pandemic [ 2 , 55 ]. This finding should be acknowledged and taken into consideration in future research and maternity care practice.

Finally, a minority of women reported experiencing more serious forms of abuse in health facilities, such as physical abuse. One woman described the midwives as aggressive during the postpartum period. However, based on the general nature of the woman’s comment, her experience may refer to criticism from the midwives rather than physical aggression. Other narratives in this category included accounts of forced use of instruments during childbirth and pulling on the cord to remove the placenta, which the woman perceived as a direct cause of her subsequent haemorrhage. Data from the IMAgiNE EURO study, indicate that 9.6% of women who gave birth during the COVID-19 pandemic in Switzerland experienced some form of abuse, without specifying the type of abuse experienced (physical/verbal/emotional) [ 27 ]. This proportion is relatively low compared to other European countries, ranging from 7.0% in Sweden to 23.4% in Serbia [ 31 ]. Regardless of whether this finding is directly attributable to the pandemic, such mistreatment should never be tolerated and HCP, institutions and researchers must address these issues to prevent their recurrence in the future, as stated by the WHO [ 56 ].

Lack of resources to cope with the pandemic context

Analysis of women’s comments identified other themes related to disrespect and abuse in maternity care. These themes highlight structural weaknesses in health facilities, such as the critical lack of resources to effectively manage the challenges of the pandemic context while ensuring the provision of respectful maternity care. The lack of human and material resources appears to be perceived by women as directly related to the pandemic context. These qualitative findings corroborate the quantitative results of the IMAgiNE EURO study, which showed that approximately one in five women perceived an insufficient number of HCP as a result of the COVID-19 pandemic [ 27 ]. Gaps in emotional support from HCP (mentioned above in the category of non-dignified care) also appear to be partly related to understaffing during the COVID-19 pandemic. Switzerland has the second highest number of physicians and nurses per 1000 inhabitants in the entire European Region, with 4.1 physicians and 17.7 nurses (including midwives) [ 57 ]. Despite the relatively high staffing level, the Swiss health care system has been facing long-standing issues even before the pandemic. Notably, there is a persistent shortage of HCP [ 58 ] and their working conditions are physically and emotionally demanding [ 59 ]. These challenges have impaired the system’s ability to adapt in the face of this unprecedented global health crisis. It is plausible to hypothesise that the pandemic further strained an already fragile system. Some women reported that they were reluctant to seek help from staff, knowing that they were overwhelmed with stress. In some cases, health workers themselves discouraged women from seeking help unless it was considered a real emergency. Health facilities bear the responsibility to create an environment that enables HCP to provide respectful, high-quality maternity care under optimal conditions [ 25 , 60 ]. Indeed, HCP’ negative attitudes and behaviours are largely dependent on structural factors [ 54 ]. The mixed-methods systematic review conducted by Bohren et al. [ 61 ] revealed that HCP attributed shortcomings in the healthcare system, such as understaffing, high patient volumes, and long working hours, as contributing to a stressful environment that could lead to unprofessional behaviour. As reported by van der Pijl et al. [ 42 ], mistreatment in maternity care can manifest itself in both active and passive behaviours. The former is directly related to the behaviour of the HCP, while the latter is related to the conditions of the health system. This study supports these findings, suggesting that deficiencies in the health care system contribute to disrespect and abuse in maternity care. Improving the attitudes and behaviours of HCP alone will not be sufficient to ensure respectful maternity care. Possible ways of improvement should take into account all stakeholders involved, including professional associations, institutional and political authorities [ 62 ].

Although the focus of the present study was on disrespect and abuse in maternity care experienced by women around the time of childbirth during the COVID-19 pandemic, some participants also reported positive experiences of care provided by HCP, such as being treated with empathy, clear communication and respect for their choices. Quantitative results from the IMAgiNE EURO study in Switzerland [ 27 ], as well as in other European countries [ 29 , 30 , 31 ], show that good care coexists with important QMNC gaps. In line with the salutogenetic approach, it is important to recognise and explore positive experiences around childbirth [ 63 ], even during a pandemic. Future research could adopt a salutogenetic framework to explore protective factors, which may be particularly relevant in addressing health crises in the future. In this sense, future research should investigate how respectful maternal care can be maintained. One possible avenue is to use the 10 fundamental rights of childbearing women and newborns outlined in the Respectful Maternity Care (RMC) Charter [ 20 , 64 ]. Ensuring respectful maternity care is arguably more than the absence of disrespect and abuse. Such investigation could complement the current study and provide valuable insights for health promotion research and practice.

Strengths and limitations

This study presents original findings in the Swiss context and contributes to a better understanding of disrespectful and abusive practices in facility-based maternity care in high-income countries. To the best of our knowledge, this is the first study in Switzerland to collect women’s experiences around the time of childbirth during the COVID-19 pandemic using the ICM RESPECT toolkit as a framework for analysis. This instrument proved valuable in analysing women’s comments through the lens of disrespect and abuse in maternity care, as many of the participant’s comments fell into the seven categories presented in the toolkit. It was also appropriate to explore women’s experiences during the COVID-19 pandemic. Finally, it is worth noting that the ongoing IMAgiNE EURO project allows for data monitoring. Further research will explore indicators beyond the pandemic.

The limitations of the IMAgiNE EURO study have been described previously [ 31 ]. The results of the present study should be interpreted considering the following limitations. First, comments made in an open-ended question on a survey cannot fully replace in-depth interviews with women who have experienced disrespect and abuse around the time of childbirth. Furthermore, the wording of the question “Suggestions for improving the quality of care at the facility level” and its placement at the end of a questionnaire may have influenced participants’ responses, as they had already expressed their opinions about the quality of care. Second, the choice of languages for analysis (German, Italian, French and English) may have excluded the experiences and perspectives of the most vulnerable populations, such as migrant women. As these populations have been particularly affected by the COVID-19 pandemic [ 27 , 65 ], their perspectives on disrespect and abuse in maternity care should be considered in future research. In addition, their experiences may also vary according to different characteristics (such as language barriers, ethnicity, education, etc.). Third, a possible selection bias cannot be excluded, as it is possible that women who chose to participate were more inclined or interested in the topic. In addition, the use of a non-random, convenience sampling strategy and the non-mandatory nature of the open-ended question may also have introduced the possibility of selection bias (see Fig.  2 ). It is worth noting that almost all women who responded to the open-ended question had at least a high school education. Thus, the present study may not fully capture the experiences of women with lower levels of education, who may experience different forms of mistreatment or disrespect in health care settings. Forth, as the RESPECT toolkit is designed to support and train HCP to avoid disrespectful and abusive behaviours, it lacks the integration of structural components to assess these practices. These critical aspects were reported by women as important factors contributing to certain disrespectful practices. Future studies investigating disrespect and abuse in maternal care should consider these elements as they shed light on HCP behaviours and the care they provide. Finally, while the results indicate that disrespect and abuse during labour and childbirth do occur in Switzerland, the qualitative design of the study does not provide insight into the prevalence of these experiences. Very few studies [ 43 ] have examined the prevalence of disrespect and abuse in facility-based maternity care in high-income countries according to the seven categories developed by Bowser et al. [ 19 ]. Further research is needed to thoroughly investigate the occurrence of disrespectful and abusive maternity care in Swiss facilities.

The collection of women’s experiences during the COVID-19 pandemic in Switzerland proved to be highly relevant in identifying disrespectful and abusive practices in maternal care. This study highlights the importance of studying these aspects, even in high-income countries, as the results reveal certain inappropriate care practices that call for action to ensure respectful maternity care in Switzerland. The pandemic has undoubtedly played a role in compromising certain aspects of respectful care, such as patient choice [ 66 ] and dignified care. However, the COVID-19 pandemic has also acted as a magnifying glass, revealing and exacerbating pre-existing gaps in respectful maternity care [ 24 ] and structural weaknesses in health facilities. Not only should HCP pay attention to women’s distress signs and empathetically meet their needs to avoid disrespect and abuse in maternity care, but they should also have the necessary resources to do so. These lessons need to be translated into advocacy, as policy-makers and health facilities should ensure that HCP have sufficient resources to provide quality and respectful maternity care, even in times of health crisis.

Availability of data and materials

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

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Acknowledgements

We thank all the women who participated in the study and shared their experience.

This research was supported by the Ministry of Health, Rome—Italy, in collaboration with the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste—Italy and supported by human and material resources in the partner institutions. The IMAgiNE EURO study group would like to thank all the women who took the time to participate in the study.

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

IMAgiNE EURO project was funded by the Ministry of Health, Rome—Italy, in collaboration with the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste—Italy. This study was supported by the School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts Western Switzerland and Research Institute for Midwifery and Reproductive Health, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland.

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AAB: Conceptualization; Methodology; Formal analysis; Investigation; Data curation; Writing—original draft; Writing—review & editing. CDL: Conceptualization; Methodology; Investigation; Data curation; Supervision; Writing—review & editing. MGE: Conceptualization; Investigation; Writing—review & editing. SGR: Conceptualization; Investigation; Writing—review & editing. APF: Conceptualization; Investigation; Writing—review & editing. AMU: Conceptualization; Investigation; Writing—review & editing. IMA: Conceptualization; Methodology; Formal analysis; Investigation; Data curation; Writing—review & editing; Project administration; Funding acquisition. EPV: Conceptualization; Methodology; Investigation; Writing—review & editing; Supervision; Project administration; Funding acquisition. MLA: Conceptualization; Methodology; Investigation; Writing—review & editing; Supervision; Project administration; Funding acquisition.

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The study protocol was approved by the Institutional Review Board of the IRCCS Burlo Garofolo (Approval number: IRB-BURLO 05/2020, 15.07.2020). According to the Ethics Committee of the Canton of Vaud, this study did not fall under the Human Research Act (art. 2) and therefore did not require any further ethical approval in Switzerland (CER-VD, information on July 9th, 2021).

Data was stored in Italy. Data transmission and storage were secured by encryption. When accessing the link, and prior to participation, women were informed about the aims and methods of the study, including their rights to refuse to participate or to withdraw at any time. Informed consent before answering the questionnaire was obtained and a complete privacy policy was available for download if wished.

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Abderhalden-Zellweger, A., de Labrusse, C., Gemperle, M. et al. Women’s experiences of disrespect and abuse in Swiss facilities during the COVID-19 pandemic: a qualitative analysis of an open-ended question in the IMAgiNE EURO study. BMC Pregnancy Childbirth 24 , 402 (2024). https://doi.org/10.1186/s12884-024-06598-6

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Challenges and advantages of electronic prescribing system: a survey study and thematic analysis

• Hamid Bouraghi 1 ,
• Behzad Imani 2 ,
• Abolfazl Saeedi 3 ,
• Ali Mohammadpour 1 ,
• Soheila Saeedi 1   na1 ,
• Taleb Khodaveisi 1   na1 &
• Tooba Mehrabi 4  

BMC Health Services Research volume  24 , Article number:  689 ( 2024 ) Cite this article

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Introduction

Electronic prescribing (e-prescribing) systems can bring many advantages and challenges. This system has been launched in Iran for more than two years. This study aimed to investigate the challenges and advantages of the e-prescribing system from the point of view of physicians.

In this survey study and thematic analysis, which was conducted in 2023, a researcher-made questionnaire was created based on the literature review and opinions of the research team members and provided to the physician. Quantitative data were analyzed using SPSS software, and qualitative data were analyzed using ATLAS.ti software. Rank and point biserial, Kendall’s tau b, and Phi were used to investigate the correlation between variables.

Eighty-four physicians participated in this study, and 71.4% preferred to use paper-based prescribing. According to the results, 53.6%, 38.1%, and 8.3% of physicians had low, medium, and high overall satisfaction with this system, respectively. There was a statistically significant correlation between the sex and overall satisfaction with the e-prescribing system ( p -value = 0.009) and the computer skill level and the prescribing methods ( P -value = 0.042). Physicians face many challenges with this system, which can be divided into five main categories: technical, patient-related, healthcare providers-related, human resources, and architectural and design issues. Also, the main advantages of the e-prescribing system were process improvement, economic efficiency, and enhanced prescribing accuracy.

The custodian and service provider organizations should upgrade the necessary information technology infrastructures, including hardware, software, and network infrastructures. Furthermore, it would be beneficial to incorporate the perspectives of end users in the system design process.

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Medicine, a crucial commodity in healthcare due to its economic and strategic value, is a fundamental pillar in primary disease treatment. It constitutes significant health expenditures and budgets worldwide [ 1 ]. The prudent management of this valuable resource, through its appropriate prescription and usage, is essential. This is a key factor in ensuring the health security of communities [ 2 ]. Numerous studies indicate that errors in drug administration are prevalent. Although a significant proportion of these errors are preventable, they can leave serious complications for patients and even fatalities [ 3 ]. As the complexity of the drug prescribing process increases, resultant injuries and complications will likely escalate. Therefore, medication prescription is one of the main concerns and priorities of policymakers and trustees in the healthcare domain. In this regard, relentless endeavors are undertaken to enhance and optimize this process, and new supplementary solutions will be used as required. Employing electronic prescription (e-prescribing) systems as an alternative to manual prescription is a practical solution that can enhance and streamline this critical process [ 4 ].

In the traditional paper-based prescribing system, numerous issues arise, including illegible prescriptions, ambiguous orders, omissions, prescription forgery, and misidentification of patients. Studies indicate that these problems compromise patient safety and negatively impact the outcomes of drug treatments [ 5 , 6 ]. E-prescribing emerges as an effective and definitive solution to the inefficiencies, susceptibility to fraud, and administrative burdens associated with paper-based prescribing systems [ 7 ]. E-prescribing extends beyond merely utilizing a computer for prescription writing and storage. This technology encompasses all stages of the prescription process, including patient identification, prescription registration, prescription modification, duplication and renewal of prescriptions, and the transfer of prescriptions among stakeholders, all facilitated through specialized software and internet platforms [ 8 , 9 , 10 ].

As an information system, the e-prescribing system can integrate with other organizational systems, such as electronic health records and pharmacy information systems, within healthcare centers like hospitals [ 11 ]. Through the implementation and utilization of such a system, it is possible to overcome the problems and constraints of the traditional prescribing system due to the complexity of medical care and the increase in the number of drugs, thereby benefiting from its potential advantages. Some of the benefits of an e-prescribing system include reducing healthcare costs for stakeholders (patients, healthcare providers, insurers, and policymakers), reducing common prescribing errors, improving medication outcomes, increasing patient safety, increasing the readability and accuracy of prescriptions, enhancing coordination among stakeholders involved in the drug therapy process, and supporting clinical decision-making at the time of drug administration [ 12 , 13 , 14 ].

Despite the potential benefits of e-prescribing systems in the healthcare industry and significant investments and efforts by stakeholders to support such systems, their usage and adoption remain low, resulting in the failure of numerous implemented projects [ 11 , 12 ]. Given that e-prescribing systems are designed according to the specific needs and internal standards of each country, numerous studies have been conducted worldwide to investigate the benefits, challenges, the reasons for the failure and lack of acceptance of such systems [ 15 , 16 ].

E-prescribing systems in countries like Denmark, the United States, Finland, Sweden, and the United Kingdom are commonly tested and implemented at state, local, or regional levels. These systems cover the entire or a significant portion of the prescribing process. Variations in healthcare and insurance systems across different countries lead to diverse approaches regarding e-prescribing and its evolution. Consequently, these countries exhibit distinct starting points, implementation procedures, and technical strategies. Moreover, e-prescribing systems and models vary not only across different countries but also within the same country [ 17 ]. While meticulously developed and successfully implemented in the United States of America, England, and Germany, this system has reached significant maturity and yielded substantial advantages for the health systems of these countries. However, in other nations, especially developing countries, e-prescribing still encounters significant challenges on its path to widespread acceptance and goal achievement [ 18 , 19 , 20 , 21 ].

Recognizing that the implementation of e-prescribing is a priority for the Iran Ministry of Health and Medical Education (MOH), the Iran Food and Drug Administration (IFDA) established a multi-stakeholder working group in 2015. This group, composed of medical informatics experts, aimed to develop recommendations for effective e-prescribing implementation [ 22 ]. In Iran, adopting e-prescribing in governmental and university hospitals has been proposed as a legal requirement since 2020. The Social Security Organization, a pioneering institution in this domain, has aligned with the implementation policies of this plan and has ceased issuing treatment booklets since early 2021 [ 23 ]. The Health Insurance Organization, as another government institution, independently developed and deployed its e-prescription system across all medical education centers affiliated with universities of medical sciences in Iran. Consequently, the two primary organizations (Social Security Organization and Health Insurance Organization) have successfully implemented the e-prescribing system. Their goals include efficient management of healthcare resources, reduction of common manual prescribing errors, and enhancement of patient safety [ 24 ].

In general, medical centers in Iran employ three distinct electronic prescription systems. “Electronic Prescription (EP)” and “Dinad” serve outpatients covered by the Social Security and Health Insurance Organization, while “Shafa” caters to all inpatients. For individuals without coverage from these insurances, physicians resort to paper prescriptions [ 25 ]. Electronic prescribing was not implemented simultaneously in all provinces of Iran. It was first used on a trial basis in a few provinces and then implemented throughout the country. Although these systems have provided significant benefits to their users in Iran, they have also encountered numerous challenges. Consequently, this comprehensive study was undertaken to explore both the advantages and obstacles associated with e-prescribing systems in Iran.

This survey study and thematic analysis was conducted to examine the challenges and advantages of the e-prescribing system in Iran in 2023. This study was conducted in three main steps: literature review and questionnaire design, data collection, and data analysis.

Literature review and questionnaire design

In the first step of this research, a questionnaire was designed based on the review of similar studies and the opinions of the research team members. To design the questionnaire, various databases, including PubMed, Google Scholar, and Scopus, were searched with related terms such as “electronic prescribing,” “electronic prescribing challenges,” and “electronic prescribing advantages.” Then, the most relevant articles retrieved from these databases were examined, and relevant data were extracted from these articles. Then, focus group sessions were held with the research team. The data extracted from the articles were presented in the sessions, and based on these data and the opinions of the research team, the questionnaire was finalized. This questionnaire had three sections: (1) demographic data (2), questions related to the advantages and challenges of e-prescribing, and (3) open-ended questions related to the challenges and advantages of the e-prescribing system. A five-point Likert scale from completely agree to completely disagree was used for the questions of the second part of the questionnaire. The face and content validity of the questionnaire was checked and confirmed with the cooperation of five experts in health information management, medical informatics, and information technology who were thoroughly familiar with prescribing systems. The content validity of the questionnaire was measured using the Content Validity Index (CVI) and Content Validity Ratio (CVR). To determine CVR, the experts were asked to classify each of the questions based on the three-point Likert scale as follows:

The question is necessary

The question is useful but not necessary

The question is not necessary

Then, the following formula was used to calculate CVR:

CVR = (Ne − N/2)/ (N/2), (N: total number of experts, Ne: the number of experts who have chosen the “necessary” option.).

Based on the Lawshe table for minimum values of CVR, items with CVR equal to or greater than 0.99 were kept. To calculate the CVI, the experts determined the degree of relevance of each question on a 4-point Likert scale from not relevant to completely relevant. The following formula was used to decide about the acceptance of each question:

CVI: The number of experts who chose options 3 and 4 / the total number of experts. It was decided to reject or accept each question as follows: < 0.7 = rejected, 0.7–0.79 = revised, > 0.79 = accepted. The reliability of the questionnaire was calculated using Cronbach’s alpha and Guttman coefficient. Values greater than 0.7, 0.5–0.7, and less than 0.5 indicate high, acceptable, and low reliability of the questionnaire, respectively.

The third part of the questionnaire included open-ended questions. Two following questions were placed at the end of the questionnaire and were asked to the physicians:

In your opinion, what other advantages does this electronic prescribing system have?

In your opinion, what other challenges does this electronic prescribing system have?

Data collection

After the questionnaire was finalized, it was prepared in both paper and electronic formats. The electronic version of the questionnaire was prepared on the Porsline platform. For the survey, first, a list of physicians working in the teaching hospitals was prepared, and then we tried to get the contact numbers of the physicians as well. The questionnaire link was sent to physicians through the local social networks whose contact numbers were available, and physicians whose contact numbers were not available were referred to them in person. Many physicians refused to receive the questionnaire and answers due to lack of time. Two reminder messages were also sent to the doctors who had received the questionnaire link through social networks. In the face-to-face group, the doctors who did not have enough time to complete the questionnaire at that moment, the researcher provided the questionnaire to the physicians and coordinated with them to receive it at a later time. A total of 122 physicians agreed to participate in the study. It should be noted that to avoid missing data, it was mandatory to answer all the questions in the electronic questionnaire, and in the paper-based questionnaire, the researchers checked the questionnaire immediately, and if any fields were not completed, they asked the physicians to complete the incomplete items of the questionnaire again.

Data analysis

Descriptive statistics including mean, standard deviation, frequency median, interquartile range and percentage were used for data analysis.

The relationship of “sex,” “specialty,” “physician’s computer skills,” “age,” and “duration” with “satisfaction” was investigated. Since “satisfaction” is a qualitative ordinal variable, the Rank-biserial index was used to examine the relationship between this variable and two-level nominal variables such as “gender” and “specialty.” Kendall’s tau b index was also used to examine the relationship between “satisfaction” (ordinal variable) with rank variables such as “physician’s computer skills” and continuous quantitative variables such as “age” and “duration.” To investigate the relationship between “willingness to use paper-based or e-prescribing” with “sex,” “specialty,” “physician’s computer skills,” “age,” and “duration,” Phi, Rank-biserial, and Point-biserial were used respectively. The p -values obtained from the chi-square test were also reported to check the presence or absence of a relationship between two variables. The type I error in this study was considered 5%. Data analysis was carried out using SPSS version 26.

The answers given by 84 physicians to two open-ended questions were typed in Word.

Thematic analysis was used to analyze the open-ended questions and identify themes within qualitative data. For thematic analysis, first, the answers typed in the Word were imported into the ATLAS.ti software, and then the pattern extraction process was carried out according to the following steps:

The imported text was read several times to get familiar with the data

After familiarizing with the data, initial coding was done

After coding, the extracted codes were checked and revised many times

Similar codes were merged and grouped, and subthemes were created

Finally, the sub-themes were reviewed and linked, and the main themes were created

The designed questionnaire was given to 122 physicians, of which 84 physicians completed the questionnaires (response rate: 68.85%). Demographic characteristics of physicians are given in Table  1 . Most of the participants were general practitioners (56%) and women (53.6%). 91.7% of the physicians believed that they have medium and high computer skills and the average duration of using the e-prescribing system was 15.50 ± 8.798 months.

The results showed that the questionnaire had acceptable reliability (Cronbach’s alpha = 0.605, Guttman’s coefficient = 0.718). The mean (std. deviation), median and interquartile range of each question in the questionnaire are given in Table  2 . The questions were categorized into two sections: advantages and challenges of the e-prescribing system. The total mean score of advantages for the e-prescribing system was 2.15 and this value for challenges of this system was 2.75. Out of the advantages of this technology, the highest mean score (2.79) was related to the “E-prescribing system has reduced the possibility of wrong drug delivery due to illegible prescriptions” and the lowest (1.24) was related to the “The e-prescribing system has led to improved physician performance”. The most important challenge that physicians had with the e-prescribing system was the insufficient bandwidth with an average of 3.49. Two other challenges mentioned by physicians about this system and received a high mean score (3.43) were the challenges related to lengthening the duration of each visit and increasing the waiting time of patients.

The results of investigating the correlation between the duration of e-prescribing system use, age, sex, specialty, and the physician’s computer skills with the overall satisfaction with the e-prescribing system are reported in Table  3 . According to the results, 45 (53.6%), 32 (38.1%), and 7 (8.3%) physicians had low, medium and high overall satisfaction with this system, respectively. There was a statistically significant correlation between the sex and overall satisfaction with the e-prescribing system ( p -value = 0.009).

The results of the correlation between duration, age, sex, specialty, and the physician’s computer skills with the willingness to use paper-based prescribing or the e-prescribing system are reported in Table  4 . According to the results, 60 (71.4%) and 24 (28.6%) physicians preferred to use paper-based and e-prescribing respectively. There was a statistically significant correlation between the computer skill level and the prescribing methods ( P -value = 0.042).

The themes and sub-themes extracted from the question related to the advantages of the e-prescribing system are shown in Fig.  1 . The main themes of the e-prescribing system’s advantages were the following:

Process improvement

Economic efficiency

Enhance the accuracy of prescribing

These three themes included a total of 10 sub-themes.

Among the advantages noted for electronic prescribing, the possibility of editing prescriptions, providing different dosages of drugs, and the impossibility of manipulating prescriptions by patients or other people were mentioned more than other advantages. Also another mentioned advantage was the possibility of providing pre-prepared prescriptions for common diseases, which led to the acceleration of prescribing for these diseases.

Thematic map of concepts extracted from qualitative data related to the advantages of the e-prescribing system

Concepts related to the challenges of the e-prescribing system were categorized into five main themes as follows (Fig.  2 ):

Technical issues

Patient-related issues

Healthcare providers-related issues

Human resources challenges

Architectural and design issues

These five themes included more than 30 sub-themes.

Many challenges for electronic prescribing were mentioned in the form of given themes. One of the most important challenges mentioned by many physicians was various technical problems including network disconnection. Also, another big challenge that caused the dissatisfaction of the patients was the lack of skill of many physicians in working with computer systems, which led to the low speed of typing the drugs in the system and as a result, increased the duration of the patients’ visits. Also, many physicians did not have computer systems in their clinics, which led to the lack of electronic prescriptions and, as a result, the lack of use of insurance services for patients. Also, considering that many physicians are used to the paper prescription method, they were not willing to accept the changes and resisted these changes, as a result, they needed personnel to register the prescriptions.

Thematic map of concepts related to the challenges of the e-prescribing system

E-prescribing systems have many advantages, but they also pose certain challenges. These systems can enhance medication safety by reducing prescription errors caused by illegible handwriting or oral miscommunication. They can also improve efficiency by streamlining the prescription process, reducing the time spent on phone calls and faxes between healthcare providers and pharmacies. Furthermore, e-prescribing can provide clinicians with up-to-date information about patients’ medications and allergies, thereby improving patient care.

Although e-prescribing systems have many advantages, their implementation is not without any challenges. These include the costs associated with system implementation and maintenance, issues related to system interoperability, and the necessity for user training and technical support. Moreover, while these systems can mitigate traditional medication errors, they may also introduce new types of errors, such as those caused by user interface design or software glitches. Maximizing the benefits and minimizing the challenges associated with e-prescribing systems requires meticulous system design, comprehensive user training, and continuous system evaluation.

As demonstrated in the results section, the e-prescribing system’s mean overall benefit score was 2.15. This score suggests a moderate level of perceived benefits. It implies that while certain advantages are acknowledged, the system still needs to be improved to enhance user satisfaction and the perception of benefits. In this context, among the factors associated with the system’s benefits from the users’ perspective, the statements “Improved workflow has resulted from e-prescribing” and “The e-prescribing system has led to improved physician performance” received average scores of 1.48 and 1.24, respectively. These relatively low scores suggest that respondents of the survey or study largely disagree that the electronic system has enhanced their workflow or improved their performance. Several studies [ 11 , 12 , 26 , 27 ] have demonstrated that users do not concur that the use of prescribing systems leads to workflow improvement or performance enhancement. There are multiple possible reasons for this, including:

Usability issues: The e-prescribing system might not be user-friendly or intuitive, leading to difficulties in adoption among healthcare professionals.

Training and support: There might be a lack of adequate training and support for the users, making it challenging for them to adapt to the new system.

System limitations: The system might not be flexible enough to accommodate the diverse needs of different healthcare settings, leading to workflow inefficiencies.

Resistance to change: Healthcare professionals, like any other group, might resist changes to established routines. This resistance could affect their perception of the system’s benefits.

Among the challenges identified in the use of e-prescribing systems, the statement “Doctors have faced challenges with e-prescribing due to insufficient bandwidth” received the highest score of 3.49. According to this relatively high score, the survey or study respondents strongly agree that insufficient bandwidth has been a significant obstacle to the use of e-prescribing. This issue results in prolonged patient waiting times, leading to extended queues and a decrease in physician productivity. There are multiple factors that can cause insufficient bandwidth, such as:

Network Infrastructure: In areas with poor network infrastructure, insufficient bandwidth can significantly slow down the operation of e-prescribing systems, making it difficult for doctors to use them effectively.

System Requirements: To function optimally, e-prescribing systems may need a certain level of bandwidth. System lags or downtime could result if the available bandwidth is below this level.

Data Transfer: E-prescribing systems often need to transfer large amounts of data, including patient records, prescriptions, and other related information. Insufficient bandwidth can slow down this data transfer, affecting the system’s efficiency.

Real-time Updates: Many e-prescribing systems provide real-time updates to ensure that all users have the most current information. If there is not enough bandwidth, these updates can be delayed, resulting in potential errors or miscommunications.

Generally, as indicated by various studies [ 28 , 29 , 30 ], the implementation of e-prescribing systems requires robust hardware, sophisticated software, and a reliable network infrastructure. These elements are integral to the successful deployment and operation of such systems. According to this study, the hardware, software, and network infrastructure in Iran are not suitable for the implementation of e-prescribing systems. This inadequacy has caused increased challenges and dissatisfaction among users. Furthermore, our evaluation of physicians’ overall satisfaction with the e-prescribing system revealed that the majority, 45 (53.6%), had low satisfaction. Conversely, only a small proportion, 7 (8.3%), reported high satisfaction. Subsequently, the e-prescribing system is not widely accepted by users, with the majority (71.4%) favoring paper-based prescribing. Many other studies have indicated higher levels of user satisfaction and a greater willingness to accept and use e-prescribing systems, contrary to our study’s findings [ 31 , 32 , 33 , 34 ]. The low level of satisfaction and users’ reluctance to adopt the e-prescribing system can be attributed to various challenges and problems identified by them. Users have been greatly impacted by these issues, which range from technical difficulties to system design and architecture issues, resulting in dissatisfaction, diminished motivation, and resistance towards the system.

Although e-prescribing systems represent a novel and transformative approach in healthcare, they offer numerous benefits, including improved efficiency, reduced medication errors, and enhanced patient safety. However, our study highlights the presence of significant challenges, such as technical issues and problems related to system design and architecture, which result in low user satisfaction and hinder system adoption. The custodian and service provider organizations should upgrade the necessary information technology infrastructures, including hardware, software, and network infrastructures, to address the technical challenges. Furthermore, given that the design and architectural issues of the e-prescribing systems have resulted in user dissatisfaction and diminished motivation to use the system, identifying and addressing these problems and shortcomings in future updates is recommended. Moreover, it is important to take into account the end users’ perspectives during the system design process.

Data availability

All data generated or analyzed during this study are included within this article.

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Acknowledgements

This work was supported by a grant from Hamadan University of Medical Sciences Research Council (140206074578).

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Soheila Saeedi and Taleb Khodaveisi contributed equally to this work.

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Department of Health Information Technology, School of Allied Medical Sciences, Hamadan University of Medical Sciences, Shahid Fahmideh Blvd, Hamadan, Iran

Hamid Bouraghi, Ali Mohammadpour, Soheila Saeedi & Taleb Khodaveisi

Department of Operating Room, School of Paramedicine, Hamadan University of Medical Sciences, Hamadan, Iran

Behzad Imani

School of Medicine, Iran University of Medical Sciences, Tehran, Iran

Abolfazl Saeedi

Health Information Management Department, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran

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SS, TKH and HB developed the concept for the study. SS, TM, and AS collected data. SS and TKH carried out the analysis and interpretation under the supervision of HB and BI. Finally, SS, AM, AS, and HB drafted the manuscript. All authors reviewed the content and approved it.

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The study was conducted in accordance with the Declaration of Helsinki and approved by a local ethics committee in Iran, namely Ethics Committee of the Hamadan University of Medical Sciences (IR.UMSHA.REC.1402.408). Verbal informed consent obtained from all the participants included in the study and was approved by the Ethics Committee of the Hamadan University of Medical Sciences.

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Bouraghi, H., Imani, B., Saeedi, A. et al. Challenges and advantages of electronic prescribing system: a survey study and thematic analysis. BMC Health Serv Res 24 , 689 (2024). https://doi.org/10.1186/s12913-024-11144-3

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Received : 11 December 2023

Accepted : 23 May 2024

Published : 30 May 2024

DOI : https://doi.org/10.1186/s12913-024-11144-3

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