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Empirical Research: Definition, Methods, Types and Examples

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Empirical research: Definition

Empirical research: origin, quantitative research methods, qualitative research methods, steps for conducting empirical research, empirical research methodology cycle, advantages of empirical research, disadvantages of empirical research, why is there a need for empirical research.

Empirical research is defined as any research where conclusions of the study is strictly drawn from concretely empirical evidence, and therefore “verifiable” evidence.

This empirical evidence can be gathered using quantitative market research and qualitative market research methods.

For example: A research is being conducted to find out if listening to happy music in the workplace while working may promote creativity? An experiment is conducted by using a music website survey on a set of audience who are exposed to happy music and another set who are not listening to music at all, and the subjects are then observed. The results derived from such a research will give empirical evidence if it does promote creativity or not.

LEARN ABOUT: Behavioral Research

You must have heard the quote” I will not believe it unless I see it”. This came from the ancient empiricists, a fundamental understanding that powered the emergence of medieval science during the renaissance period and laid the foundation of modern science, as we know it today. The word itself has its roots in greek. It is derived from the greek word empeirikos which means “experienced”.

In today’s world, the word empirical refers to collection of data using evidence that is collected through observation or experience or by using calibrated scientific instruments. All of the above origins have one thing in common which is dependence of observation and experiments to collect data and test them to come up with conclusions.

LEARN ABOUT: Causal Research

Types and methodologies of empirical research

Empirical research can be conducted and analysed using qualitative or quantitative methods.

Quantitative research : Quantitative research methods are used to gather information through numerical data. It is used to quantify opinions, behaviors or other defined variables . These are predetermined and are in a more structured format. Some of the commonly used methods are survey, longitudinal studies, polls, etc
Qualitative research: Qualitative research methods are used to gather non numerical data. It is used to find meanings, opinions, or the underlying reasons from its subjects. These methods are unstructured or semi structured. The sample size for such a research is usually small and it is a conversational type of method to provide more insight or in-depth information about the problem Some of the most popular forms of methods are focus groups, experiments, interviews, etc.

Data collected from these will need to be analysed. Empirical evidence can also be analysed either quantitatively and qualitatively. Using this, the researcher can answer empirical questions which have to be clearly defined and answerable with the findings he has got. The type of research design used will vary depending on the field in which it is going to be used. Many of them might choose to do a collective research involving quantitative and qualitative method to better answer questions which cannot be studied in a laboratory setting.

LEARN ABOUT: Qualitative Research Questions and Questionnaires

Quantitative research methods aid in analyzing the empirical evidence gathered. By using these a researcher can find out if his hypothesis is supported or not.

Survey research: Survey research generally involves a large audience to collect a large amount of data. This is a quantitative method having a predetermined set of closed questions which are pretty easy to answer. Because of the simplicity of such a method, high responses are achieved. It is one of the most commonly used methods for all kinds of research in today’s world.

Previously, surveys were taken face to face only with maybe a recorder. However, with advancement in technology and for ease, new mediums such as emails , or social media have emerged.

For example: Depletion of energy resources is a growing concern and hence there is a need for awareness about renewable energy. According to recent studies, fossil fuels still account for around 80% of energy consumption in the United States. Even though there is a rise in the use of green energy every year, there are certain parameters because of which the general population is still not opting for green energy. In order to understand why, a survey can be conducted to gather opinions of the general population about green energy and the factors that influence their choice of switching to renewable energy. Such a survey can help institutions or governing bodies to promote appropriate awareness and incentive schemes to push the use of greener energy.

Learn more: Renewable Energy Survey Template Descriptive Research vs Correlational Research

Experimental research: In experimental research , an experiment is set up and a hypothesis is tested by creating a situation in which one of the variable is manipulated. This is also used to check cause and effect. It is tested to see what happens to the independent variable if the other one is removed or altered. The process for such a method is usually proposing a hypothesis, experimenting on it, analyzing the findings and reporting the findings to understand if it supports the theory or not.

For example: A particular product company is trying to find what is the reason for them to not be able to capture the market. So the organisation makes changes in each one of the processes like manufacturing, marketing, sales and operations. Through the experiment they understand that sales training directly impacts the market coverage for their product. If the person is trained well, then the product will have better coverage.

Correlational research: Correlational research is used to find relation between two set of variables . Regression analysis is generally used to predict outcomes of such a method. It can be positive, negative or neutral correlation.

LEARN ABOUT: Level of Analysis

For example: Higher educated individuals will get higher paying jobs. This means higher education enables the individual to high paying job and less education will lead to lower paying jobs.

Longitudinal study: Longitudinal study is used to understand the traits or behavior of a subject under observation after repeatedly testing the subject over a period of time. Data collected from such a method can be qualitative or quantitative in nature.

For example: A research to find out benefits of exercise. The target is asked to exercise everyday for a particular period of time and the results show higher endurance, stamina, and muscle growth. This supports the fact that exercise benefits an individual body.

Cross sectional: Cross sectional study is an observational type of method, in which a set of audience is observed at a given point in time. In this type, the set of people are chosen in a fashion which depicts similarity in all the variables except the one which is being researched. This type does not enable the researcher to establish a cause and effect relationship as it is not observed for a continuous time period. It is majorly used by healthcare sector or the retail industry.

For example: A medical study to find the prevalence of under-nutrition disorders in kids of a given population. This will involve looking at a wide range of parameters like age, ethnicity, location, incomes and social backgrounds. If a significant number of kids coming from poor families show under-nutrition disorders, the researcher can further investigate into it. Usually a cross sectional study is followed by a longitudinal study to find out the exact reason.

Causal-Comparative research : This method is based on comparison. It is mainly used to find out cause-effect relationship between two variables or even multiple variables.

For example: A researcher measured the productivity of employees in a company which gave breaks to the employees during work and compared that to the employees of the company which did not give breaks at all.

LEARN ABOUT: Action Research

Some research questions need to be analysed qualitatively, as quantitative methods are not applicable there. In many cases, in-depth information is needed or a researcher may need to observe a target audience behavior, hence the results needed are in a descriptive analysis form. Qualitative research results will be descriptive rather than predictive. It enables the researcher to build or support theories for future potential quantitative research. In such a situation qualitative research methods are used to derive a conclusion to support the theory or hypothesis being studied.

LEARN ABOUT: Qualitative Interview

Case study: Case study method is used to find more information through carefully analyzing existing cases. It is very often used for business research or to gather empirical evidence for investigation purpose. It is a method to investigate a problem within its real life context through existing cases. The researcher has to carefully analyse making sure the parameter and variables in the existing case are the same as to the case that is being investigated. Using the findings from the case study, conclusions can be drawn regarding the topic that is being studied.

For example: A report mentioning the solution provided by a company to its client. The challenges they faced during initiation and deployment, the findings of the case and solutions they offered for the problems. Such case studies are used by most companies as it forms an empirical evidence for the company to promote in order to get more business.

Observational method: Observational method is a process to observe and gather data from its target. Since it is a qualitative method it is time consuming and very personal. It can be said that observational research method is a part of ethnographic research which is also used to gather empirical evidence. This is usually a qualitative form of research, however in some cases it can be quantitative as well depending on what is being studied.

For example: setting up a research to observe a particular animal in the rain-forests of amazon. Such a research usually take a lot of time as observation has to be done for a set amount of time to study patterns or behavior of the subject. Another example used widely nowadays is to observe people shopping in a mall to figure out buying behavior of consumers.

One-on-one interview: Such a method is purely qualitative and one of the most widely used. The reason being it enables a researcher get precise meaningful data if the right questions are asked. It is a conversational method where in-depth data can be gathered depending on where the conversation leads.

For example: A one-on-one interview with the finance minister to gather data on financial policies of the country and its implications on the public.

Focus groups: Focus groups are used when a researcher wants to find answers to why, what and how questions. A small group is generally chosen for such a method and it is not necessary to interact with the group in person. A moderator is generally needed in case the group is being addressed in person. This is widely used by product companies to collect data about their brands and the product.

For example: A mobile phone manufacturer wanting to have a feedback on the dimensions of one of their models which is yet to be launched. Such studies help the company meet the demand of the customer and position their model appropriately in the market.

Text analysis: Text analysis method is a little new compared to the other types. Such a method is used to analyse social life by going through images or words used by the individual. In today’s world, with social media playing a major part of everyone’s life, such a method enables the research to follow the pattern that relates to his study.

For example: A lot of companies ask for feedback from the customer in detail mentioning how satisfied are they with their customer support team. Such data enables the researcher to take appropriate decisions to make their support team better.

Sometimes a combination of the methods is also needed for some questions that cannot be answered using only one type of method especially when a researcher needs to gain a complete understanding of complex subject matter.

We recently published a blog that talks about examples of qualitative data in education ; why don’t you check it out for more ideas?

Since empirical research is based on observation and capturing experiences, it is important to plan the steps to conduct the experiment and how to analyse it. This will enable the researcher to resolve problems or obstacles which can occur during the experiment.

Step #1: Define the purpose of the research

This is the step where the researcher has to answer questions like what exactly do I want to find out? What is the problem statement? Are there any issues in terms of the availability of knowledge, data, time or resources. Will this research be more beneficial than what it will cost.

Before going ahead, a researcher has to clearly define his purpose for the research and set up a plan to carry out further tasks.

Step #2 : Supporting theories and relevant literature

The researcher needs to find out if there are theories which can be linked to his research problem . He has to figure out if any theory can help him support his findings. All kind of relevant literature will help the researcher to find if there are others who have researched this before, or what are the problems faced during this research. The researcher will also have to set up assumptions and also find out if there is any history regarding his research problem

Step #3: Creation of Hypothesis and measurement

Before beginning the actual research he needs to provide himself a working hypothesis or guess what will be the probable result. Researcher has to set up variables, decide the environment for the research and find out how can he relate between the variables.

Researcher will also need to define the units of measurements, tolerable degree for errors, and find out if the measurement chosen will be acceptable by others.

Step #4: Methodology, research design and data collection

In this step, the researcher has to define a strategy for conducting his research. He has to set up experiments to collect data which will enable him to propose the hypothesis. The researcher will decide whether he will need experimental or non experimental method for conducting the research. The type of research design will vary depending on the field in which the research is being conducted. Last but not the least, the researcher will have to find out parameters that will affect the validity of the research design. Data collection will need to be done by choosing appropriate samples depending on the research question. To carry out the research, he can use one of the many sampling techniques. Once data collection is complete, researcher will have empirical data which needs to be analysed.

LEARN ABOUT: Best Data Collection Tools

Step #5: Data Analysis and result

Data analysis can be done in two ways, qualitatively and quantitatively. Researcher will need to find out what qualitative method or quantitative method will be needed or will he need a combination of both. Depending on the unit of analysis of his data, he will know if his hypothesis is supported or rejected. Analyzing this data is the most important part to support his hypothesis.

Step #6: Conclusion

A report will need to be made with the findings of the research. The researcher can give the theories and literature that support his research. He can make suggestions or recommendations for further research on his topic.

A.D. de Groot, a famous dutch psychologist and a chess expert conducted some of the most notable experiments using chess in the 1940’s. During his study, he came up with a cycle which is consistent and now widely used to conduct empirical research. It consists of 5 phases with each phase being as important as the next one. The empirical cycle captures the process of coming up with hypothesis about how certain subjects work or behave and then testing these hypothesis against empirical data in a systematic and rigorous approach. It can be said that it characterizes the deductive approach to science. Following is the empirical cycle.

Observation: At this phase an idea is sparked for proposing a hypothesis. During this phase empirical data is gathered using observation. For example: a particular species of flower bloom in a different color only during a specific season.
Induction: Inductive reasoning is then carried out to form a general conclusion from the data gathered through observation. For example: As stated above it is observed that the species of flower blooms in a different color during a specific season. A researcher may ask a question “does the temperature in the season cause the color change in the flower?” He can assume that is the case, however it is a mere conjecture and hence an experiment needs to be set up to support this hypothesis. So he tags a few set of flowers kept at a different temperature and observes if they still change the color?
Deduction: This phase helps the researcher to deduce a conclusion out of his experiment. This has to be based on logic and rationality to come up with specific unbiased results.For example: In the experiment, if the tagged flowers in a different temperature environment do not change the color then it can be concluded that temperature plays a role in changing the color of the bloom.
Testing: This phase involves the researcher to return to empirical methods to put his hypothesis to the test. The researcher now needs to make sense of his data and hence needs to use statistical analysis plans to determine the temperature and bloom color relationship. If the researcher finds out that most flowers bloom a different color when exposed to the certain temperature and the others do not when the temperature is different, he has found support to his hypothesis. Please note this not proof but just a support to his hypothesis.
Evaluation: This phase is generally forgotten by most but is an important one to keep gaining knowledge. During this phase the researcher puts forth the data he has collected, the support argument and his conclusion. The researcher also states the limitations for the experiment and his hypothesis and suggests tips for others to pick it up and continue a more in-depth research for others in the future. LEARN MORE: Population vs Sample

LEARN MORE: Population vs Sample

There is a reason why empirical research is one of the most widely used method. There are a few advantages associated with it. Following are a few of them.

It is used to authenticate traditional research through various experiments and observations.
This research methodology makes the research being conducted more competent and authentic.
It enables a researcher understand the dynamic changes that can happen and change his strategy accordingly.
The level of control in such a research is high so the researcher can control multiple variables.
It plays a vital role in increasing internal validity .

Even though empirical research makes the research more competent and authentic, it does have a few disadvantages. Following are a few of them.

Such a research needs patience as it can be very time consuming. The researcher has to collect data from multiple sources and the parameters involved are quite a few, which will lead to a time consuming research.
Most of the time, a researcher will need to conduct research at different locations or in different environments, this can lead to an expensive affair.
There are a few rules in which experiments can be performed and hence permissions are needed. Many a times, it is very difficult to get certain permissions to carry out different methods of this research.
Collection of data can be a problem sometimes, as it has to be collected from a variety of sources through different methods.

LEARN ABOUT: Social Communication Questionnaire

Empirical research is important in today’s world because most people believe in something only that they can see, hear or experience. It is used to validate multiple hypothesis and increase human knowledge and continue doing it to keep advancing in various fields.

For example: Pharmaceutical companies use empirical research to try out a specific drug on controlled groups or random groups to study the effect and cause. This way, they prove certain theories they had proposed for the specific drug. Such research is very important as sometimes it can lead to finding a cure for a disease that has existed for many years. It is useful in science and many other fields like history, social sciences, business, etc.

LEARN ABOUT: 12 Best Tools for Researchers

With the advancement in today’s world, empirical research has become critical and a norm in many fields to support their hypothesis and gain more knowledge. The methods mentioned above are very useful for carrying out such research. However, a number of new methods will keep coming up as the nature of new investigative questions keeps getting unique or changing.

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Chapter 1. Introduction

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

Why an Open Access Textbook on Qualitative Research Methods?

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

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

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

What is Research?

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

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

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

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

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

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

What is Qualitative Research?

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

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

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

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

Examples of Qualitative Research

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

Example 1 : The End Game (ethnography + interviews)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How Is This Book Organized?

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

Chapter Descriptions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patton’s Ten Suggestions for Doing Qualitative Research

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Empirical Research

Introduction: What is Empirical Research?

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Empirical research is based on phenomena that can be observed and measured. Empirical research derives knowledge from actual experience rather than from theory or belief.

Key characteristics of empirical research include:

Specific research questions to be answered;
Definitions of the population, behavior, or phenomena being studied;
Description of the methodology or research design used to study this population or phenomena, including selection criteria, controls, and testing instruments (such as surveys);
Two basic research processes or methods in empirical research: quantitative methods and qualitative methods (see the rest of the guide for more about these methods).

(based on the original from the Connelly LIbrary of LaSalle University)

Empirical Research: Qualitative vs. Quantitative

Learn about common types of journal articles that use APA Style, including empirical studies; meta-analyses; literature reviews; and replication, theoretical, and methodological articles.

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Quantitative Research

A quantitative research project is characterized by having a population about which the researcher wants to draw conclusions, but it is not possible to collect data on the entire population.

For an observational study, it is necessary to select a proper, statistical random sample and to use methods of statistical inference to draw conclusions about the population.
For an experimental study, it is necessary to have a random assignment of subjects to experimental and control groups in order to use methods of statistical inference.

Statistical methods are used in all three stages of a quantitative research project.

For observational studies, the data are collected using statistical sampling theory. Then, the sample data are analyzed using descriptive statistical analysis. Finally, generalizations are made from the sample data to the entire population using statistical inference.

For experimental studies, the subjects are allocated to experimental and control group using randomizing methods. Then, the experimental data are analyzed using descriptive statistical analysis. Finally, just as for observational data, generalizations are made to a larger population.

Iversen, G. (2004). Quantitative research . In M. Lewis-Beck, A. Bryman, & T. Liao (Eds.), Encyclopedia of social science research methods . (pp. 897-898). Thousand Oaks, CA: SAGE Publications, Inc.

Qualitative Research

What makes a work deserving of the label qualitative research is the demonstrable effort to produce richly and relevantly detailed descriptions and particularized interpretations of people and the social, linguistic, material, and other practices and events that shape and are shaped by them.

Qualitative research typically includes, but is not limited to, discerning the perspectives of these people, or what is often referred to as the actor’s point of view. Although both philosophically and methodologically a highly diverse entity, qualitative research is marked by certain defining imperatives that include its case (as opposed to its variable) orientation, sensitivity to cultural and historical context, and reflexivity.

In its many guises, qualitative research is a form of empirical inquiry that typically entails some form of purposive sampling for information-rich cases; in-depth interviews and open-ended interviews, lengthy participant/field observations, and/or document or artifact study; and techniques for analysis and interpretation of data that move beyond the data generated and their surface appearances.

Sandelowski, M. (2004). Qualitative research . In M. Lewis-Beck, A. Bryman, & T. Liao (Eds.), Encyclopedia of social science research methods . (pp. 893-894). Thousand Oaks, CA: SAGE Publications, Inc.

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Empirical Research: Defining, Identifying, & Finding

Defining empirical research, what is empirical research, quantitative or qualitative.

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Calfee & Chambliss (2005) (UofM login required) describe empirical research as a "systematic approach for answering certain types of questions." Those questions are answered "[t]hrough the collection of evidence under carefully defined and replicable conditions" (p. 43).

The evidence collected during empirical research is often referred to as "data."

Characteristics of Empirical Research

Emerald Publishing's guide to conducting empirical research identifies a number of common elements to empirical research:

A research question , which will determine research objectives.
A particular and planned design for the research, which will depend on the question and which will find ways of answering it with appropriate use of resources.
The gathering of primary data , which is then analysed.
A particular methodology for collecting and analysing the data, such as an experiment or survey.
The limitation of the data to a particular group, area or time scale, known as a sample [emphasis added]: for example, a specific number of employees of a particular company type, or all users of a library over a given time scale. The sample should be somehow representative of a wider population.
The ability to recreate the study and test the results. This is known as reliability .
The ability to generalize from the findings to a larger sample and to other situations.

If you see these elements in a research article, you can feel confident that you have found empirical research. Emerald's guide goes into more detail on each element.

Empirical research methodologies can be described as quantitative, qualitative, or a mix of both (usually called mixed-methods).

Ruane (2016) (UofM login required) gets at the basic differences in approach between quantitative and qualitative research:

Quantitative research -- an approach to documenting reality that relies heavily on numbers both for the measurement of variables and for data analysis (p. 33).
Qualitative research -- an approach to documenting reality that relies on words and images as the primary data source (p. 33).

Both quantitative and qualitative methods are empirical . If you can recognize that a research study is quantitative or qualitative study, then you have also recognized that it is empirical study.

Below are information on the characteristics of quantitative and qualitative research. This video from Scribbr also offers a good overall introduction to the two approaches to research methodology:

Characteristics of Quantitative Research

Researchers test hypotheses, or theories, based in assumptions about causality, i.e. we expect variable X to cause variable Y. Variables have to be controlled as much as possible to ensure validity. The results explain the relationship between the variables. Measures are based in pre-defined instruments.

Examples: experimental or quasi-experimental design, pretest & post-test, survey or questionnaire with closed-ended questions. Studies that identify factors that influence an outcomes, the utility of an intervention, or understanding predictors of outcomes.

Characteristics of Qualitative Research

Researchers explore “meaning individuals or groups ascribe to social or human problems (Creswell & Creswell, 2018, p3).” Questions and procedures emerge rather than being prescribed. Complexity, nuance, and individual meaning are valued. Research is both inductive and deductive. Data sources are multiple and varied, i.e. interviews, observations, documents, photographs, etc. The researcher is a key instrument and must be reflective of their background, culture, and experiences as influential of the research.

Examples: open question interviews and surveys, focus groups, case studies, grounded theory, ethnography, discourse analysis, narrative, phenomenology, participatory action research.

Calfee, R. C. & Chambliss, M. (2005). The design of empirical research. In J. Flood, D. Lapp, J. R. Squire, & J. Jensen (Eds.), Methods of research on teaching the English language arts: The methodology chapters from the handbook of research on teaching the English language arts (pp. 43-78). Routledge. http://ezproxy.memphis.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=125955&site=eds-live&scope=site .

Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Thousand Oaks: Sage.

How to... conduct empirical research . (n.d.). Emerald Publishing. https://www.emeraldgrouppublishing.com/how-to/research-methods/conduct-empirical-research .

Scribbr. (2019). Quantitative vs. qualitative: The differences explained [video]. YouTube. https://www.youtube.com/watch?v=a-XtVF7Bofg .

Ruane, J. M. (2016). Introducing social research methods : Essentials for getting the edge . Wiley-Blackwell. http://ezproxy.memphis.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=1107215&site=eds-live&scope=site .

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Qualitative and Quantitative Research

What is "empirical research".

empirical research
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Getting the Articles

Empirical research is based on observed and measured phenomena and derives knowledge from actual experience rather than from theory or belief.

How do you know if a study is empirical? Read the subheadings within the article, book, or report and look for a description of the research "methodology." Ask yourself: Could I recreate this study and test these results?

Key characteristics to look for:

Specific research questions to be answered
Definition of the population, behavior, or phenomena being studied
Description of the process used to study this population or phenomena, including selection criteria, controls, and testing instruments (such as surveys)

Another hint: some scholarly journals use a specific layout, called the "IMRaD" format, to communicate empirical research findings. Such articles typically have 4 components:

Introduction : sometimes called "literature review" -- what is currently known about the topic -- usually includes a theoretical framework and/or discussion of previous studies
Methodology: sometimes called "research design" -- how to recreate the study -- usually describes the population, research process, and analytical tools
Results : sometimes called "findings" -- what was learned through the study -- usually appears as statistical data or as substantial quotations from research participants
Discussion : sometimes called "conclusion" or "implications" -- why the study is important -- usually describes how the research results influence professional practices or future studies
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Methodical Basics of Empirical Research

First Online: 12 January 2022

Cite this chapter

Hans E. Fischer 4 ,
William Boone 5 &
Heiko Krabbe 6

Part of the book series: Challenges in Physics Education ((CPE))

1 Citations

To be up-to date, teachers should be able to follow current research on teaching and learning in physics. Therefore, they have to be able to assess if the results presented in publications are meaningful and trustworthy. In this chapter, we detail requirements research studies should comply with in order that measuring results, conclusions and generalisations can be trusted. In the case of the calculation of means for example, the requirements of such calculations are familiar to physics teachers. However, when considering more complicated statistics, for example the meaning of correlations or Rasch analysis, physics teachers may be less familiar with such statistical topics. To identify the relations between numerous variables, for example, the effect of migration background, social status and cognitive abilities on school success, more complex mathematical models are necessary. The starting point for all empirical investigations must be a valid theoretical model. Such a model should include both the variables considered important and the design of a study.

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Acknowledgements

We would like to thank Robert Evans (University of Copenhagen) and William Romine (Wright State University, Dayton) for carefully and critically reviewing this chapter.

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Fischer, H.E., Boone, W., Krabbe, H. (2021). Methodical Basics of Empirical Research. In: Fischer, H.E., Girwidz, R. (eds) Physics Education. Challenges in Physics Education. Springer, Cham. https://doi.org/10.1007/978-3-030-87391-2_16

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Published: 21 November 2018

Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period

Konstantina Vasileiou ORCID: orcid.org/0000-0001-5047-3920 1 ,
Julie Barnett 1 ,
Susan Thorpe 2 &
Terry Young 3

BMC Medical Research Methodology volume 18 , Article number: 148 ( 2018 ) Cite this article

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Choosing a suitable sample size in qualitative research is an area of conceptual debate and practical uncertainty. That sample size principles, guidelines and tools have been developed to enable researchers to set, and justify the acceptability of, their sample size is an indication that the issue constitutes an important marker of the quality of qualitative research. Nevertheless, research shows that sample size sufficiency reporting is often poor, if not absent, across a range of disciplinary fields.

A systematic analysis of single-interview-per-participant designs within three health-related journals from the disciplines of psychology, sociology and medicine, over a 15-year period, was conducted to examine whether and how sample sizes were justified and how sample size was characterised and discussed by authors. Data pertinent to sample size were extracted and analysed using qualitative and quantitative analytic techniques.

Our findings demonstrate that provision of sample size justifications in qualitative health research is limited; is not contingent on the number of interviews; and relates to the journal of publication. Defence of sample size was most frequently supported across all three journals with reference to the principle of saturation and to pragmatic considerations. Qualitative sample sizes were predominantly – and often without justification – characterised as insufficient (i.e., ‘small’) and discussed in the context of study limitations. Sample size insufficiency was seen to threaten the validity and generalizability of studies’ results, with the latter being frequently conceived in nomothetic terms.

Conclusions

We recommend, firstly, that qualitative health researchers be more transparent about evaluations of their sample size sufficiency, situating these within broader and more encompassing assessments of data adequacy . Secondly, we invite researchers critically to consider how saturation parameters found in prior methodological studies and sample size community norms might best inform, and apply to, their own project and encourage that data adequacy is best appraised with reference to features that are intrinsic to the study at hand. Finally, those reviewing papers have a vital role in supporting and encouraging transparent study-specific reporting.

Peer Review reports

Sample adequacy in qualitative inquiry pertains to the appropriateness of the sample composition and size . It is an important consideration in evaluations of the quality and trustworthiness of much qualitative research [ 1 ] and is implicated – particularly for research that is situated within a post-positivist tradition and retains a degree of commitment to realist ontological premises – in appraisals of validity and generalizability [ 2 , 3 , 4 , 5 ].

Samples in qualitative research tend to be small in order to support the depth of case-oriented analysis that is fundamental to this mode of inquiry [ 5 ]. Additionally, qualitative samples are purposive, that is, selected by virtue of their capacity to provide richly-textured information, relevant to the phenomenon under investigation. As a result, purposive sampling [ 6 , 7 ] – as opposed to probability sampling employed in quantitative research – selects ‘information-rich’ cases [ 8 ]. Indeed, recent research demonstrates the greater efficiency of purposive sampling compared to random sampling in qualitative studies [ 9 ], supporting related assertions long put forward by qualitative methodologists.

Sample size in qualitative research has been the subject of enduring discussions [ 4 , 10 , 11 ]. Whilst the quantitative research community has established relatively straightforward statistics-based rules to set sample sizes precisely, the intricacies of qualitative sample size determination and assessment arise from the methodological, theoretical, epistemological, and ideological pluralism that characterises qualitative inquiry (for a discussion focused on the discipline of psychology see [ 12 ]). This mitigates against clear-cut guidelines, invariably applied. Despite these challenges, various conceptual developments have sought to address this issue, with guidance and principles [ 4 , 10 , 11 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ], and more recently, an evidence-based approach to sample size determination seeks to ground the discussion empirically [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ].

Focusing on single-interview-per-participant qualitative designs, the present study aims to further contribute to the dialogue of sample size in qualitative research by offering empirical evidence around justification practices associated with sample size. We next review the existing conceptual and empirical literature on sample size determination.

Sample size in qualitative research: Conceptual developments and empirical investigations

Qualitative research experts argue that there is no straightforward answer to the question of ‘how many’ and that sample size is contingent on a number of factors relating to epistemological, methodological and practical issues [ 36 ]. Sandelowski [ 4 ] recommends that qualitative sample sizes are large enough to allow the unfolding of a ‘new and richly textured understanding’ of the phenomenon under study, but small enough so that the ‘deep, case-oriented analysis’ (p. 183) of qualitative data is not precluded. Morse [ 11 ] posits that the more useable data are collected from each person, the fewer participants are needed. She invites researchers to take into account parameters, such as the scope of study, the nature of topic (i.e. complexity, accessibility), the quality of data, and the study design. Indeed, the level of structure of questions in qualitative interviewing has been found to influence the richness of data generated [ 37 ], and so, requires attention; empirical research shows that open questions, which are asked later on in the interview, tend to produce richer data [ 37 ].

Beyond such guidance, specific numerical recommendations have also been proffered, often based on experts’ experience of qualitative research. For example, Green and Thorogood [ 38 ] maintain that the experience of most qualitative researchers conducting an interview-based study with a fairly specific research question is that little new information is generated after interviewing 20 people or so belonging to one analytically relevant participant ‘category’ (pp. 102–104). Ritchie et al. [ 39 ] suggest that studies employing individual interviews conduct no more than 50 interviews so that researchers are able to manage the complexity of the analytic task. Similarly, Britten [ 40 ] notes that large interview studies will often comprise of 50 to 60 people. Experts have also offered numerical guidelines tailored to different theoretical and methodological traditions and specific research approaches, e.g. grounded theory, phenomenology [ 11 , 41 ]. More recently, a quantitative tool was proposed [ 42 ] to support a priori sample size determination based on estimates of the prevalence of themes in the population. Nevertheless, this more formulaic approach raised criticisms relating to assumptions about the conceptual [ 43 ] and ontological status of ‘themes’ [ 44 ] and the linearity ascribed to the processes of sampling, data collection and data analysis [ 45 ].

In terms of principles, Lincoln and Guba [ 17 ] proposed that sample size determination be guided by the criterion of informational redundancy , that is, sampling can be terminated when no new information is elicited by sampling more units. Following the logic of informational comprehensiveness Malterud et al. [ 18 ] introduced the concept of information power as a pragmatic guiding principle, suggesting that the more information power the sample provides, the smaller the sample size needs to be, and vice versa.

Undoubtedly, the most widely used principle for determining sample size and evaluating its sufficiency is that of saturation . The notion of saturation originates in grounded theory [ 15 ] – a qualitative methodological approach explicitly concerned with empirically-derived theory development – and is inextricably linked to theoretical sampling. Theoretical sampling describes an iterative process of data collection, data analysis and theory development whereby data collection is governed by emerging theory rather than predefined characteristics of the population. Grounded theory saturation (often called theoretical saturation) concerns the theoretical categories – as opposed to data – that are being developed and becomes evident when ‘gathering fresh data no longer sparks new theoretical insights, nor reveals new properties of your core theoretical categories’ [ 46 p. 113]. Saturation in grounded theory, therefore, does not equate to the more common focus on data repetition and moves beyond a singular focus on sample size as the justification of sampling adequacy [ 46 , 47 ]. Sample size in grounded theory cannot be determined a priori as it is contingent on the evolving theoretical categories.

Saturation – often under the terms of ‘data’ or ‘thematic’ saturation – has diffused into several qualitative communities beyond its origins in grounded theory. Alongside the expansion of its meaning, being variously equated with ‘no new data’, ‘no new themes’, and ‘no new codes’, saturation has emerged as the ‘gold standard’ in qualitative inquiry [ 2 , 26 ]. Nevertheless, and as Morse [ 48 ] asserts, whilst saturation is the most frequently invoked ‘guarantee of qualitative rigor’, ‘it is the one we know least about’ (p. 587). Certainly researchers caution that saturation is less applicable to, or appropriate for, particular types of qualitative research (e.g. conversation analysis, [ 49 ]; phenomenological research, [ 50 ]) whilst others reject the concept altogether [ 19 , 51 ].

Methodological studies in this area aim to provide guidance about saturation and develop a practical application of processes that ‘operationalise’ and evidence saturation. Guest, Bunce, and Johnson [ 26 ] analysed 60 interviews and found that saturation of themes was reached by the twelfth interview. They noted that their sample was relatively homogeneous, their research aims focused, so studies of more heterogeneous samples and with a broader scope would be likely to need a larger size to achieve saturation. Extending the enquiry to multi-site, cross-cultural research, Hagaman and Wutich [ 28 ] showed that sample sizes of 20 to 40 interviews were required to achieve data saturation of meta-themes that cut across research sites. In a theory-driven content analysis, Francis et al. [ 25 ] reached data saturation at the 17th interview for all their pre-determined theoretical constructs. The authors further proposed two main principles upon which specification of saturation be based: (a) researchers should a priori specify an initial analysis sample (e.g. 10 interviews) which will be used for the first round of analysis and (b) a stopping criterion , that is, a number of interviews (e.g. 3) that needs to be further conducted, the analysis of which will not yield any new themes or ideas. For greater transparency, Francis et al. [ 25 ] recommend that researchers present cumulative frequency graphs supporting their judgment that saturation was achieved. A comparative method for themes saturation (CoMeTS) has also been suggested [ 23 ] whereby the findings of each new interview are compared with those that have already emerged and if it does not yield any new theme, the ‘saturated terrain’ is assumed to have been established. Because the order in which interviews are analysed can influence saturation thresholds depending on the richness of the data, Constantinou et al. [ 23 ] recommend reordering and re-analysing interviews to confirm saturation. Hennink, Kaiser and Marconi’s [ 29 ] methodological study sheds further light on the problem of specifying and demonstrating saturation. Their analysis of interview data showed that code saturation (i.e. the point at which no additional issues are identified) was achieved at 9 interviews, but meaning saturation (i.e. the point at which no further dimensions, nuances, or insights of issues are identified) required 16–24 interviews. Although breadth can be achieved relatively soon, especially for high-prevalence and concrete codes, depth requires additional data, especially for codes of a more conceptual nature.

Critiquing the concept of saturation, Nelson [ 19 ] proposes five conceptual depth criteria in grounded theory projects to assess the robustness of the developing theory: (a) theoretical concepts should be supported by a wide range of evidence drawn from the data; (b) be demonstrably part of a network of inter-connected concepts; (c) demonstrate subtlety; (d) resonate with existing literature; and (e) can be successfully submitted to tests of external validity.

Other work has sought to examine practices of sample size reporting and sufficiency assessment across a range of disciplinary fields and research domains, from nutrition [ 34 ] and health education [ 32 ], to education and the health sciences [ 22 , 27 ], information systems [ 30 ], organisation and workplace studies [ 33 ], human computer interaction [ 21 ], and accounting studies [ 24 ]. Others investigated PhD qualitative studies [ 31 ] and grounded theory studies [ 35 ]. Incomplete and imprecise sample size reporting is commonly pinpointed by these investigations whilst assessment and justifications of sample size sufficiency are even more sporadic.

Sobal [ 34 ] examined the sample size of qualitative studies published in the Journal of Nutrition Education over a period of 30 years. Studies that employed individual interviews ( n = 30) had an average sample size of 45 individuals and none of these explicitly reported whether their sample size sought and/or attained saturation. A minority of articles discussed how sample-related limitations (with the latter most often concerning the type of sample, rather than the size) limited generalizability. A further systematic analysis [ 32 ] of health education research over 20 years demonstrated that interview-based studies averaged 104 participants (range 2 to 720 interviewees). However, 40% did not report the number of participants. An examination of 83 qualitative interview studies in leading information systems journals [ 30 ] indicated little defence of sample sizes on the basis of recommendations by qualitative methodologists, prior relevant work, or the criterion of saturation. Rather, sample size seemed to correlate with factors such as the journal of publication or the region of study (US vs Europe vs Asia). These results led the authors to call for more rigor in determining and reporting sample size in qualitative information systems research and to recommend optimal sample size ranges for grounded theory (i.e. 20–30 interviews) and single case (i.e. 15–30 interviews) projects.

Similarly, fewer than 10% of articles in organisation and workplace studies provided a sample size justification relating to existing recommendations by methodologists, prior relevant work, or saturation [ 33 ], whilst only 17% of focus groups studies in health-related journals provided an explanation of sample size (i.e. number of focus groups), with saturation being the most frequently invoked argument, followed by published sample size recommendations and practical reasons [ 22 ]. The notion of saturation was also invoked by 11 out of the 51 most highly cited studies that Guetterman [ 27 ] reviewed in the fields of education and health sciences, of which six were grounded theory studies, four phenomenological and one a narrative inquiry. Finally, analysing 641 interview-based articles in accounting, Dai et al. [ 24 ] called for more rigor since a significant minority of studies did not report precise sample size.

Despite increasing attention to rigor in qualitative research (e.g. [ 52 ]) and more extensive methodological and analytical disclosures that seek to validate qualitative work [ 24 ], sample size reporting and sufficiency assessment remain inconsistent and partial, if not absent, across a range of research domains.

Objectives of the present study

The present study sought to enrich existing systematic analyses of the customs and practices of sample size reporting and justification by focusing on qualitative research relating to health. Additionally, this study attempted to expand previous empirical investigations by examining how qualitative sample sizes are characterised and discussed in academic narratives. Qualitative health research is an inter-disciplinary field that due to its affiliation with medical sciences, often faces views and positions reflective of a quantitative ethos. Thus qualitative health research constitutes an emblematic case that may help to unfold underlying philosophical and methodological differences across the scientific community that are crystallised in considerations of sample size. The present research, therefore, incorporates a comparative element on the basis of three different disciplines engaging with qualitative health research: medicine, psychology, and sociology. We chose to focus our analysis on single-per-participant-interview designs as this not only presents a popular and widespread methodological choice in qualitative health research, but also as the method where consideration of sample size – defined as the number of interviewees – is particularly salient.

Study design

A structured search for articles reporting cross-sectional, interview-based qualitative studies was carried out and eligible reports were systematically reviewed and analysed employing both quantitative and qualitative analytic techniques.

We selected journals which (a) follow a peer review process, (b) are considered high quality and influential in their field as reflected in journal metrics, and (c) are receptive to, and publish, qualitative research (Additional File 1 presents the journals’ editorial positions in relation to qualitative research and sample considerations where available). Three health-related journals were chosen, each representing a different disciplinary field; the British Medical Journal (BMJ) representing medicine, the British Journal of Health Psychology (BJHP) representing psychology, and the Sociology of Health & Illness (SHI) representing sociology.

Search strategy to identify studies

Employing the search function of each individual journal, we used the terms ‘interview*’ AND ‘qualitative’ and limited the results to articles published between 1 January 2003 and 22 September 2017 (i.e. a 15-year review period).

Eligibility criteria

To be eligible for inclusion in the review, the article had to report a cross-sectional study design. Longitudinal studies were thus excluded whilst studies conducted within a broader research programme (e.g. interview studies nested in a trial, as part of a broader ethnography, as part of a longitudinal research) were included if they reported only single-time qualitative interviews. The method of data collection had to be individual, synchronous qualitative interviews (i.e. group interviews, structured interviews and e-mail interviews over a period of time were excluded), and the data had to be analysed qualitatively (i.e. studies that quantified their qualitative data were excluded). Mixed method studies and articles reporting more than one qualitative method of data collection (e.g. individual interviews and focus groups) were excluded. Figure 1 , a PRISMA flow diagram [ 53 ], shows the number of: articles obtained from the searches and screened; papers assessed for eligibility; and articles included in the review (Additional File 2 provides the full list of articles included in the review and their unique identifying code – e.g. BMJ01, BJHP02, SHI03). One review author (KV) assessed the eligibility of all papers identified from the searches. When in doubt, discussions about retaining or excluding articles were held between KV and JB in regular meetings, and decisions were jointly made.

PRISMA flow diagram

Data extraction and analysis

A data extraction form was developed (see Additional File 3 ) recording three areas of information: (a) information about the article (e.g. authors, title, journal, year of publication etc.); (b) information about the aims of the study, the sample size and any justification for this, the participant characteristics, the sampling technique and any sample-related observations or comments made by the authors; and (c) information about the method or technique(s) of data analysis, the number of researchers involved in the analysis, the potential use of software, and any discussion around epistemological considerations. The Abstract, Methods and Discussion (and/or Conclusion) sections of each article were examined by one author (KV) who extracted all the relevant information. This was directly copied from the articles and, when appropriate, comments, notes and initial thoughts were written down.

To examine the kinds of sample size justifications provided by articles, an inductive content analysis [ 54 ] was initially conducted. On the basis of this analysis, the categories that expressed qualitatively different sample size justifications were developed.

We also extracted or coded quantitative data regarding the following aspects:

Journal and year of publication

Number of interviews

Number of participants

Presence of sample size justification(s) (Yes/No)

Presence of a particular sample size justification category (Yes/No), and

Number of sample size justifications provided

Descriptive and inferential statistical analyses were used to explore these data.

A thematic analysis [ 55 ] was then performed on all scientific narratives that discussed or commented on the sample size of the study. These narratives were evident both in papers that justified their sample size and those that did not. To identify these narratives, in addition to the methods sections, the discussion sections of the reviewed articles were also examined and relevant data were extracted and analysed.

In total, 214 articles – 21 in the BMJ, 53 in the BJHP and 140 in the SHI – were eligible for inclusion in the review. Table 1 provides basic information about the sample sizes – measured in number of interviews – of the studies reviewed across the three journals. Figure 2 depicts the number of eligible articles published each year per journal.

The publication of qualitative studies in the BMJ was significantly reduced from 2012 onwards and this appears to coincide with the initiation of the BMJ Open to which qualitative studies were possibly directed.

Pairwise comparisons following a significant Kruskal-Wallis Footnote 2 test indicated that the studies published in the BJHP had significantly ( p < .001) smaller samples sizes than those published either in the BMJ or the SHI. Sample sizes of BMJ and SHI articles did not differ significantly from each other.

Sample size justifications: Results from the quantitative and qualitative content analysis

Ten (47.6%) of the 21 BMJ studies, 26 (49.1%) of the 53 BJHP papers and 24 (17.1%) of the 140 SHI articles provided some sort of sample size justification. As shown in Table 2 , the majority of articles which justified their sample size provided one justification (70% of articles); fourteen studies (25%) provided two distinct justifications; one study (1.7%) gave three justifications and two studies (3.3%) expressed four distinct justifications.

There was no association between the number of interviews (i.e. sample size) conducted and the provision of a justification (rpb = .054, p = .433). Within journals, Mann-Whitney tests indicated that sample sizes of ‘justifying’ and ‘non-justifying’ articles in the BMJ and SHI did not differ significantly from each other. In the BJHP, ‘justifying’ articles ( Mean rank = 31.3) had significantly larger sample sizes than ‘non-justifying’ studies ( Mean rank = 22.7; U = 237.000, p < .05).

There was a significant association between the journal a paper was published in and the provision of a justification (χ 2 (2) = 23.83, p < .001). BJHP studies provided a sample size justification significantly more often than would be expected ( z = 2.9); SHI studies significantly less often ( z = − 2.4). If an article was published in the BJHP, the odds of providing a justification were 4.8 times higher than if published in the SHI. Similarly if published in the BMJ, the odds of a study justifying its sample size were 4.5 times higher than in the SHI.

The qualitative content analysis of the scientific narratives identified eleven different sample size justifications. These are described below and illustrated with excerpts from relevant articles. By way of a summary, the frequency with which these were deployed across the three journals is indicated in Table 3 .

Saturation was the most commonly invoked principle (55.4% of all justifications) deployed by studies across all three journals to justify the sufficiency of their sample size. In the BMJ, two studies claimed that they achieved data saturation (BMJ17; BMJ18) and one article referred descriptively to achieving saturation without explicitly using the term (BMJ13). Interestingly, BMJ13 included data in the analysis beyond the point of saturation in search of ‘unusual/deviant observations’ and with a view to establishing findings consistency.

Thirty three women were approached to take part in the interview study. Twenty seven agreed and 21 (aged 21–64, median 40) were interviewed before data saturation was reached (one tape failure meant that 20 interviews were available for analysis). (BMJ17). No new topics were identified following analysis of approximately two thirds of the interviews; however, all interviews were coded in order to develop a better understanding of how characteristic the views and reported behaviours were, and also to collect further examples of unusual/deviant observations. (BMJ13).

Two articles reported pre-determining their sample size with a view to achieving data saturation (BMJ08 – see extract in section In line with existing research ; BMJ15 – see extract in section Pragmatic considerations ) without further specifying if this was achieved. One paper claimed theoretical saturation (BMJ06) conceived as being when “no further recurring themes emerging from the analysis” whilst another study argued that although the analytic categories were highly saturated, it was not possible to determine whether theoretical saturation had been achieved (BMJ04). One article (BMJ18) cited a reference to support its position on saturation.

In the BJHP, six articles claimed that they achieved data saturation (BJHP21; BJHP32; BJHP39; BJHP48; BJHP49; BJHP52) and one article stated that, given their sample size and the guidelines for achieving data saturation, it anticipated that saturation would be attained (BJHP50).

Recruitment continued until data saturation was reached, defined as the point at which no new themes emerged. (BJHP48). It has previously been recommended that qualitative studies require a minimum sample size of at least 12 to reach data saturation (Clarke & Braun, 2013; Fugard & Potts, 2014; Guest, Bunce, & Johnson, 2006) Therefore, a sample of 13 was deemed sufficient for the qualitative analysis and scale of this study. (BJHP50).

Two studies argued that they achieved thematic saturation (BJHP28 – see extract in section Sample size guidelines ; BJHP31) and one (BJHP30) article, explicitly concerned with theory development and deploying theoretical sampling, claimed both theoretical and data saturation.

The final sample size was determined by thematic saturation, the point at which new data appears to no longer contribute to the findings due to repetition of themes and comments by participants (Morse, 1995). At this point, data generation was terminated. (BJHP31).

Five studies argued that they achieved (BJHP05; BJHP33; BJHP40; BJHP13 – see extract in section Pragmatic considerations ) or anticipated (BJHP46) saturation without any further specification of the term. BJHP17 referred descriptively to a state of achieved saturation without specifically using the term. Saturation of coding , but not saturation of themes, was claimed to have been reached by one article (BJHP18). Two articles explicitly stated that they did not achieve saturation; instead claiming a level of theme completeness (BJHP27) or that themes being replicated (BJHP53) were arguments for sufficiency of their sample size.

Furthermore, data collection ceased on pragmatic grounds rather than at the point when saturation point was reached. Despite this, although nuances within sub-themes were still emerging towards the end of data analysis, the themes themselves were being replicated indicating a level of completeness. (BJHP27).

Finally, one article criticised and explicitly renounced the notion of data saturation claiming that, on the contrary, the criterion of theoretical sufficiency determined its sample size (BJHP16).

According to the original Grounded Theory texts, data collection should continue until there are no new discoveries ( i.e. , ‘data saturation’; Glaser & Strauss, 1967). However, recent revisions of this process have discussed how it is rare that data collection is an exhaustive process and researchers should rely on how well their data are able to create a sufficient theoretical account or ‘theoretical sufficiency’ (Dey, 1999). For this study, it was decided that theoretical sufficiency would guide recruitment, rather than looking for data saturation. (BJHP16).

Ten out of the 20 BJHP articles that employed the argument of saturation used one or more citations relating to this principle.

In the SHI, one article (SHI01) claimed that it achieved category saturation based on authors’ judgment.

This number was not fixed in advance, but was guided by the sampling strategy and the judgement, based on the analysis of the data, of the point at which ‘category saturation’ was achieved. (SHI01).

Three articles described a state of achieved saturation without using the term or specifying what sort of saturation they had achieved (i.e. data, theoretical, thematic saturation) (SHI04; SHI13; SHI30) whilst another four articles explicitly stated that they achieved saturation (SHI100; SHI125; SHI136; SHI137). Two papers stated that they achieved data saturation (SHI73 – see extract in section Sample size guidelines ; SHI113), two claimed theoretical saturation (SHI78; SHI115) and two referred to achieving thematic saturation (SHI87; SHI139) or to saturated themes (SHI29; SHI50).

Recruitment and analysis ceased once theoretical saturation was reached in the categories described below (Lincoln and Guba 1985). (SHI115). The respondents’ quotes drawn on below were chosen as representative, and illustrate saturated themes. (SHI50).

One article stated that thematic saturation was anticipated with its sample size (SHI94). Briefly referring to the difficulty in pinpointing achievement of theoretical saturation, SHI32 (see extract in section Richness and volume of data ) defended the sufficiency of its sample size on the basis of “the high degree of consensus [that] had begun to emerge among those interviewed”, suggesting that information from interviews was being replicated. Finally, SHI112 (see extract in section Further sampling to check findings consistency ) argued that it achieved saturation of discursive patterns . Seven of the 19 SHI articles cited references to support their position on saturation (see Additional File 4 for the full list of citations used by articles to support their position on saturation across the three journals).

Overall, it is clear that the concept of saturation encompassed a wide range of variants expressed in terms such as saturation, data saturation, thematic saturation, theoretical saturation, category saturation, saturation of coding, saturation of discursive themes, theme completeness. It is noteworthy, however, that although these various claims were sometimes supported with reference to the literature, they were not evidenced in relation to the study at hand.

Pragmatic considerations

The determination of sample size on the basis of pragmatic considerations was the second most frequently invoked argument (9.6% of all justifications) appearing in all three journals. In the BMJ, one article (BMJ15) appealed to pragmatic reasons, relating to time constraints and the difficulty to access certain study populations, to justify the determination of its sample size.

On the basis of the researchers’ previous experience and the literature, [30, 31] we estimated that recruitment of 15–20 patients at each site would achieve data saturation when data from each site were analysed separately. We set a target of seven to 10 caregivers per site because of time constraints and the anticipated difficulty of accessing caregivers at some home based care services. This gave a target sample of 75–100 patients and 35–50 caregivers overall. (BMJ15).

In the BJHP, four articles mentioned pragmatic considerations relating to time or financial constraints (BJHP27 – see extract in section Saturation ; BJHP53), the participant response rate (BJHP13), and the fixed (and thus limited) size of the participant pool from which interviewees were sampled (BJHP18).

We had aimed to continue interviewing until we had reached saturation, a point whereby further data collection would yield no further themes. In practice, the number of individuals volunteering to participate dictated when recruitment into the study ceased (15 young people, 15 parents). Nonetheless, by the last few interviews, significant repetition of concepts was occurring, suggesting ample sampling. (BJHP13).

Finally, three SHI articles explained their sample size with reference to practical aspects: time constraints and project manageability (SHI56), limited availability of respondents and project resources (SHI131), and time constraints (SHI113).

The size of the sample was largely determined by the availability of respondents and resources to complete the study. Its composition reflected, as far as practicable, our interest in how contextual factors (for example, gender relations and ethnicity) mediated the illness experience. (SHI131).

Qualities of the analysis

This sample size justification (8.4% of all justifications) was mainly employed by BJHP articles and referred to an intensive, idiographic and/or latently focused analysis, i.e. that moved beyond description. More specifically, six articles defended their sample size on the basis of an intensive analysis of transcripts and/or the idiographic focus of the study/analysis. Four of these papers (BJHP02; BJHP19; BJHP24; BJHP47) adopted an Interpretative Phenomenological Analysis (IPA) approach.

The current study employed a sample of 10 in keeping with the aim of exploring each participant’s account (Smith et al. , 1999). (BJHP19).

BJHP47 explicitly renounced the notion of saturation within an IPA approach. The other two BJHP articles conducted thematic analysis (BJHP34; BJHP38). The level of analysis – i.e. latent as opposed to a more superficial descriptive analysis – was also invoked as a justification by BJHP38 alongside the argument of an intensive analysis of individual transcripts

The resulting sample size was at the lower end of the range of sample sizes employed in thematic analysis (Braun & Clarke, 2013). This was in order to enable significant reflection, dialogue, and time on each transcript and was in line with the more latent level of analysis employed, to identify underlying ideas, rather than a more superficial descriptive analysis (Braun & Clarke, 2006). (BJHP38).

Finally, one BMJ paper (BMJ21) defended its sample size with reference to the complexity of the analytic task.

We stopped recruitment when we reached 30–35 interviews, owing to the depth and duration of interviews, richness of data, and complexity of the analytical task. (BMJ21).

Meet sampling requirements

Meeting sampling requirements (7.2% of all justifications) was another argument employed by two BMJ and four SHI articles to explain their sample size. Achieving maximum variation sampling in terms of specific interviewee characteristics determined and explained the sample size of two BMJ studies (BMJ02; BMJ16 – see extract in section Meet research design requirements ).

Recruitment continued until sampling frame requirements were met for diversity in age, sex, ethnicity, frequency of attendance, and health status. (BMJ02).

Regarding the SHI articles, two papers explained their numbers on the basis of their sampling strategy (SHI01- see extract in section Saturation ; SHI23) whilst sampling requirements that would help attain sample heterogeneity in terms of a particular characteristic of interest was cited by one paper (SHI127).

The combination of matching the recruitment sites for the quantitative research and the additional purposive criteria led to 104 phase 2 interviews (Internet (OLC): 21; Internet (FTF): 20); Gyms (FTF): 23; HIV testing (FTF): 20; HIV treatment (FTF): 20.) (SHI23). Of the fifty interviews conducted, thirty were translated from Spanish into English. These thirty, from which we draw our findings, were chosen for translation based on heterogeneity in depressive symptomology and educational attainment. (SHI127).

Finally, the pre-determination of sample size on the basis of sampling requirements was stated by one article though this was not used to justify the number of interviews (SHI10).

Sample size guidelines

Five BJHP articles (BJHP28; BJHP38 – see extract in section Qualities of the analysis ; BJHP46; BJHP47; BJHP50 – see extract in section Saturation ) and one SHI paper (SHI73) relied on citing existing sample size guidelines or norms within research traditions to determine and subsequently defend their sample size (7.2% of all justifications).

Sample size guidelines suggested a range between 20 and 30 interviews to be adequate (Creswell, 1998). Interviewer and note taker agreed that thematic saturation, the point at which no new concepts emerge from subsequent interviews (Patton, 2002), was achieved following completion of 20 interviews. (BJHP28). Interviewing continued until we deemed data saturation to have been reached (the point at which no new themes were emerging). Researchers have proposed 30 as an approximate or working number of interviews at which one could expect to be reaching theoretical saturation when using a semi-structured interview approach (Morse 2000), although this can vary depending on the heterogeneity of respondents interviewed and complexity of the issues explored. (SHI73).

In line with existing research

Sample sizes of published literature in the area of the subject matter under investigation (3.5% of all justifications) were used by 2 BMJ articles as guidance and a precedent for determining and defending their own sample size (BMJ08; BMJ15 – see extract in section Pragmatic considerations ).

We drew participants from a list of prisoners who were scheduled for release each week, sampling them until we reached the target of 35 cases, with a view to achieving data saturation within the scope of the study and sufficient follow-up interviews and in line with recent studies [8–10]. (BMJ08).

Similarly, BJHP38 (see extract in section Qualities of the analysis ) claimed that its sample size was within the range of sample sizes of published studies that use its analytic approach.

Richness and volume of data

BMJ21 (see extract in section Qualities of the analysis ) and SHI32 referred to the richness, detailed nature, and volume of data collected (2.3% of all justifications) to justify the sufficiency of their sample size.

Although there were more potential interviewees from those contacted by postcode selection, it was decided to stop recruitment after the 10th interview and focus on analysis of this sample. The material collected was considerable and, given the focused nature of the study, extremely detailed. Moreover, a high degree of consensus had begun to emerge among those interviewed, and while it is always difficult to judge at what point ‘theoretical saturation’ has been reached, or how many interviews would be required to uncover exception(s), it was felt the number was sufficient to satisfy the aims of this small in-depth investigation (Strauss and Corbin 1990). (SHI32).

Meet research design requirements

Determination of sample size so that it is in line with, and serves the requirements of, the research design (2.3% of all justifications) that the study adopted was another justification used by 2 BMJ papers (BMJ16; BMJ08 – see extract in section In line with existing research ).

We aimed for diverse, maximum variation samples [20] totalling 80 respondents from different social backgrounds and ethnic groups and those bereaved due to different types of suicide and traumatic death. We could have interviewed a smaller sample at different points in time (a qualitative longitudinal study) but chose instead to seek a broad range of experiences by interviewing those bereaved many years ago and others bereaved more recently; those bereaved in different circumstances and with different relations to the deceased; and people who lived in different parts of the UK; with different support systems and coroners’ procedures (see Tables 1 and 2 for more details). (BMJ16).

Researchers’ previous experience

The researchers’ previous experience (possibly referring to experience with qualitative research) was invoked by BMJ15 (see extract in section Pragmatic considerations ) as a justification for the determination of sample size.

Nature of study

One BJHP paper argued that the sample size was appropriate for the exploratory nature of the study (BJHP38).

A sample of eight participants was deemed appropriate because of the exploratory nature of this research and the focus on identifying underlying ideas about the topic. (BJHP38).

Further sampling to check findings consistency

Finally, SHI112 argued that once it had achieved saturation of discursive patterns, further sampling was decided and conducted to check for consistency of the findings.

Within each of the age-stratified groups, interviews were randomly sampled until saturation of discursive patterns was achieved. This resulted in a sample of 67 interviews. Once this sample had been analysed, one further interview from each age-stratified group was randomly chosen to check for consistency of the findings. Using this approach it was possible to more carefully explore children’s discourse about the ‘I’, agency, relationality and power in the thematic areas, revealing the subtle discursive variations described in this article. (SHI112).

Thematic analysis of passages discussing sample size

This analysis resulted in two overarching thematic areas; the first concerned the variation in the characterisation of sample size sufficiency, and the second related to the perceived threats deriving from sample size insufficiency.

Characterisations of sample size sufficiency

The analysis showed that there were three main characterisations of the sample size in the articles that provided relevant comments and discussion: (a) the vast majority of these qualitative studies ( n = 42) considered their sample size as ‘small’ and this was seen and discussed as a limitation; only two articles viewed their small sample size as desirable and appropriate (b) a minority of articles ( n = 4) proclaimed that their achieved sample size was ‘sufficient’; and (c) finally, a small group of studies ( n = 5) characterised their sample size as ‘large’. Whilst achieving a ‘large’ sample size was sometimes viewed positively because it led to richer results, there were also occasions when a large sample size was problematic rather than desirable.

‘Small’ but why and for whom?

A number of articles which characterised their sample size as ‘small’ did so against an implicit or explicit quantitative framework of reference. Interestingly, three studies that claimed to have achieved data saturation or ‘theoretical sufficiency’ with their sample size, discussed or noted as a limitation in their discussion their ‘small’ sample size, raising the question of why, or for whom, the sample size was considered small given that the qualitative criterion of saturation had been satisfied.

The current study has a number of limitations. The sample size was small (n = 11) and, however, large enough for no new themes to emerge. (BJHP39). The study has two principal limitations. The first of these relates to the small number of respondents who took part in the study. (SHI73).

Other articles appeared to accept and acknowledge that their sample was flawed because of its small size (as well as other compositional ‘deficits’ e.g. non-representativeness, biases, self-selection) or anticipated that they might be criticized for their small sample size. It seemed that the imagined audience – perhaps reviewer or reader – was one inclined to hold the tenets of quantitative research, and certainly one to whom it was important to indicate the recognition that small samples were likely to be problematic. That one’s sample might be thought small was often construed as a limitation couched in a discourse of regret or apology.

Very occasionally, the articulation of the small size as a limitation was explicitly aligned against an espoused positivist framework and quantitative research.

This study has some limitations. Firstly, the 100 incidents sample represents a small number of the total number of serious incidents that occurs every year. 26 We sent out a nationwide invitation and do not know why more people did not volunteer for the study. Our lack of epidemiological knowledge about healthcare incidents, however, means that determining an appropriate sample size continues to be difficult. (BMJ20).

Indicative of an apparent oscillation of qualitative researchers between the different requirements and protocols demarcating the quantitative and qualitative worlds, there were a few instances of articles which briefly recognised their ‘small’ sample size as a limitation, but then defended their study on more qualitative grounds, such as their ability and success at capturing the complexity of experience and delving into the idiographic, and at generating particularly rich data.

This research, while limited in size, has sought to capture some of the complexity attached to men’s attitudes and experiences concerning incomes and material circumstances. (SHI35). Our numbers are small because negotiating access to social networks was slow and labour intensive, but our methods generated exceptionally rich data. (BMJ21). This study could be criticised for using a small and unrepresentative sample. Given that older adults have been ignored in the research concerning suntanning, fair-skinned older adults are the most likely to experience skin cancer, and women privilege appearance over health when it comes to sunbathing practices, our study offers depth and richness of data in a demographic group much in need of research attention. (SHI57).

‘Good enough’ sample sizes

Only four articles expressed some degree of confidence that their achieved sample size was sufficient. For example, SHI139, in line with the justification of thematic saturation that it offered, expressed trust in its sample size sufficiency despite the poor response rate. Similarly, BJHP04, which did not provide a sample size justification, argued that it targeted a larger sample size in order to eventually recruit a sufficient number of interviewees, due to anticipated low response rate.

Twenty-three people with type I diabetes from the target population of 133 ( i.e. 17.3%) consented to participate but four did not then respond to further contacts (total N = 19). The relatively low response rate was anticipated, due to the busy life-styles of young people in the age range, the geographical constraints, and the time required to participate in a semi-structured interview, so a larger target sample allowed a sufficient number of participants to be recruited. (BJHP04).

Two other articles (BJHP35; SHI32) linked the claimed sufficiency to the scope (i.e. ‘small, in-depth investigation’), aims and nature (i.e. ‘exploratory’) of their studies, thus anchoring their numbers to the particular context of their research. Nevertheless, claims of sample size sufficiency were sometimes undermined when they were juxtaposed with an acknowledgement that a larger sample size would be more scientifically productive.

Although our sample size was sufficient for this exploratory study, a more diverse sample including participants with lower socioeconomic status and more ethnic variation would be informative. A larger sample could also ensure inclusion of a more representative range of apps operating on a wider range of platforms. (BJHP35).

‘Large’ sample sizes - Promise or peril?

Three articles (BMJ13; BJHP05; BJHP48) which all provided the justification of saturation, characterised their sample size as ‘large’ and narrated this oversufficiency in positive terms as it allowed richer data and findings and enhanced the potential for generalisation. The type of generalisation aspired to (BJHP48) was not further specified however.

This study used rich data provided by a relatively large sample of expert informants on an important but under-researched topic. (BMJ13). Qualitative research provides a unique opportunity to understand a clinical problem from the patient’s perspective. This study had a large diverse sample, recruited through a range of locations and used in-depth interviews which enhance the richness and generalizability of the results. (BJHP48).

And whilst a ‘large’ sample size was endorsed and valued by some qualitative researchers, within the psychological tradition of IPA, a ‘large’ sample size was counter-normative and therefore needed to be justified. Four BJHP studies, all adopting IPA, expressed the appropriateness or desirability of ‘small’ sample sizes (BJHP41; BJHP45) or hastened to explain why they included a larger than typical sample size (BJHP32; BJHP47). For example, BJHP32 below provides a rationale for how an IPA study can accommodate a large sample size and how this was indeed suitable for the purposes of the particular research. To strengthen the explanation for choosing a non-normative sample size, previous IPA research citing a similar sample size approach is used as a precedent.

Small scale IPA studies allow in-depth analysis which would not be possible with larger samples (Smith et al. , 2009). (BJHP41). Although IPA generally involves intense scrutiny of a small number of transcripts, it was decided to recruit a larger diverse sample as this is the first qualitative study of this population in the United Kingdom (as far as we know) and we wanted to gain an overview. Indeed, Smith, Flowers, and Larkin (2009) agree that IPA is suitable for larger groups. However, the emphasis changes from an in-depth individualistic analysis to one in which common themes from shared experiences of a group of people can be elicited and used to understand the network of relationships between themes that emerge from the interviews. This large-scale format of IPA has been used by other researchers in the field of false-positive research. Baillie, Smith, Hewison, and Mason (2000) conducted an IPA study, with 24 participants, of ultrasound screening for chromosomal abnormality; they found that this larger number of participants enabled them to produce a more refined and cohesive account. (BJHP32).

The IPA articles found in the BJHP were the only instances where a ‘small’ sample size was advocated and a ‘large’ sample size problematized and defended. These IPA studies illustrate that the characterisation of sample size sufficiency can be a function of researchers’ theoretical and epistemological commitments rather than the result of an ‘objective’ sample size assessment.

Threats from sample size insufficiency

As shown above, the majority of articles that commented on their sample size, simultaneously characterized it as small and problematic. On those occasions that authors did not simply cite their ‘small’ sample size as a study limitation but rather continued and provided an account of how and why a small sample size was problematic, two important scientific qualities of the research seemed to be threatened: the generalizability and validity of results.

Generalizability

Those who characterised their sample as ‘small’ connected this to the limited potential for generalization of the results. Other features related to the sample – often some kind of compositional particularity – were also linked to limited potential for generalisation. Though not always explicitly articulated to what form of generalisation the articles referred to (see BJHP09), generalisation was mostly conceived in nomothetic terms, that is, it concerned the potential to draw inferences from the sample to the broader study population (‘representational generalisation’ – see BJHP31) and less often to other populations or cultures.

It must be noted that samples are small and whilst in both groups the majority of those women eligible participated, generalizability cannot be assumed. (BJHP09). The study’s limitations should be acknowledged: Data are presented from interviews with a relatively small group of participants, and thus, the views are not necessarily generalizable to all patients and clinicians. In particular, patients were only recruited from secondary care services where COFP diagnoses are typically confirmed. The sample therefore is unlikely to represent the full spectrum of patients, particularly those who are not referred to, or who have been discharged from dental services. (BJHP31).

Without explicitly using the term generalisation, two SHI articles noted how their ‘small’ sample size imposed limits on ‘the extent that we can extrapolate from these participants’ accounts’ (SHI114) or to the possibility ‘to draw far-reaching conclusions from the results’ (SHI124).

Interestingly, only a minority of articles alluded to, or invoked, a type of generalisation that is aligned with qualitative research, that is, idiographic generalisation (i.e. generalisation that can be made from and about cases [ 5 ]). These articles, all published in the discipline of sociology, defended their findings in terms of the possibility of drawing logical and conceptual inferences to other contexts and of generating understanding that has the potential to advance knowledge, despite their ‘small’ size. One article (SHI139) clearly contrasted nomothetic (statistical) generalisation to idiographic generalisation, arguing that the lack of statistical generalizability does not nullify the ability of qualitative research to still be relevant beyond the sample studied.

Further, these data do not need to be statistically generalisable for us to draw inferences that may advance medicalisation analyses (Charmaz 2014). These data may be seen as an opportunity to generate further hypotheses and are a unique application of the medicalisation framework. (SHI139). Although a small-scale qualitative study related to school counselling, this analysis can be usefully regarded as a case study of the successful utilisation of mental health-related resources by adolescents. As many of the issues explored are of relevance to mental health stigma more generally, it may also provide insights into adult engagement in services. It shows how a sociological analysis, which uses positioning theory to examine how people negotiate, partially accept and simultaneously resist stigmatisation in relation to mental health concerns, can contribute to an elucidation of the social processes and narrative constructions which may maintain as well as bridge the mental health service gap. (SHI103).

Only one article (SHI30) used the term transferability to argue for the potential of wider relevance of the results which was thought to be more the product of the composition of the sample (i.e. diverse sample), rather than the sample size.

The second major concern that arose from a ‘small’ sample size pertained to the internal validity of findings (i.e. here the term is used to denote the ‘truth’ or credibility of research findings). Authors expressed uncertainty about the degree of confidence in particular aspects or patterns of their results, primarily those that concerned some form of differentiation on the basis of relevant participant characteristics.

The information source preferred seemed to vary according to parents’ education; however, the sample size is too small to draw conclusions about such patterns. (SHI80). Although our numbers were too small to demonstrate gender differences with any certainty, it does seem that the biomedical and erotic scripts may be more common in the accounts of men and the relational script more common in the accounts of women. (SHI81).

In other instances, articles expressed uncertainty about whether their results accounted for the full spectrum and variation of the phenomenon under investigation. In other words, a ‘small’ sample size (alongside compositional ‘deficits’ such as a not statistically representative sample) was seen to threaten the ‘content validity’ of the results which in turn led to constructions of the study conclusions as tentative.

Data collection ceased on pragmatic grounds rather than when no new information appeared to be obtained ( i.e. , saturation point). As such, care should be taken not to overstate the findings. Whilst the themes from the initial interviews seemed to be replicated in the later interviews, further interviews may have identified additional themes or provided more nuanced explanations. (BJHP53). …it should be acknowledged that this study was based on a small sample of self-selected couples in enduring marriages who were not broadly representative of the population. Thus, participants may not be representative of couples that experience postnatal PTSD. It is therefore unlikely that all the key themes have been identified and explored. For example, couples who were excluded from the study because the male partner declined to participate may have been experiencing greater interpersonal difficulties. (BJHP03).

In other instances, articles attempted to preserve a degree of credibility of their results, despite the recognition that the sample size was ‘small’. Clarity and sharpness of emerging themes and alignment with previous relevant work were the arguments employed to warrant the validity of the results.

This study focused on British Chinese carers of patients with affective disorders, using a qualitative methodology to synthesise the sociocultural representations of illness within this community. Despite the small sample size, clear themes emerged from the narratives that were sufficient for this exploratory investigation. (SHI98).

The present study sought to examine how qualitative sample sizes in health-related research are characterised and justified. In line with previous studies [ 22 , 30 , 33 , 34 ] the findings demonstrate that reporting of sample size sufficiency is limited; just over 50% of articles in the BMJ and BJHP and 82% in the SHI did not provide any sample size justification. Providing a sample size justification was not related to the number of interviews conducted, but it was associated with the journal that the article was published in, indicating the influence of disciplinary or publishing norms, also reported in prior research [ 30 ]. This lack of transparency about sample size sufficiency is problematic given that most qualitative researchers would agree that it is an important marker of quality [ 56 , 57 ]. Moreover, and with the rise of qualitative research in social sciences, efforts to synthesise existing evidence and assess its quality are obstructed by poor reporting [ 58 , 59 ].

When authors justified their sample size, our findings indicate that sufficiency was mostly appraised with reference to features that were intrinsic to the study, in agreement with general advice on sample size determination [ 4 , 11 , 36 ]. The principle of saturation was the most commonly invoked argument [ 22 ] accounting for 55% of all justifications. A wide range of variants of saturation was evident corroborating the proliferation of the meaning of the term [ 49 ] and reflecting different underlying conceptualisations or models of saturation [ 20 ]. Nevertheless, claims of saturation were never substantiated in relation to procedures conducted in the study itself, endorsing similar observations in the literature [ 25 , 30 , 47 ]. Claims of saturation were sometimes supported with citations of other literature, suggesting a removal of the concept away from the characteristics of the study at hand. Pragmatic considerations, such as resource constraints or participant response rate and availability, was the second most frequently used argument accounting for approximately 10% of justifications and another 23% of justifications also represented intrinsic-to-the-study characteristics (i.e. qualities of the analysis, meeting sampling or research design requirements, richness and volume of the data obtained, nature of study, further sampling to check findings consistency).

Only, 12% of mentions of sample size justification pertained to arguments that were external to the study at hand, in the form of existing sample size guidelines and prior research that sets precedents. Whilst community norms and prior research can establish useful rules of thumb for estimating sample sizes [ 60 ] – and reveal what sizes are more likely to be acceptable within research communities – researchers should avoid adopting these norms uncritically, especially when such guidelines [e.g. 30 , 35 ], might be based on research that does not provide adequate evidence of sample size sufficiency. Similarly, whilst methodological research that seeks to demonstrate the achievement of saturation is invaluable since it explicates the parameters upon which saturation is contingent and indicates when a research project is likely to require a smaller or a larger sample [e.g. 29 ], specific numbers at which saturation was achieved within these projects cannot be routinely extrapolated for other projects. We concur with existing views [ 11 , 36 ] that the consideration of the characteristics of the study at hand, such as the epistemological and theoretical approach, the nature of the phenomenon under investigation, the aims and scope of the study, the quality and richness of data, or the researcher’s experience and skills of conducting qualitative research, should be the primary guide in determining sample size and assessing its sufficiency.

Moreover, although numbers in qualitative research are not unimportant [ 61 ], sample size should not be considered alone but be embedded in the more encompassing examination of data adequacy [ 56 , 57 ]. Erickson’s [ 62 ] dimensions of ‘evidentiary adequacy’ are useful here. He explains the concept in terms of adequate amounts of evidence, adequate variety in kinds of evidence, adequate interpretive status of evidence, adequate disconfirming evidence, and adequate discrepant case analysis. All dimensions might not be relevant across all qualitative research designs, but this illustrates the thickness of the concept of data adequacy, taking it beyond sample size.

The present research also demonstrated that sample sizes were commonly seen as ‘small’ and insufficient and discussed as limitation. Often unjustified (and in two cases incongruent with their own claims of saturation) these findings imply that sample size in qualitative health research is often adversely judged (or expected to be judged) against an implicit, yet omnipresent, quasi-quantitative standpoint. Indeed there were a few instances in our data where authors appeared, possibly in response to reviewers, to resist to some sort of quantification of their results. This implicit reference point became more apparent when authors discussed the threats deriving from an insufficient sample size. Whilst the concerns about internal validity might be legitimate to the extent that qualitative research projects, which are broadly related to realism, are set to examine phenomena in sufficient breadth and depth, the concerns around generalizability revealed a conceptualisation that is not compatible with purposive sampling. The limited potential for generalisation, as a result of a small sample size, was often discussed in nomothetic, statistical terms. Only occasionally was analytic or idiographic generalisation invoked to warrant the value of the study’s findings [ 5 , 17 ].

Strengths and limitations of the present study

We note, first, the limited number of health-related journals reviewed, so that only a ‘snapshot’ of qualitative health research has been captured. Examining additional disciplines (e.g. nursing sciences) as well as inter-disciplinary journals would add to the findings of this analysis. Nevertheless, our study is the first to provide some comparative insights on the basis of disciplines that are differently attached to the legacy of positivism and analysed literature published over a lengthy period of time (15 years). Guetterman [ 27 ] also examined health-related literature but this analysis was restricted to 26 most highly cited articles published over a period of five years whilst Carlsen and Glenton’s [ 22 ] study concentrated on focus groups health research. Moreover, although it was our intention to examine sample size justification in relation to the epistemological and theoretical positions of articles, this proved to be challenging largely due to absence of relevant information, or the difficulty into discerning clearly articles’ positions [ 63 ] and classifying them under specific approaches (e.g. studies often combined elements from different theoretical and epistemological traditions). We believe that such an analysis would yield useful insights as it links the methodological issue of sample size to the broader philosophical stance of the research. Despite these limitations, the analysis of the characterisation of sample size and of the threats seen to accrue from insufficient sample size, enriches our understanding of sample size (in)sufficiency argumentation by linking it to other features of the research. As the peer-review process becomes increasingly public, future research could usefully examine how reporting around sample size sufficiency and data adequacy might be influenced by the interactions between authors and reviewers.

The past decade has seen a growing appetite in qualitative research for an evidence-based approach to sample size determination and to evaluations of the sufficiency of sample size. Despite the conceptual and methodological developments in the area, the findings of the present study confirm previous studies in concluding that appraisals of sample size sufficiency are either absent or poorly substantiated. To ensure and maintain high quality research that will encourage greater appreciation of qualitative work in health-related sciences [ 64 ], we argue that qualitative researchers should be more transparent and thorough in their evaluation of sample size as part of their appraisal of data adequacy. We would encourage the practice of appraising sample size sufficiency with close reference to the study at hand and would thus caution against responding to the growing methodological research in this area with a decontextualised application of sample size numerical guidelines, norms and principles. Although researchers might find sample size community norms serve as useful rules of thumb, we recommend methodological knowledge is used to critically consider how saturation and other parameters that affect sample size sufficiency pertain to the specifics of the particular project. Those reviewing papers have a vital role in encouraging transparent study-specific reporting. The review process should support authors to exercise nuanced judgments in decisions about sample size determination in the context of the range of factors that influence sample size sufficiency and the specifics of a particular study. In light of the growing methodological evidence in the area, transparent presentation of such evidence-based judgement is crucial and in time should surely obviate the seemingly routine practice of citing the ‘small’ size of qualitative samples among the study limitations.

A non-parametric test of difference for independent samples was performed since the variable number of interviews violated assumptions of normality according to the standardized scores of skewness and kurtosis (BMJ: z skewness = 3.23, z kurtosis = 1.52; BJHP: z skewness = 4.73, z kurtosis = 4.85; SHI: z skewness = 12.04, z kurtosis = 21.72) and the Shapiro-Wilk test of normality ( p < .001).

Abbreviations

British Journal of Health Psychology

British Medical Journal

Interpretative Phenomenological Analysis

Sociology of Health & Illness

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Acknowledgments

We would like to thank Dr. Paula Smith and Katharine Lee for their comments on a previous draft of this paper as well as Natalie Ann Mitchell and Meron Teferra for assisting us with data extraction.

This research was initially conceived of and partly conducted with financial support from the Multidisciplinary Assessment of Technology Centre for Healthcare (MATCH) programme (EP/F063822/1 and EP/G012393/1). The research continued and was completed independent of any support. The funding body did not have any role in the study design, the collection, analysis and interpretation of the data, in the writing of the paper, and in the decision to submit the manuscript for publication. The views expressed are those of the authors alone.

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JB and TY conceived the study; KV, JB, and TY designed the study; KV identified the articles and extracted the data; KV and JB assessed eligibility of articles; KV, JB, ST, and TY contributed to the analysis of the data, discussed the findings and early drafts of the paper; KV developed the final manuscript; KV, JB, ST, and TY read and approved the manuscript.

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Additional Files

Additional file 1:.

Editorial positions on qualitative research and sample considerations (where available). (DOCX 12 kb)

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List of eligible articles included in the review ( N = 214). (DOCX 38 kb)

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Citations used by articles to support their position on saturation. (DOCX 14 kb)

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Vasileiou, K., Barnett, J., Thorpe, S. et al. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol 18 , 148 (2018). https://doi.org/10.1186/s12874-018-0594-7

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Qualitative Research in Organizations and Management

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The purpose of this paper is to report the findings of research which explores how the concept qualitative management research is variably constructed and defined by those who have a direct interest in, and influence upon, important aspects of qualitative management research.

Design/methodology/approach

Information was gathered through the use of semi‐structured interviews conducted with 44 individuals who were drawn from four observer‐identified types of “expert” informant who were taken to generally represent key groups of stakeholders in the conduct, evaluation and dissemination of qualitative management research. Interview data from these individuals were analysed though an iterative process using the NVivo software package to inductively generate definitional categories and explore aspects of their interrelationships.

From data analysis it was apparent that there are eight different, but often interrelated, ways in which interviewees define qualitative management research. The philosophical dimensions of each of these variable definitions are outlined and their relationships to the methodological literature are explored. The variety identified amongst informants, indicates how there is a potential dissensus possible regarding what qualitative management research might entail, as well as regarding its provenance and its academic status. This dissensus potentially can create problems with regard to its evaluation.

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So whist there is little evidence to suggest any systematic relationship between the variable institutional backgrounds of informants and how they variably define and perceive qualitative management research, philosophical influences upon this contested terrain are explored and the implications of the identified dissensus for how qualitative management research is perceived and evaluated is discussed. The implications of this evidently contested terrain are discussed with particular reference to the future constitution of qualitative management research and its evaluation.

Qualitative methods
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Johnson, P. , Buehring, A. , Cassell, C. and Symon, G. (2007), "Defining qualitative management research: an empirical investigation", Qualitative Research in Organizations and Management , Vol. 2 No. 1, pp. 23-42. https://doi.org/10.1108/17465640710749108

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Published: 21 May 2024

Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium

Monica Verhofstadt 1 ,
Loïc Moureau 2 ,
Koen Pardon 1 &
Axel Liégeois 2 , 3

BMC Medical Ethics volume 25 , Article number: 60 ( 2024 ) Cite this article

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Introduction

Previous research has explored euthanasia’s ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium.

Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts.

Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient’s inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent.

The study underscores ethical discourse’s central role in navigating euthanasia’s intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors’ needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia’s multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

Peer Review reports

Medical assistance in dying is allowed in 27 jurisdictions in the world and if so, it is mainly restricted to the terminally ill (see BOX 1 in OSF) [ 1 ]. Medical assistance in dying entails that a patient’s death request can be granted via euthanasia , defined as the intentional termination of life by a physician at the patient’s explicit request, which is currently decriminalised in Australia, Belgium, Canada, Colombia, Luxembourg, the Netherlands, Spain, and New Zealand. In addition, it can be granted by means of assisted suicide , also defined as the intentional termination of life by a physician at the patient’s explicit request, but in these cases, the lethal drugs are provided by a physician and self-administered by the patient at a time of the latter’s own choosing (e.g., Australia, Austria, Switzerland, United States). In some countries, not only a physician, but also a nurse practitioner can be involved in the procedure (e.g., Canada, New Zealand).

Euthanasia has been legal in Belgium since 2002, positioning the country as a pioneer in this field with two decades of euthanasia practice [ 2 ]. According to Belgian legislation, individuals can be deemed eligible for euthanasia when they are, among other criteria, in a medically futile state characterized by constant and unbearable physical or psychological suffering resulting from a serious and incurable disorder caused by accident or illness [ 2 ]. Belgium is one of the few countries that does not exclude people from assisted dying who suffer predominantly from irremediable psychiatric conditions (see BOX 2 in OSF for all legal criteria in Belgium). As regards prevalence, euthanasia accounted for up to 3.1% of all registered deaths in 2023 in Belgium [ 3 ]. Whereas most registered euthanasia deaths concerned the terminally ill (approximately 84%), predominantly suffering from cancer, only 48 or 1.4% of euthanasia deaths concerned non-terminally ill adults predominantly suffering from psychiatric conditions. Since euthanasia was legalised, in total 457 such euthanasia cases have been reported, less than 1.5% of all registered euthanasia cases in Belgium [ 3 , 4 , 5 , 6 , 7 , 8 , 9 ].

However, this is only the tip of the iceberg, as there is reason to believe that the total number of requests for euthanasia in Belgium (regardless of outcome), is at least 10 times higher. For instance, recent annual reports from Vonkel, an end-of-life consultation centre in Belgium, revealed around 100 unique patients per year applying for euthanasia for psychiatric reasons. Less than 10% of those euthanasia requests were reported to be carried out [ 10 , 11 , 12 ]. Moreover, a recent survey among psychiatrists working in Flanders, Belgium, revealed that 8 out of 10 respondents had been confronted at least once throughout their career with patients requesting euthanasia for psychiatric reasons [ 13 ]. The survey also showed that, although three-quarters are supportive of not excluding the option of euthanasia for this specific patient group [ 14 ], the majority is hesitant to be actively engaged in a euthanasia procedure [ 13 , 14 ]. The literature ascribed the reluctance to the complexity of euthanasia assessment in this patient group, inherently high in professional and emotional demands [ 15 , 16 , 17 , 18 , 19 ]. The complexity was for a large part described in terms of the practical considerations surrounding euthanasia requests and assessment, e.g., whether and when these patients can meet the legal criteria.

There is thus reason to believe that healthcare workers’ overarching ethical considerations influence their attitudes on euthanasia in general and in the context of psychiatry specifically, and their practice. As empirical in-depth studies are lacking, this area is largely understudied. To date, only two recent qualitative studies among Dutch physicians emphasised the value-based reasons for euthanasia decision-making, but did not [ 20 ] or only summarily [ 21 ] scratch the specific context of psychiatry. Another recent qualitative study among Dutch physicians, including psychiatrists, emphasized the value-based reasons for supportive attitudes towards euthanasia, e.g. the value of self-determination, compassion, fairness, and suicide prevention, versus the value-based reasons for not supporting euthanasia, e.g. the mission of medicine of hope and healing [ 22 ]. Furthermore, a recent systematic review described the main ethical challenges surrounding the euthanasia practice in the context of psychiatry [ 23 ]. However, this ethical debate was mainly concentrated on the permissibility and implementation of euthanasia from a practical-clinical point of view, e.g. whether euthanasia in the context of psychiatry should be permitted, and why the legal requirements can (not) be adequately embedded in the field of psychiatric medicine. How practically and juridically relevant these considerations may be, they remain the outcome of ethical values being weighed up, which means that no single consideration can be considered ethically irrelevant, neutral, or value-free. Moreover, the review was based on articles that have been selected in a timeframe in which sound empirical data regarding euthanasia in the context of psychiatry were largely lacking.

Also, the overarching value-based views of other professionals involved in psychiatric euthanasia practice have not yet been studied. This is striking, as a recent Belgian survey study revealed that that half of the psychiatric nurses (53%) are frequently and directly confronted with such euthanasia requests [ 24 ], but in-depth insights into their value-based views are lacking. Furthermore, there are many more formal caregivers, other than psychiatric nurses, involved in euthanasia assessment procedures. End-of-life centres employ e.g., paramedical personnel such as psychologists, psychiatric nurses for intake and registration purposes, and well-trained volunteer personnel such as buddies, entrusted with the task to help these patients to cope with the euthanasia procedure. In addition, rehabilitation-oriented support groups (REAKIRO) were established to help these patients (and their relatives) in walking the tightrope of life and death [ 25 ]. All of these caregivers may also have an unacknowledged but influential role in these euthanasia assessment procedures, and therefore, an interesting perspective to reflect on euthanasia legislation and practice. Gaining insight into healthcare workers’ ethical considerations related to euthanasia in psychiatry will lay bare the ethical foundations underlying current practice and is important to inform and spark further debate around this extremely thorny issue, and to promote sound ethical analysis.

Hence, the purpose of this research is to explore healthcare workers’ ethical considerations regarding euthanasia in general and euthanasia concerning adults suffering predominantly from psychiatric conditions in particular.

Theoretical research framework

Our research was guided by the framework of ‘critical social constructionism’ [ 26 ], providing a nuanced perspective that diverges from the acknowledgment of an objective reality. This approach intricately examines the interplay of personal, social, and societal dimensions within the phenomena under study. It necessitates an acknowledgment of the layered complexities influencing our understanding of phenomena such as euthanasia, a notion supported by both our prior research [ 27 ] and additional studies [ 23 , 28 ].

Our interpretation of the data was informed by social constructionism, which recognizes the role of internalized societal norms in shaping individuals’ perceptions of reality over time. Furthermore, we embraced a contextualist epistemology [ 29 ], acknowledging the contextual influence on knowledge formation among both researchers and participants. This methodological approach aimed to capture diverse lived experiences (e.g., diversity in clinical and euthanasia trajectories) and perspectives, including varied attitudes toward euthanasia based on specific relationships (e.g., professional healthcare worker or volunteer). Consequently, we maintained a reflexive stance regarding the potential impact of our individual experiences and identities on our analyses and interpretations, as elaborated in the Ethical Considerations section.

Study design

The qualitative research design consisted of semi-structured face-to-face interviews with healthcare workers in Flanders and Brussels, Belgium.

Participants

All participants were Dutch-speaking and had at least one concrete experience with euthanasia requests and procedures concerning adults with psychiatric conditions in the period 2016–2020, either as professional or volunteer healthcare workers. We adopted a broad recruitment approach, with a particular focus on all healthcare providers directly involved in medical practice rather than in managerial or policy-making roles. No further exclusion criteria were employed.

Recruitment and interview procedure

Purposive sampling was used to ensure diversity and heterogeneity in terms of: participants’ affiliation with institutions holding different stances on ‘euthanasia and psychiatry’; being to a different extent confronted with these euthanasia procedures as regards the amount of experiences (sporadically versus regularly); the nature of the experiences (e.g. confronted with or engaged in euthanasia procedures that were still under review or that had been rejected, granted, performed or withdrawn); and their specific role as professional or volunteer healthcare worker.

Participants were recruited via assistance of our contact persons at: (1) the end-of-life consultation centre Vonkel; (2) the Brothers of Charity; (3) the rehabilitation-oriented centre REAKIRO in Louvain; and (4) the Review Belgian Euthanasia Law for psychological suffering (REBEL) group, a group of Belgian physicians (e.g. psychiatrists), therapists (e.g. psychologists) as well as academics who express their concern on euthanasia in the context of psychiatry via the media. Participants were also recruited via a notice on the sites, newsflashes and/or in the online newsletters of LEIF (Life End Information Forum), Recht op Waardig Sterven (the Flemish Right to Die with Dignity Society) and Vlaamse Vereniging voor Psychiatrie (Flemish Psychiatric Association).

Potential participants contacted MV or a study assistant by phone or mail. The patients were then given an information letter and informed consent form that consisted of 2 main parts. All interviews were conducted by MV or a study assistant, who both have experience in conducting interviews on end-of-life topics. Interviews were held at the participant’s location of choice, except for five interviews which were held online via video call by Whereby 14 due to the Covid-19 crisis lockdown regulations. Interviews lasted between 55 min and 2 h, and were audio recorded (the online video interviews were recorded by Whereby’s software and immediately transferred in an mp.3 format).

Measurements

The interview guide (see OSF) contained the following consecutive questions of importance to the present report: (1) What is your personal stance regarding euthanasia as a legalised medical end-of-life option? and (2) What is your personal stance regarding euthanasia in the context of psychiatry?

Data management and analysis

We used a model of sampling-based saturation, namely inductive thematic saturation, that relates to the emergence of new themes (defined as 7 consecutive interviews without new themes) [ 30 ]. We continued to recruit and conduct interviews so that the sample would be heterogenous in terms of socio-demographics, clinical profile, and clinical setting. In particular, our focus was on recruiting individuals with the following profiles: psychologists, male psychiatric nurses and moral consultants/spiritual caregivers employed in residential psychiatric settings ( n = 5).

All interviews were then transcribed verbatim and de-identified by the interviewers.

We made use of hybrid inductive and deductive coding and theme development by means of a 2-staged process. Stage 1 consisted of an inductive data-driven thematic coding procedure.

We made use of these four phases; (1) identification and coding of all transcripts; (2) the placing of the codes in subthemes, i.e., arguments in favour versus critical concerns; (3) the placing of these subthemes in overarching main themes, i.e., different stakeholders (patient/medicine/society); (4) the comparison and discussion of the findings (with all co-authors). In addition to the inductive approach, we also used a deductive, theory-driven template approach during stage 2. We made use of these four phases; 1) the development of an ethical interpretation framework (see OSF). The framework consists of four key concepts, each involving a multitude of ethical concepts: (a) ethical theories and methodologies, (b) ethical values, (c) basic ethical virtues, and (d) dialogue/decision making ethics; 2) the identification of codes that fit the ethical framework and the theory-driven renaming of these codes; 3) the placing of some of the subthemes in an additional main theme; and 4) the comparison and discussion of the findings (with all co-authors).

Ethical considerations

The research team comprised two experienced clinical psychologists, one specializing in euthanasia within the cancer patient population and the other skilled in conducting interviews on this sensitive topic within the adult psychiatric context. Additionally, two ethicists with expertise in assisted dying, including euthanasia, were part of the team. Some authors also have backgrounds in psychiatric practice, including outpatient and residential settings, while others bring expertise through personal experiences. Furthermore, all contributing authors have personal and/or professional connections with individuals navigating death ideation, offering diverse perspectives on euthanasia. Additionally, some authors hold religious beliefs, while others maintain a more agnostic stance. These perspectives vary depending on the predominant viewpoints adopted—whether that of the patient, a close relation, a clinician, an ethicist, or policy stances. To mitigate potential undue influence on data interpretation, three team assemblies were convened. These sessions served to share firsthand encounters from interviews and their outcomes, fostering reflection and deliberation among team members. This proactive measure was implemented to prevent both personal and professional biases from affecting the interpretation of the data.

The main characteristics of the 30 participants are listed in Table 1 . The sample consisted of 16 physicians, 7 other care professionals (ranging from psychiatric nurses to mobile support teams), and 7 volunteers, all of whom were engaged in one or more euthanasia procedures predominantly based on psychiatric conditions.

The participating physicians held various roles regarding the handling of euthanasia requests:

1 physician refused to discuss the request with the patient on principle grounds.

7 physicians managed the clarification of euthanasia requests from their own patients or referred them to colleagues for further clarification.

10 physicians provided one of the two legally required formal advices or an additional advice on the euthanasia request.

5 physicians performed the act of euthanasia.

3 physicians held a more normative, dissuasive stance against euthanasia in the context of psychiatry but were willing to explore and discuss the euthanasia request with the patient.

The sample further included 14 non-physicians, among them members holding one or more roles:

2 members were part of mobile teams providing psychiatric care and support in the patient’s home setting.

3 were psychiatric nurses working either in a general hospital or in a psychiatric residential setting.

2 were Experts by Experience, individuals with a history of mental distress trained to provide support for individuals new to the euthanasia procedure and/or rehabilitation approaches.

3 were buddies, individuals entrusted with assisting and supporting the patient throughout the euthanasia procedure.

3 were moral consultants/spiritual caregiver, tasked with offering various forms of existential guidance and support to patients considering euthanasia, including religious, moral, and/or other perspectives.

5 were consultants at end-of-life information and/or consultation centers responsible for patient intake.

Participants’ ethical considerations regarding euthanasia, in the broadest context of medicine

As can be seen from the coding structure in Table 2 , we ordered coding categories on the level of 1) the individual patient, 2) the patient’s social inner circle, 3) the (para)medical field, and 4) the society. Note that words used verbatim by the interviewees (often interview fragments instead of quotes, as to better illuminate the complexities and nuances of interviewees’ first-hand lived experiences) from the transcribed interviews are incorporated that provide both additional insightful details and reveal the at times interwoven nature of the analysed codes.”

The level of the individual patient

On the level of the individual patient, the following five ethical considerations were distinguished: (1) autonomy, (2) dignity, (3) quality of life, (4) compassion, and (5) the meaning and transformative value of suffering.

First, Autonomy was a recurrent theme in all the interviews. Some participants expressly valued individual autonomy , and more specifically its following two underpinning characteristics: (1) self-determination in terms of the fundamental right for each individual to direct the course of one’s own life, which also includes ‘taking control over the timing and circumstances of one’s end-of-life’, and (2) freedom of choice , as they strongly believed that individuals are free to choose what meaning and purpose they assign to their lives. According to them, as each individual should be enabled ‘to live according to one’s own value system’, so should the ending of one’s life also be congruent with one’s own value system. Hence, in their opinion, euthanasia should remain ‘one of the many options to die’.

Other participants called this individualistic approach of autonomy ‘unrealistic’ or even ‘delusional’, as it shies away from: (1) the relational account of autonomy, in which a true autonomous decision was seen as the outcome of a decision-making process which is shaped by individual, social and contextual components, and (2) the internalised downside of autonomy, as the feeling underpinning many euthanasia requests, namely ‘not wanting to be a burden to others’ may lead to ‘self-sacrifice’ and ‘the duty to die’ under the false pretence of autonomy. In addition, some pointed to the power of susceptibility and subliminality, as human beings are subliminal creatures whose behaviour is continuously influenced on both a subconscious and even conscious level. Consequently, internalised pressure cannot be excluded when a patient requests euthanasia. One psychiatrist even stated that ‘ there exists no such thing as a free will, as human beings are always manipulated in many areas of human life and functioning’ .

“I believe that that there should still be places in society where you could die without considering euthanasia. While many people today are facing dementia, and you almost must…. Interviewer: Yes. “Yes, like how should I deal with it? Should I exit life before it becomes inevitable dementia or something similar? Because I think that in a neo-liberal society, many people internalize the idea that at some point, it becomes a moral duty to step aside. They feel obliged to eliminate themselves. Self-elimination. In a neo-liberal model, as long as you can keep up and contribute, everything is fine. But if you can’t keep up, well, if you cannot fully exercise autonomy, then… Essentially, you should hold your honour and step aside.” (spiritual caregiver)

Second, participants mentioned euthanasia as an option to die with dignity . For those in favour of the Law, euthanasia is considered (1) a ‘dignified way of dying’ when everything that leads up to death, including individual, medical, and social needs and expectations, is consistent with one’s own sense of integrity, belief-system and lifestyle, and (2) a ‘good death’, when referring to the literal meaning of the concept ‘euthanasia’, namely ‘a soft and gentle passing’. Other participants raised concerns on the reference to euthanasia and dignified dying in the same breath, as if “ other ways of dying are not or less dignified ”.

Third, the value of quality of life underpinned the arguments made in favour of the Law on Euthanasia, as (1) life itself should not be prolonged unnecessarily, (2) meaningless suffering should be prevented, and (3) a good life should pertain to all stages in life, from the very beginning until the very end, which is feasible if quality of dying circumstances can be guaranteed. As one buddy stated: “ Living a full and good life implies dying a good death ”. Other participants made use of this value underpinning their argument against euthanasia, based on (1) the “protect-worthiness” of life itself and (2) the suffering that must be considered an inherent feature of the human condition.

Fourth, and seamlessly fitting with the former value, divergent courses also emerged regarding the aspect of how to deal with suffering . Some participants were in favour of euthanasia out of compassion in terms of (1) bringing a kind of relief to the patient when providing her the prospect of an end to the suffering and (2) ending the suffering once it has become ‘useless and meaningless’ and ‘disclosing the limits of the carrying capacity of the self’. Some participants referred to the insufficient degree of quality of life in some patients and valued euthanasia as sort of ‘ compensation for a life gone wrong’.

Others considered the option of euthanasia as compromising patients’ ability to accept, bear and cope with suffering experiences by offering the opportunity ‘to quickly resign from it’.

Some participants referred to the dynamic features and hence, the potential enriching value of suffering. They believed that one can and must revolt against the perception of pointless suffering, as suffering may offer unique opportunities to achieve personal growth through the realisation of self-actualising tendencies amidst the suffering and though all kinds of hardship and adversity in life. Therefore, the real challenge is to support the sufferer to (re)gain the ability to transform the suffering by means of redefining, accepting, and making sense of it. One psychiatrist referred to the Myth of Sisyphus and stated:

A rock that must be pushed up the mountain, which is terrible, and then Sisyphus lets the rock fall back down, and he must start all over again. And what is the purpose of that suffering? Pushing the rock up? It’s absurd, really, but still. I find it so vital, human, uh, yes. That is something that inspires me enormously and often makes me, well, yes, vitality and suffering, suffering is inherent to being, of course, and one can suffer, of course, that is very serious suffering, terrible suffering. I know that. But well, accept suffering, right? I’m not glorifying suffering, no, I don’t belong to that category. Some Catholics do that; the suffering of Christ, we must… No, not at all. Suffering is inherent to life. Interviewer: It’s just more bearable for some than for others. Interviewee: Then it’s our task to make it more bearable. Yes. (…) Look, that sets a dynamic in motion. By dynamic, I also mean movement. A euthanasia request is often rigid. I am for movement. That’s what Eastern philosophy teaches us too, that everything moves, and we must keep that movement and that the question may change or that people may also discover things. Or indeed, a suffering that is even more exposed, but on which one can then work. There is still much to do, yes, before the ultimate and final act of euthanasia, by a doctor for all sakes, should be considered. (psychiatrist)

The level of the patient’s inner circle

On the level of the social inner circle, the following three ethical considerations were distinguished: (1) involvement, (2) connectedness, and (3) attentiveness.

Some participants stressed that euthanasia can only be a soft and thus ‘good’ way of dying, if the patient’s social inner circle can be involved in the euthanasia procedure and if sufficient support to them can be provided. All participants in favour of the legal framework on euthanasia echoed the importance of the social circle being involved in an early stage of the euthanasia procedure, as the prospect of the end of life may challenge a patient’s ability of staying and feeling connected . If the euthanasia request is to be carried out, it offers a unique opportunity for both the patient and her social inner circle of consciously being present and sharing goodbyes. Other participants considered this reasoning as potentially deceiving, as concern was raised regarding the trap of false assumptions, in terms of words being left unspoken and the bottling up of one’s own needs for the sake of the other.

As the third doctor, I was asked to provide advice about someone, and the [adult child] was present, a charming [adult child]. The [adult child] was also very friendly but didn’t say much. The man explained why he himself wanted euthanasia and so on. To be honest, at first, I thought, “Well, this won’t take long,” because there were many arguments and reports I had received, but as the conversation went on, I started to feel something different. It turned into a very long conversation, during which the [adult child] also had their say. In short, the father believed that he couldn’t burden his children. He was a kind man who knew what he wanted, and his children were inclined to follow his idea, to follow his vision. However, the children thought, “Yes, we are actually going to agree with our father, and we’ll allow it,” but deep down, they still wanted to take good care of him. The father didn’t want them to take care of him, and there were many other things, but after that long conversation with the [adult child] and the father, and everything else, like, “We’ll still celebrate Christmas together,” there was a complete turnaround. The other physicians involved accepted this very well, and they said, “Okay, for us, it wasn’t clear. (physician)

In addition, concern was raised regarding the inner circle’s respect of individual patient autonomy and freedom of choice outweighing their r esponsibility and accountabilit y to take care for one another and to act according to all these subjects’ best interest.

Consequently, divergent discourses on the virtue of attentiveness emerged. Whereas for some, the euthanasia procedure may offer a unique opportunity for both the patient and her relatives to be better prepared for death and for the bereaved to better cope with grief, others pointed to the inner circle’s continued grappling with unresolved feelings and perceived helplessness after such a fast-track to death.

Yes, and sometimes I also see people, family members after such euthanasia, yeah, I’ve experienced it several times. They say things like, “Yes, I supported it, but I didn’t know it would affect me like this,” you know? They try to convince themselves, saying, “It was good, it was good, and I stand behind it.” Yeah, you are hardly allowed to do otherwise, but you feel that inner struggle in them, you know? Like, “Was it really okay?” But you can’t question it because you think, “Poor them,” but you still feel it, like, “How sad, how sad. (psychiatrist)

The level of medicine

The following five ethical considerations were distinguished: (1) professional duties, (2) responsibility to alleviate suffering, (3) subsidiarity, (4) professional integrity, and (5) monologic versus dialogic approaches.

First and as regards professional duties, it was (only) reported by some physicians that the physician’s duty is “ to provide good care, which includes good end-of-life care ”. Hence, physicians are the ones who should have euthanasia “as a tool in their end-of-life toolbox”. Others held a different stance and referred to Hippocrates’ Oath when stating that the physician’s duty is to save life at all costs.

Second, all the participants agreed that clinicians have the responsibility to alleviate the patient’s suffering . Whereas some welcomed the option of euthanasia due to the experienced limits of palliative care, that in some cases is deemed an insufficient response to intractable suffering, others stated that euthanasia is not needed as physicians have proper palliative care in their toolbox to alleviate all kinds and degrees of suffering.

Third and as regards the subsidiarity principle , opinions differed on the use of a palliative filter, i.e., whether a consultation with specialist palliative care units should precede euthanasia.

Fourth and as regards professional integrity , some participants relativized the physicians’ executive autonomy. As one psychiatrist stated “because in the end, we do not decide whether someone might die or not. We only decide whether we want to be of help and assist in it.” All the ones in favour of the current legal framework echoed that as physicians are the ones that have better access to the lethal drugs and the technical expertise to end the patient’s life in more efficacious ways than non-physicians, they should remain entrusted with euthanasia assessment procedures. Others (only physicians) criticized the Belgian legislator for placing too much power in the physicians’ hands so that the latter “ can play for God instead of using their pharmacological and technical know-how to save lives ”.

Fifth, and as regards the decision-making process, most participants valued the ethical principle of shared decision-making between the patient and her physicians, and some even preferred a triadic dialogue in which the patient, her relevant health carers and her social inner circle is involved in euthanasia assessment procedures. For most of them, this type of extended or relational autonomy is considered as best clinical euthanasia practice, especially when death is not foreseeable. According to some non-physicians, a strict dyadic patient-physician approach is to be preferred when death is reasonably foreseeable in a patient with sufficient mental competence. In this event, no intermediary should be tolerated as the medical secret is considered ‘sacred’. One participant elaborated further on this strict dyadic approach and said:

“ But actually, in my opinion, the request for euthanasia is something between two people. So…. Interviewer: The singular dialogue? “So, a relationship between the patient and the doctor, yes. That’s what I think. And I do understand that the legislation exists, primarily to protect the doctor against misuse or accusations, because euthanasia used to happen before too, but in secret. But for me as a doctor, it would be enough if a patient whom I’ve known for years, followed for years, maybe 20 years, 30 years, 40 years, and who is terminally ill, asks me in private, ‘I want it.’ For me, it doesn’t need to be more than that for me to say, ‘yes.’ So, there’s no need for a whole set of legislation, except of course to protect myself, maybe from the heirs who might have a different idea about it, yes, but I find it beautiful. And they say, you know, our legislation is such that you can write your euthanasia request on the back of a beer coaster and that’s enough, you know? But how it used to be, euthanasia happened just as well, that’s what I heard from my older colleagues. But it was done in private. Actually, that is the most beautiful sign of trust between a doctor and a patient. ” (Physician and consultant)

Others, all physicians without a favourable stance on euthanasia, considered medical paternalism morally justified in the end-of-life context, as (1) physicians have more intimate knowledge of the patient and are thus best placed to act in the patient’s best interests, (2) only the independent evaluation from well-trained and experienced physicians may rule out external or internalized pressure from the patient’s social inner circle, and (3) some patients may show impaired decision-making capacity when confronted with the end of life.

The level of society

As regards the origins and impact of euthanasia legislation on the level of society, the following four ethical themes emerged: (1) protection, (2) dignified dying, (3) solidarity, and (4) distributive justice.

First and as regards protection , some participants valued the existence of a legal framework for an ‘underground’ practice before 2002. According to them, this framework was highly needed to protect the patient against malicious practices and the physician against being charged for murder when ensuring herself that all the legal requirements are met.

So, I believe that it should be well-regulated in a state. In a country, it should be well-regulated. You can either be in favour of it, have reservations, or question it, but when it happens and many people want it or think it’s okay, then it should be regulated. And those, like me, who may be against it, have doubts about it, or wonder, “Is this really necessary?” I would say, or “Does it align with our purpose?” the existential comments that you can make about it, we must accept it because it would be terrible if it, well, it would be even worse if it happened in the underground, like before those laws were established, that’s, yeah. So, I think the laws should exist. Whether I would have made those laws is a different question, or whether I would vote for the parties in parliament that, you know, that support it, that’s another question, but apparently, here in North-western Europe, the need for those practices exists, and it should be regulated properly. And yes, it shouldn’t be left to amateurs or something like that, that’s not the intention. Yes, well, it serves to protect, both in terms of health and to ensure that it doesn’t become a business, of course. I’d prefer it to be integrated into the healthcare system rather than turning it into a profit-driven and exploitative affair for some others. So, that’s…. (psychiatric nurse)

Critical concerns were raised on the lack of protection of the most vulnerable people, i.e., the mentally ill and the elderly. Some of them referred to the amended Law in 2014, that also allowed minors to die by means of euthanasia – be it under more strict circumstances, inter alia, when based on unbearable physical suffering resulting from a medically terminal condition – and feared that the Law will be amended again, so it would no longer exclude the people suffering from dementia or for groups without serious incurable illness, e.g., the elderly with a perceived ‘completed life’.

Second, a major societal shift in thoughts regarding what constitutes dignified dying was reported. For some, the Law on Euthanasia reflects a nascent movement of death revivalism, in terms of people reclaiming control over their dying process. In this respect, euthanasia is deemed a counterreaction to the former dominant paternalistic attitude in Western society to systematically marginalise conversations on death and dying, e.g., due to the mechanisms of denial, avoidance, and postponement, and with the line between life and death increasingly held in physician’s hands, which has left many people ill-equipped to deal with dying and death. The current broad public support for euthanasia is seen as the individual patient taking back the decision-making process of dying and death in her own hands. They further considered euthanasia as a logical consequence of living an artificially prolonged life due to e.g., advances in medicine, that have not necessarily enhanced the quality of life.

“ One thing I also consider is that a part of our lives is artificially prolonged, you know. We don’t live longer because we are healthier, but because we have good pills or better surgical procedures, so we can afford to buy our health. So that part of life is still valuable to me, it’s not less valuable, but it’s artificially extended. So, I think we should keep that in mind, that we can prolong something artificially and maybe even go beyond a point where it no longer works. Interviewer: Beyond the expiration date? That’s what I was looking for (laughs). So, in that sense, I believe we should keep in mind that we can artificially extend something and then maybe, even if it’s just that artificial part, stop or be allowed to stop when the person no longer wants to, I think that makes perfect sense. ” (psychiatrist)

Others provided arguments against the increased death revivalism, referring to euthanasia as a ‘fast-track to death’ resulting in ‘the trivialisation of death’ in the face of formerly known and experienced Art of Dying. For instance, the current societal tendency to avoid suffering and the fear of dying may lead to patients (too quickly) resigning from a slow track to death, in which there is time to e.g., hold a wake.

But I won’t just grab a syringe, fill it up, and administer a lethal injection, you know? I follow the symptoms. And if they become uncomfortable, then I’ll increase the dosage so they can rest peacefully and not have to suffer. That’s what I call a dignified death. And if the family can be present, sometimes it takes a while for them to arrive, and they’ll say, “Come on, even a dog is not allowed to suffer that long.” Meanwhile, the person is just lying peacefully. But that too. Everything should, even that, should progress, and there isn’t much time left for vigil and, yes, I don’t want to romanticize it, but sometimes you see so much happening between families. There’re all kinds of things happening in those rooms, with the family, reconciliations being made. Memories being shared. “Oh, I didn’t know that about our father.“, an aunt walking in and telling a story. Well, so much still happens. I don’t want to romanticize it, but to say that all that time is useless, that’s not true either. And at the farewell, there’s always, the time, you think there’s time for it, but people are still taken aback when an infusion is given, that it can happen within a minute, even if they’re behind it and have been informed beforehand. Just a minute… and it’s done. The banality of death, it’s almost like that. (psychiatrist)

These and other participants also criticised ‘the romanticised image of euthanasia’, that masks the economics of the death system, taking financial advantage of ‘patients not wanting to be a burden to society’.

Third and consequently, divergent discourses on the value of solidarity emerged. For some, decades of civic engagement pointed to the need of death revivalism and patient empowerment, that resulted in the current legal framework. Others strongly criticised the lack of solidarity underpinning the legal framework on the following three counts: 1) the emphasis on patient autonomy is deemed a ’societal negligence in disguise’, as citizens are no longer urged to take care of others, 2) equating autonomy and dignity in euthanasia debates leads to the trap of viewing the ill or the elderly as having ‘undignified’ lives, and 3) wealth over health has become the credo of the current neoliberal society, as the Law on Euthanasia discourages further investments in health care but settles on the ‘commodification’ of health care.

“ I believe that we should take care of each other and especially care for the most vulnerable in our society. We shouldn’t just leave them to fend for themselves. I don’t think the motto should be all about autonomy, autonomy, and then the flip side, saying, “figure it out on your own.” That’s not acceptable. We have a responsibility to take care of each other. We are meant to care for one another. In biblical terms, we are each other’s keeper, right? “Am I my brother’s keeper?” Yes, I am my brother’s keeper. I must take care of each other, take care of others. So, I think in the long term, speaking maybe 100 years from now, people might say, “Sorry, that was a real mistake in the way they approached things.” I don’t know, but that’s looking at it from a meta-level, as historians call it, “longue durée,” and combining it with a neoliberal model, right? Neoliberalism and euthanasia thinking, it would be interesting to do a doctoral thesis on how they fit together perfectly. How they fit together perfectly… They are no longer patients, they are no longer clients, and I also don’t like the word ‘clients.’ They have become ‘users’. Sorry, but that’s our Dutch translation of the English word ‘consumers’ right? It’s like buying Dash detergent or a car; you buy care, just like the Personal Budget for people with disabilities. You buy your care, sorry, this goes against the very essence of what care fundamentally is. Care is a relationship between people; it’s not something you buy. It’s not something you say, “It’s a contract, and I want that.” It doesn’t work like that. [raising voice] The burden is on society. [end of raising voice] And when the money runs out, you have nothing left. If you can’t buy it, then it doesn’t come. “Here’s your little package,” that’s how it’s translated, and it’s always a hidden cost-cutting operation, let’s be very honest about it, a nice story, but it’s always a hidden cost-saving measure. I see right through that story, but well, big stories are always told, and they are always about saving money. [raising voice] It doesn’t bring anything, right? [end of raising voice] People’s self-reliance, they must stay at home, etc. How many people would benefit from going to a care centre, not at the end of their lives, but just because they feel totally lonely at home, but they can’t get in because nobody wants them there, as they don’t bring any profit. ” (spiritual caregiver)

Fourth, critical concerns were expressed concerning the lack of (distributive) justice due to the many existing misperceptions and misconceptions regarding medical end-of-life options that need to be uncovered. For instance, many people would be unaware of euthanasia and palliative sedation can both be dignified ways of dying, with euthanasia functioning as a fast-track and palliative sedation functioning as slow track to death. Also, the evolution of death literacy was contested: there was a sense that patients did not become more death literate, as many of them have insufficient knowledge of the content of the many end-of-life documents in circulation.

Yeah, I mean, you see, and I hear many people saying, “My papers are in order.” I won’t say every day, but I hear it almost every day, “My papers are in order.” That’s also something. It’s an illusion of control, right? Because what papers are they talking about? “My papers are in order.” When you ask them about it, they themselves don’t really know what that means, some kind of ‘living will’, ‘an advance care plan’, but yeah, with all… A living will or advance care plan is not that simple either, and then they think, “Oh, if I get dementia and I don’t recognize anyone anymore, they will give me an injection.” Ah yes, but then we are in a different domain, and that’s a whole other… But yeah, people are not well-informed, I find. They have totally wrong ideas and sometimes fear the wrong things, don’t know what is possible and what is not, and they also let themselves believe all kinds of things. Well, there are many misconceptions out there. (psychiatrist)

Participants’ ethical considerations regarding the additional procedural criteria for people with a non-terminal illness

As can be seen from the coding structure in Table 3 , participants made use of the principle justice to motivate their stance on additional (procedural) criteria that people with a non-terminal illness must meet before euthanasia can be carried out, in comparison with people with terminal illness. Those in favour of the additional procedural criteria referred to the differences between the terminally ill and the non-terminally ill regarding the aspect of content (i.e., the difference between general life expectancy and healthy life expectancy) and the aspect of time (i.e., the probability verging on certainty concerning the terminally ill versus the rough estimation concerning the non-terminally ill). Some of them also referred to the legal proceedings and stated that the Law was meant only for people with terminal illnesses to die by means of euthanasia. Others were of the opinion that it concerns only an arbitrary difference due to 1) the vagueness of the concept ‘naturally foreseeable’, i.e., suffering from a terminal illness, and the subjectivity of the calculated course and prognosis of e.g., degenerative somatic illnesses and dementia. A few participants said that this is beside the question, as one’s individual carrying capacity trumps the course and prognosis of an illness.

Participants’ ethical considerations regarding adults with psychiatric conditions

As can be seen from the coding structure in Table 4 , when asked about participants’ stances on euthanasia in the context of psychiatry, we distinguished value-based themes at the level of (1) the patient, (2) the field of psychiatry, and (3) society in general.

The level of the patient

Justice was the main value-based principle that emerged at the level of the patient. Participants in favour of not legally amending additional procedural criteria in the context of psychiatry stated that every patient with a non-terminal illness should receive equal end-of-life care options. The main counterargument given concerned the differences in patient profile, as some questioned whether the mentally ill can meet the legal criteria or stated that extreme caution is needed and thus additional criteria are in place due to the factor of e.g., ambiguity, impulsivity, and manipulation in the mentally ill.

“I find, the way the procedure is conducted for psychiatric suffering, I find it only natural that they handle it more cautiously because it’s indeed less… It’s not so easy to determine everything, is there really no other option left? And then I understand somewhere that time must be taken to investigate all of that. Because some of these people can be very impulsive, and that impulsivity needs to be addressed somewhere, of course. You also have people who can use their setbacks in the sense of, ‘I’ve been through all that, so I deserve euthanasia.’ And those are the people you need to single out because that’s just… I think those are also people who, with the necessary guidance, can still get out of it. Do you understand? It’s a form of self-pity, in a way. I think there might be resilience there, but they haven’t tapped into it themselves yet; it’s a kind of deflection or something. People with a history of, who say ‘I’ve experienced this and that, so I don’t need it anymore, just give me euthanasia, I deserve that. I’ve been through all that.’ While maybe, if they see, that’s still worth something to me, who knows, maybe that can still happen. They’re people who give up a little too quickly.” (Moral consultant)

Regarding the field of medicine, the following four value-based considerations emerged: (1) justice, (2) responsiveness to suffering, (3) protection, and (4) proportionality.

First, and as regards the principle of justice , participants in favour of equal procedural criteria for all non-terminally ill pointed to the indissociable unity of soma and psyche. A few physicians went one step further and reported that some psychiatric conditions can be considered terminal, e.g., suicidality, or predominantly of somatic nature, e.g., anorexia. The main counterarguments in this respect were (1) the firm belief in the inexistence of irremediableness in psychiatry (only mentioned by some physicians) or (2) that more caution is needed due to the higher level of subjectivity in terms of diagnostics, prognosis, and outcome.

Second, arguments against the distinction between the somatically versus the mentally ill were based on the attitude of responsiveness to the extreme extent and duration of mental suffering that can also render the mentally ill in a medically futile situation and the field of psychiatry empty-handed.

And many of the psychiatric patients I see suffer more than the average ALS patient who has to endure it for three years. In my experience, we’re less advanced in psychiatry compared to most other medical fields. You can easily say “we don’t know” in other areas of medicine and people will understand, but when it comes to psychiatric conditions, it’s different. Doctors might admit “it’s not working” or “there’s no trust,” and they might refer patients elsewhere or even refuse further appointments. I’ve even told a judge during a forced admission, “There’s simply no treatment available.” Yes, sometimes it’s just over and society must accept that there’s no solution. I’m not saying euthanasia is the solution for everyone, but I think it can be an option for some people. (Psychiatrist)

Other participants were not blind to the deep suffering, but strongly believed in the ground principle and core strength of psychiatry, namely the beneficial effect of hope. In addition, they pointed to the differences in the nature and course of somatic versus psychiatric illnesses when stating that considerably more time is needed in psychiatry, with inclusion of the therapeutic effect of hope to become effective.

“And I also believe that collectively, within psychiatry, we can and must provide additional support to endure profound despair. So, even in the face of seemingly endless hopelessness, we must maintain hope, look towards the future with trust, and continuously offer encouragement to those who feel hopeless. Our unwavering optimism and support convey the message that together, we can overcome. Because individuals who suffer from severe mental illness are treatable, I consider myself to be a genuinely optimistic psychiatrist. I have witnessed individuals who have harbored feelings of hopelessness and despair for extended periods, sometimes even decades, undergo profound transformations and experience significant improvement, and in some cases, complete recovery.” (Psychiatrist)

Third, participants in favour of the current legal framework reported that allowing euthanasia for the mentally ill was needed in the light of protection , as it might protect the patient against brutal suicides and also against therapeutic tenacity that more often occurs in psychiatry. Other participants in favour of, as well as participants against the current framework held a different stance on the following two counts: (1) allowing euthanasia conflicts with the aim of psychiatry to prevent suicide at all costs, and (2) the mentally ill are insufficiently protected by the Law as there are insufficient built-in safeguards against therapeutic negligence.

But usually with a psychiatric condition, death isn’t imminent. That’s the tricky part, you know? How many suicides do we have here? But anyway, I have an issue with that, using euthanasia as a kind of antidote against, well, against suicide, that’s a completely different matter. But death and psychiatry, why do we have all those government programs against suicide then? Isn’t that dying as a result of a psychiatric condition? (Psychiatrist, supportive of maintaining euthanasia option in psychiatric settings)

Fourth and as regards proportionality , a few participants with a normative stance against euthanasia in the context of psychiatry argued that psychiatric patients may not be allowed to die by means of euthanasia for as long as the field of psychiatry is under-resourced. They pointed to e.g., the lack of sufficient crisis shelters with a 24/7 availability and the lack of palliative approaches in the field of psychiatry. Instead of allowing euthanasia, they argue ‘to jolt the Belgian government’s conscience on mental health policies’. As a revolution to defeat the built-up inequalities in the field of medicine and knowing that palliative and rehabilitation initiatives in psychiatry require time.

“I oppose euthanasia in psychiatry. Compared to somatic medicine, psychiatry lags behind by 50 years. While physical pain can be managed with medication, there’s insufficient research on treatments for psychological suffering. Promising options like psilocybin and ketamine show potential in easing existential mental struggles. Magnetic stimulation can also alleviate depression, yet access remains limited. Unfortunately, these treatments are underused and under-researched. Many patients aren’t informed about these alternatives to euthanasia. It’s frustrating to see reluctance in exploring these options, especially when they offer hope to long-suffering patients. Utilizing these methods in psychiatric settings carries no risk of addiction. However, current restrictions impede access to these treatments, depriving patients of viable alternatives.” (Shortened excerpt from an interview with a psychiatrist)

When taking a societal perspective, no new arguments emerged from the respondents strongly in favour of the current euthanasia legislation, other than the main value of justice described in the subsection above. According to some, the current Law on Euthanasia busts some myths on the malleability of life and medical omnipotence, and even on psychiatric illnesses as a ‘Western phenomenon’, with e.g., depression and suicidality as a consequence of material wealth instead of a neurologic issue in the brain (only reported by some non-physicians).

There are quite a few people who consider the whole issue of the unbearable nature of psychological suffering a luxury problem, you know? They say something like, “Yeah, where are the suicide rates, to put it in equivalent terms, the lowest in the world? In Africa, because they obviously don’t have the luxury to concern themselves with that. They are already happy if they have a potato on their plate every day.” This is a viewpoint held by many, right? They call it a luxury problem, a modern, typical Western luxury problem. And perhaps there is some truth to it, right? But there are other causes of mortality there, which are much higher, such as child mortality, for example. (non-physician)

Counterarguments were also given and pointed to the value of (distributive) Justice. First, euthanasia was considered as ‘a logical but perverse consequence of systemic societal inequities’ on the one hand and the ‘further evolution towards the commodification or commercialisation of health care in individualised Western societies’ on the other. This would then lead to another vicious circle, with a rapidly growing ‘perception of vulnerable patient groups as irremediable’ and hence less likely to receive potentially beneficial treatment or other interventions. Some took a more radical stance against euthanasia in psychiatry, as they were convinced that euthanasia is nothing but ‘a perverse means to cover societal failures’. In addition, some participants with permissive stances on euthanasia in the context of psychiatry pointed to gender disparities in euthanasia requestors. This was based on the evidence that in the context of psychiatry, many more females request and die by means of euthanasia than males, and proportionally more female patient suffering from psychiatric disorders request and die by means of euthanasia compared to their fellow peers suffering from life-limiting or predominantly somatic conditions.

Finally, some respondents said that they could understand and, in some cases, even support euthanasia in some individual cases, but felt uncomfortable with its impact on the societal level. They pointed to the vicious circle of stigma and self-stigma that may impede the mentally ill to fully participate in societal encounters. In the long run, this type of societal disability may lead to vulnerable patients no longer wanting to perceive themselves a burden to society or to remain ‘socially dead’.

While considering their ethical perspectives towards euthanasia, participants weigh up various values related to and intertwining with the following levels: (1) the patient, (2) the patient’s inner circle, (3) the field of medicine, and (4) society in general. Overall, the participants shared an amalgam of ethical values on each of these four levels, regardless of their stance on euthanasia. It was mainly the interpretation of some values, the emphasis they placed on the key components underpinning each value and the importance they attach to each of the four levels, that determined their stance towards euthanasia. It was uncommon for different ethical values to be explicitly mentioned, which could distinguish distinct stances for or against euthanasia.

As regards euthanasia in the context of psychiatry, the focus has primarily been on arguments for and against euthanasia [ 23 ]. However, our study takes a more comprehensive approach, exploring the issue from a wider range of perspectives. This approach allowed us to uncover more complex insights that may have been overlooked if we had only considered it as a black-and-white issue.

Both the systematic review of Nicolini et al. [ 23 ] and our study emphasized fundamental ethical domains such as autonomy, professional duties, and the broader implications of euthanasia on mental healthcare. While our findings aligned with those of the systematic review, our inquiry delved deeper into psychiatry-specific considerations, including the influence of sudden impulses and feelings of hopelessness. This underscores the importance of healthcare professionals carefully assessing the timing and contextual aspects of such decisions within psychiatric contexts, ensuring individuals receive timely and tailored support and interventions.

Furthermore, our study extended beyond the boundaries of medical discourse, addressing broader societal ramifications. Participants engaged in discussions about ‘social death,’ a phenomenon that describes the marginalization of individuals despite their physical existence. This discussion highlighted entrenched structural inequities and societal attitudes perpetuating social alienation, particularly affecting marginalized demographics, including individuals grappling with mental health issues. Advocating for societal inclusivity and supportive measures, our study strongly emphasized the need to foster a sense of unity and respect for everyone’s worth, regardless of their circumstances.

Interpretation of the main findings

We make explicit and discuss the values corresponding to the four classical principles of biomedical ethics, in particular beneficence, non-maleficence, respect for autonomy and justice [ 31 ]. We place these values in the context of different ethical approaches, such as religious, professional, emancipatory, social, societal, and virtue-oriented approaches (see the ethical interpretation framework in OSF).

In the discussion section, therefore, the following main values and virtues are addressed: (1) the values of beneficence and non-maleficence in a religious perspective, (2) those same values in the professional context, (3) the value of autonomy in the contemporary emancipation paradigm, (4) the virtue of compassion stemming from virtue ethics theory, (5) the value of quality care in a social approach, and (6) the value of justice in societal policy contexts.

Beneficence and non-maleficence: religious perspective

In the realm of euthanasia debates, the interplay of religious beliefs and the values of ‘beneficence’ (the act of doing good) and ‘non-maleficence’ (do no harm) has emerged as a pivotal point of contention, often giving rise to divergent perspectives on this complex ethical issue [ 32 , 33 ]. Some religious traditions staunchly oppose medical end-of-life decisions, including euthanasia and abortion, viewing them as morally wrong and as disruptive to the natural order of life and death. The principle of ‘sanctity of life’ forms the bedrock of their belief system, underscoring the significance they attach to preserving life at all costs, as an embodiment of beneficence [ 34 , 35 ]. Conversely, those who argue for the ethical consideration of euthanasia emphasize the concept of beneficence in alleviating suffering and granting autonomy to individuals in their final moments. However, intriguingly, our examination of the topic has revealed a nuanced relationship between religious beliefs and attitudes toward euthanasia. While some individuals in our sample expressed strong religious convictions ( n = 5) and even considered themselves as practicing Catholics, they did not necessarily adopt a firm normative stance against euthanasia, signifying a complex balancing of beneficence and possible maleficence within their belief system. Conversely, certain participants who held steadfastly against euthanasia ( n = 3) did not identify with any religious belief system, yet their position was firmly grounded in their perception of potential maleficence associated with medical intervention in life and death decisions. This observation aligns with recent studies highlighting the intricate and multifaceted nature of religiosity, where individuals within various religious frameworks may hold diverse beliefs and values surrounding beneficence and non-maleficence [ 36 , 37 ]. Moreover, it underscores the powerful influence of societal culture on shaping personal perspectives on euthanasia, and how these views are entwined with the values of beneficence and non-maleficence [ 36 , 37 ].

Beneficence and non-maleficence: professional values

Second, a profound division arises between proponents and opponents, particularly in the field of medicine, where interpretations of the Oath of Hippocrates play a central role. At its core, the Oath emphasizes the deontological values of beneficence and non-maleficence, as physicians are bound by a prohibition against administering a deadly drug to ‘anyone,’ even at their explicit request, highlighting the reverence for the sanctity of life inherent in medical practice. This interpretation has led some to perceive active euthanasia as contrary to these sacred principles of preserving life. The notion of beneficence, understood as promoting the well-being of patients, appears to be in tension with the act of intentionally ending a life. Critics argue that euthanasia undermines the fundamental duty of physicians to protect and preserve life. Additionally, the principle of ‘non-maleficence,’ which entails not harming the patient or their life, is seen by some as being in accordance with the ‘sanctity of life’. However, the Oath also recognizes the significance of alleviating relentless suffering, opening the door to a nuanced debate on how these timeless principles align with the modern concept of euthanasia. As the discourse unfolds, perspectives emerge, with some viewing euthanasia as a compassionate form of care, that respects the autonomy and dignity of patients facing terminal illness or unbearable suffering. Advocates argue that euthanasia can be an act of beneficence, providing relief from pain and allowing individuals to die with dignity and control over their own fate. On the other hand, opponents of euthanasia steadfastly uphold the sanctity of life principle, viewing it as an ethical imperative that must not be compromised. They argue that intentionally ending a life, even in the context of relieving suffering, undermines the fundamental values of medical ethics and the intrinsic worth of every human life. For these individuals, euthanasia represents a profound ethical dilemma that conflicts with the near sanctity of medical ethics and the value of preserving life [ 38 , 39 , 40 ].

Autonomy: contemporary emancipation paradigm

The principle of autonomy emerges as one of the most prominent and contentious values in our contemporary emancipation paradigm. Autonomy, grounded in the belief in individual self-governance, is often cited as a foundational ethical principle in euthanasia legislation, emphasizing the significance of an individual’s capacity to make choices aligned with their own personal values and desires [ 31 ]. However, the discussion on autonomy extends beyond pure individualism, with considerations for relational autonomy, recognizing that individuals are not isolated entities but are shaped by their relationships, communities, and broader societal structures [ 41 ]. Within the context of euthanasia, the complexities of autonomy become evident as participants in the debate strived to find a delicate balance. On one hand, they stress the importance of respecting a patient’s individual autonomy in end-of-life decisions, ensuring that their choices are honoured and upheld. Simultaneously, they acknowledge the necessity of accounting for the patient’s social context and broader community when considering euthanasia as a compassionate option. Nevertheless, concerns are raised by some about the potential risks posed by euthanasia legislation, particularly for the most vulnerable individuals, such as the elderly and the mentally ill. These concerns centre on the negative consequences that may arise when individual autonomy is exercised without consideration for others or for societal well-being, and the concept of “social death,” which refers to the marginalization and exclusion of individuals from social relationships and networks due to illness or disability [ 42 , 43 ].

Amidst these complexities, the ethical value of autonomy stands as a paramount consideration. However, its application necessitates thoughtful consideration and balance with other values, including justice, equality, and societal responsibility. Recent reflections on “relational autonomy” have prompted critical evaluations of the idea of pure autonomy, emphasizing the need to delve deeper into the micro, meso, and macro levels that underpin autonomy and address potential conflicts between individual and relational autonomy [ 44 ]. Further, it highlights the imperative to take the broader societal context into account when grappling with the ethical challenges associated with euthanasia [ 45 ].

Compassion: virtue ethics

Our study confirms that while the value of autonomy holds importance, it is not the sole determinant in the ethical considerations surrounding euthanasia [ 46 ]. In this complex discourse, numerous other ethical values and virtues come to the fore, including the significance of compassion towards suffering individuals and the imperative of alleviating their distress. Notably, compassion is not merely a singular principle, but rather a profound ground attitude or virtue that motivates individuals to empathize with the pain of others and take actions to provide relief.

As revealed in our research, participants who opposed euthanasia did not invoke religious frameworks; instead, they explored diverse philosophical approaches to comprehend suffering and compassion. Among these, non-Western philosophies emphasized embracing suffering as an intrinsic aspect of life, acknowledging the impermanence of all things, including suffering. Additionally, the existentialist perspective of Albert Camus underscored suffering’s innate connection to human existence, leading to deeper self-understanding and comprehension of the world.

These philosophical viewpoints find relevance in the realm of ethics as well. Virtue ethics, in particular, highlights the significance of cultivating virtues such as courage and resilience, while narrative ethics emphasizes storytelling as a means to gain profound insight and reflection on experiences of suffering [ 47 , 48 ]. Such narratives foster empathy and create a shared sense of experience and community.

Our results show that, for some, suffering may hold positive value in various ways. The nature and intensity of suffering, alongside an individual’s values and virtues, beliefs, and coping capacity, significantly influence the ethics of euthanasia decision-making. An intricate approach that recognizes the multifaceted impacts of suffering becomes essential, acknowledging that various factors could potentially influence the experience of suffering as well as the interpretation of the consequences of the suffering experience. It’s possible that this approach doesn’t solely depend on the quantity of suffering or even its nature. Instead, it could be related to the delicate balance between one’s ability to endure suffering, the burden it places on them, and the (ir)remediableness of this burden, which can vary greatly among individuals as well as it might change over time. Such an approach aims to alleviate relentless suffering and, in certain cases, relieve unnecessary and enduring distress without consistently imposing interpretations upon it. Thus, acknowledging that, experiences of suffering are inherent to life and might act as drivers for personal development, fostering resilience, empathy, and a deeper apprehension of life’s essence, while it also might represent something irremediable, underscores the significance of a broader meaning of the concept of compassion as guiding principle in euthanasia discussions. These discussions further extend to the recognition of the dynamic trajectory inherent to the burden of suffering, as well as its potential for temporal evolution within the individual experiences of the afflicted. Such recognition not only fosters a more intricate understanding of the complex interplay between suffering and resilience but also highlights the acknowledgment that there may be moments when suffering becomes unendurable, surpassing the individual’s capacity to cope. This dimension introduces a layer of intricacy to the ethical considerations inherent in these discussions, thus necessitating a nuanced approach that contemplates the potentialities as well as the constraints of human endurance and the associated ethical ramifications.

Quality care: social approach

Examining euthanasia debates from a sociological perspective sheds light on the influence of societal inequalities in healthcare access and quality on the practice of euthanasia, and how it can shape personal, relational, and societal values, leading to the normalization or culturalization of euthanasia [ 49 ]. A noteworthy finding in this context is the contrasting perspectives on the evolving process of dying, transitioning from being perceived as in God’s hands to a more medical realm, where proponents of euthanasia view medicine as a catalyst for granting individuals greater control over the timing, manner, and circumstances of their own deaths. They envision the opportunity to be surrounded by loved ones and maintain consciousness while embracing the option of euthanasia, which they believe improves the quality of life at the end.

Proponents also emphasize additional benefits, such as enhanced transparency and regulation, ensuring ethical conduct through regulatory measures. They express concerns about a cultural environment where certain physicians adopt paternalistic attitudes and resist accepting death, prioritizing the extension of life as a moral imperative. In contrast, critical voices argue that death and dying have become increasingly medicalized, leading to their institutionalization. Some critics further contend that this medicalization has devalued the dying process and commodified life itself, leading patients, and families to increasingly rely on medical interventions at life’s end.

Moreover, as shared by some of the interviewees, the growing acceptance of medical assistance in dying may raise concerns. It’s conceivable that this evolving attitude could contribute to a perception of death undergoing a shift in seriousness, resulting in decisions about one’s life conclusion being made with less comprehensive thought and insufficient reflection. Consequently, this scenario could potentially lead individuals who are more susceptible to experiencing feelings of life’s insignificance, weariness, or sense of being ‘through with life’, to lean towards considering euthanasia. However, this inclination might also be driven by a lack of sufficient access to the necessary, long-term quality mental health care that would otherwise facilitate the pursuit of a life imbued with adequate significance, comfort, and dignity, achievable through appropriate (mental) healthcare.

Earlier research indicates that Belgium’s psychiatric care system has been grappling with underfunding and fragmentation, leading to individuals falling through the gaps in the mental health safety net [ 50 ]. One critical aspect is, e.g., the inadequate investment in long-term, intensive care, which is precisely the kind of support that individuals grappling with such existential questions may require.

Hence, in the context of euthanasia debates, the value of quality care emerges, encompassing the principle of beneficence, which emphasizes the obligation to provide good care and enhance the overall well-being of individuals. Ethical considerations go beyond the individual’s right to autonomy, extending to societal factors that influence healthcare practices and attitudes towards euthanasia. Addressing the impact of healthcare disparities and the medicalization of dying becomes imperative to ensure ethical and compassionate decision-making that upholds the true value of quality care and respect for human dignity.

Justice: societal policy contexts

In the context of euthanasia in somatic versus psychiatric medicine, ethical considerations regarding euthanasia often revolve around the fundamental value of justice [ 23 , 51 , 52 ]. Some respondents in our study emphasized the need for parity between somatic and psychiatric illnesses, recognizing that there should be no distinction between patients suffering from either. They argued that upholding the principle of justice demands equal treatment and recognition of the suffering experienced by individuals with psychiatric illnesses.

However, for others, achieving justice requires acknowledging and addressing the unique challenges faced by patients predominantly suffering from psychiatric illnesses. A comprehensive and integrated healthcare approach is proposed, where mental health is regarded as an integral part of overall health. This approach involves allocating the same level of attention and resources to psychiatric medicine as given to somatic illnesses, aiming to combat stigma and discrimination towards individuals with psychiatric conditions. Equitable treatment during life and at the end of life becomes the focus.

Yet, the Belgian context of psychiatry presents significant challenges. The field is characterized by underfunding and fragmented care, particularly for individuals with longstanding and complex psychiatric problems [ 53 ]. Additionally, the end-of-life care for psychiatric patients is still underdeveloped, and palliative psychiatry is in its early stages, lacking a uniformly agreed-upon definition or clear implementation guidelines [ 54 ]. In response, Belgium is exploring the “Oyster Care” model, designed to provide flexible, personalized care for individuals with severe and persistent mental illness who may be at risk of neglect or overburdened by psychiatric services [ 55 ]. This model aims to create a safe “exoskeleton” or supportive environment for patients, recognizing that recovery, reintegration, and resocialization might not be attainable for everyone with certain psychiatric conditions [ 55 ].

However, the integration of Oyster Care in today’s psychiatric practice is still limited and requires further development. Emphasizing the value of justice calls for continued efforts to enhance and refine psychiatric care, ensuring that individuals with psychiatric illnesses receive equitable treatment throughout their lives, including end-of-life care decisions [ 55 , 56 ].

Implications for future research, policy, and practice

In terms of policy and practice, our findings indicate that the discourse surrounding euthanasia extends beyond legal or medical considerations and encompasses fundamental ethical values that underpin our society. These values may not always be aligned and can create ethical dilemmas that are challenging to address. A value-centred approach to the euthanasia debate necessitates a constructive ethical dialogue among various actors involved, including patients, healthcare practitioners, and the wider community. This conversation should strive to comprehend the diverse values involved and endeavour to achieve a balance between these values. Additionally, ethical dialogue might encourage individuals to reflect on their own assumptions and beliefs, leading to more informed and thoughtful decision-making on ethical and moral issues. Ultimately, ethical dialogue can promote a more just and equitable society that prioritizes empathy, understanding, and mutual respect.

It is also crucial to acknowledge that patients with somatic illnesses and those with psychiatric illnesses may have different needs and expectations regarding the end of life. Hence, end-of life healthcare must be sensitive to the unique needs of each group. This recognition of differences does not justify unequal treatment or discrimination based on the type of illness. Instead, it involves addressing the different needs and expectations of each patient group while ensuring equitable and high-quality care for all.

As regards research, most articles on euthanasia legislation to date placed the emphasis on what other countries and states can learn from the Belgian and Dutch euthanasia practice. In addition, what can be learned is mainly restricted to the evidence and reflections on factual issues from a global practical-clinical perspective. Consequently, one of the main ethical, clinical, and societal issues remains unrequited, namely the impact of legislation and its consequences on an intrapersonal, interpersonal, medical, social, and societal level. Although cultural diversity is recently put high on the research agenda concerning general health care and mental health care, it is largely understudied in the context of end-of-life decisions and largely ignored in the context of psychiatry. Fewer articles have focused on what the latter countries may learn from those not implementing or not considering euthanasia legislation. In an increasingly diverse society, rapidly evolving in terms of fluidity and multi-ethnicity, cross-cultural research can help us learn from one another. To address the many dimensions of euthanasia, there is a need for input from a variety of academic fields, including sociology, anthropology, communication studies, and history. Further interdisciplinary research in all these areas could help inform policy and practice related to euthanasia.

Strengths and limitations

This is the first empirical in-depth interview study that uncovered the underlying ethical considerations of a variety and relatively large sample of health care professionals and volunteers in Belgium, a country with one of the most permissive legislative frameworks regarding euthanasia, as – unlike in some other countries – it does not exclude adults with psychiatric conditions per definition. Belgium is also one of the pioneering countries with such a legislative framework and can boast on two decades of euthanasia legislation and implementation.

We succeeded in providing a unique and representative sample of participants, varying in gender, work setting and expertise, and stances regarding euthanasia. Finally, and unlike former scientific studies that focused on either the somatic or psychiatric context, we now gauged for participants’ ethical perspectives on euthanasia in both fields of medicine.

There are also several limitations to our study. We may have experienced selection bias, as our sample of non-physicians had varying ages, but the sample of physicians was mostly older than 60. In addition, some interviews had to be postponed or cancelled due to COVID-19 restrictions and, potentially, due to legal and emotional concerns surrounding a high-profile euthanasia case being brought to court. Additionally, our sample exhibited heterogeneity regarding worldview (religious or non-religious), but possibly not regarding other culture-sensitive aspects, like migration background. As our qualitative research focused on exploring themes, narratives, and shared experiences rather than on ensuring high participation rates for statistical generalizability, drawing definitive conclusions regarding the prevalence of each opinion (pro/ambivalent/critical/against), the level of experience, or perspective across the entire spectrum of euthanasia practice is beyond the scope of our study.

Finally, although there is a growing number of countries and states around the globe with a legislative framework on euthanasia, all the legal frameworks differ from one another, so the results of our study cannot be generalized to the specific euthanasia context in e.g., Switzerland or Canada.

Our study illuminates the foundational values guiding perceptions of euthanasia, including autonomy, compassion, quality care, and justice, which permeate through four interconnected tiers: the patient, their inner circle, the medical community, and society at large. Despite varied stances on euthanasia, participants demonstrated a convergence of ethical principles across these tiers, shaped by nuanced interpretations and considerations. While explicit discussions of distinct ethical values were infrequent, their profound impact on euthanasia perspectives underscores the importance of ethical discourse in navigating this complex issue. By fostering inclusive dialogue and reconciling diverse values, we can promote informed decision-making, justice, and empathy in end-of-life care, particularly in psychiatric settings. Interdisciplinary research is essential for a comprehensive understanding of euthanasia’s dimensions and to inform policy development. While our study is rooted in Belgium, its implications extend to the broader euthanasia discourse, suggesting avenues for further exploration and cross-cultural understanding.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due reasons of privacy and anonymity, but are available from the corresponding author on reasonable request, following procedures from all 3 Medical Ethics Committees involved. To access the supplementary materials, see the Open Science Framework repository at https://osf.io/26gez/?view_only=af42caddb2554acfb7d1d5aabd4dec7a . Upon publication of this paper, the repository will be made public, and a shorter link will be provided.

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Acknowledgements

The authors wish to thank prof. dr. Kenneth Chambaere and prof. dr. Kurt Audenaert for their preliminary advice regarding the ethics of the research methodology, dr. Steven Vanderstichelen for his help with the interviews (i.e., conducting and transcribing) and all the participants for sharing their professional and in some cases also personal experiences during the interview. We’d also like to thank prof. dr. Kenneth Chambaere for the supervision during the conducting of the interviews and his feedback on the ‘near to final’ draft.

MV is funded by the Research Foundation Flanders via research project (G017818N) and PhD fellowship (1162618 N).

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The article has been developed with the following authors’ contributions: MV was responsible for the study methodology and managed ethical approval; MV conducted most of the interviews and wrote the main manuscript texts. AL drafted the ethical interpretation framework. MV, LM, KP and AL were responsible for the coding structure and data interpretation and performed a critical review and revision of the final manuscript.

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Correspondence to Monica Verhofstadt .

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This research project was performed in accordance with the Declaration of Helsinki and the European rules of the General Data Protection Regulation. It received ethical approval from the Medical Ethics Committee of the Brussels University Hospital with reference BUN 143201939499, from the Medical Ethics Committee of Ghent University Hospital with reference 2019/0456, and from the Medical Ethics Committee of the Brothers of Charity with reference OG054-2019-20. The interviews were held after obtaining informed consent from all the participants.

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MV has received research grants from the Research Foundation Flanders; no other relationships or activities that could appear to have influenced the submitted work were declared. All other authors declare that they do not have any competing interest.

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Verhofstadt, M., Moureau, L., Pardon, K. et al. Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium. BMC Med Ethics 25 , 60 (2024). https://doi.org/10.1186/s12910-024-01063-7

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Scarbrough H, D’Andreta D, Evans S, et al. Networked innovation in the health sector: comparative qualitative study of the role of Collaborations for Leadership in Applied Health Research and Care in translating research into practice. Southampton (UK): NIHR Journals Library; 2014 May. (Health Services and Delivery Research, No. 2.13.)

Cover of Networked innovation in the health sector: comparative qualitative study of the role of Collaborations for Leadership in Applied Health Research and Care in translating research into practice

Networked innovation in the health sector: comparative qualitative study of the role of Collaborations for Leadership in Applied Health Research and Care in translating research into practice.

Chapter 4 empirical analysis and findings: qualitative investigation.

Introduction

As noted previously, to be able to address the different dimensions of CLAHRC activity relevant to our study, we adopted a ‘multilevel’ approach in our fieldwork and analysis 97 that sought to integrate evidence from both our CLAHRC-level and our project-level data collection to provide a coherent, narratively structured account of the CLAHRCs’ development.

The overall approach that we adopted to data analysis incorporated a hybrid process combining both inductive and deductive thematic analysis of interview data. 98 At a basic level, thematic analysis of interview data is simply where coding ‘is used to break up and segment the data into simpler, general categories and expand and tease out the data in order to formulate new questions and levels of interpretation’ (p. 30). 99 It was important to recognise that, in building our study on a theoretical concern with networked innovation, 31 , 79 we had already made assumptions and developed ideas about the focus for the analysis. However, it was also important to allow our analysis to be data driven to allow new ideas to emerge during the process of coding. Therefore, we needed to develop an approach that allowed us to make use of our preconceived ideas and theoretical underpinning, while still maintaining the inductive flexibility of an approach that supports the generation and development of new ideas.

As interpretive research still needs to demonstrate credibility and trustworthiness through being founded on a systematic evidence of the research process, our data analysis was supported by a structured method that combined steps in which we were ‘data driven’ and inductively developed codes based on interesting ideas and themes that emerged from our study of transcripts, together with incorporating phases of review in which we reflected on how these ideas fitted in with the overall objectives of our study. Therefore, although our research analysis was based on a linear ‘step-by-step’ procedure, this still facilitated an iterative and reflexive process. 98 However, in following a structured approach, we were able to continually reframe our analysis both based on ideas from inductive study, and allowing our theoretical grounding to be an integral part of the generation of codes.

We used NVivo to support our data analysis. While NVivo can be used to support a more objective and logical categorisation of codes, we should recognise that this is only an aid to the organisation of the material and is not in itself an interpretive device.

To structure the individual case narratives outlined below, we have adopted three major headings which reflect our conceptual framework and support critical concerns around the development of the CLAHRCs. These headings are as follows: governance, management and organisation; collaboration and networks; and KT. To begin our account, however, we focus on the way in which the goals of the CLAHRC initiative were appropriated by individual CLAHRCs in terms of the vision which they defined for themselves.

The vision of the Collaborations for Leadership in Applied Health Research and Care

As the three case sites of translational initiatives within the UK were all created through the same UK NIHR funding programme, they were all designed to meet the same aim and generic mission. However, there was significant flexibility in the way in which this mission was interpreted by the leaders of different CLAHRCs. We term these interpretive acts of leadership as different ‘visions’ of collaborative translational research. Within our study we have explored how the vision of each CLAHRC has emerged from and interacted with the structuring of the initiative, particularly in terms of management and governance. By studying the CLAHRCs’ development over time, then, the qualitative fieldwork has been able to explore how these distinctive features of each CLAHRC influence their approach to KT.

Bluetown Collaboration for Leadership in Applied Health Research and Care

The Bluetown CLAHRC is based on a partnership with organisations from a large urban area. It is led by a university hospital with an established strong reputation in conducting research. The health-care partners are representative of a range of organisation types, including acute hospital, primary care and mental health trusts, which includes both organisations with extensive research experience and those that have been previously less involved. The CLAHRC was originally established around a simple ‘hub-and-spoke’ model of a small central management team and nine clinical project teams. The core of the CLAHRC, including its management team and several of the clinical project teams, is centred on a traditional medical school public health department with high-profile academic expertise in clinical sciences research, and historic links with the lead NHS site. Each project team is largely composed of members based in the same geographical base, with a number of teams based at the university, and other clinical project teams are located within one of the health-care partnership organisations. Specialist support services were included as a CLAHRC-wide resource, providing each clinical project team with access to people who could contribute medical sociology, health economics, methods such as systematic reviewing, and statistical expertise.

The director was integral to developing the vision for this CLAHRC and for embedding this within the different clinical projects. Throughout the development of this CLAHRC, his vision has been strongly influential on the form that the work programmes within the CLAHRC have taken as they have progressed. In particular, a clinical scientific tradition was incorporated into the design of study protocols at the start of the programme, with particular attention being placed on scientific methodological rigour, especially the production of outputs suitable for top-quality, peer-reviewed academic publication. In particular, all of the clinical projects were designed as prospective evaluation clinical-academic research studies and, therefore, constituted a set of work programmes all linked by a common scientific approach.

It’s to prospectively evaluate service delivery as it happens. And where possible to interact, you know, with managers and how the service delivery takes place. So that the product will be examples where this has happened prospectively and good examples that have been published in good places. In the process of doing that to export the idea or develop the idea in the local area. BLUETOWN001

This illustrates a cornerstone of the Bluetown CLAHRC model: the vision emphasises that the quality of the evidence being produced is crucial to its ultimate impact. As a result, the vision of this CLAHRC was founded on the view that any programme of work should first be grounded in a rigorous scientific approach, as only high-quality evidence should be taken up within health-care policy and practice.

Management, governance and organisation

The CLAHRC was originally formed around a small central leadership team, with the vision of the director strongly influencing the focus and direction of the CLAHRC model. As the director had a historically strong reputation in the local area, this helped to legitimise the CLAHRC as something that was perceived as of value by those in senior positions within the partner organisations.

The vision of the core management team has been strongly influential on the approach that each programme of work uses. Each programme of work is expected to use a rigorous scientific design and methodology in order to produce robust evidence that is suitable for publication in high-quality academic journals. Therefore, the model builds on the approach to scientific work that was historically conducted by the lead organisations, with the CLAHRC emphasising that through these work programmes the teams should foster collaborative relationships with relevant service areas. This vision is emphasised through the role of the leaders within each of the project teams, who provide scientific and methodological direction to the programme of work. However, although there is recognition of the overarching objectives expected from each team by the central management, there is no CLAHRC-wide strategy for how each team should be structured or how collaborative relationships should be formed and developed. As a result, the lead of each project team has been provided with extensive flexibility on how their individual programme is organised. As a consequence, each team tended to foster relationships with particular groups and communities as relevant to the local services on which they were gathering evaluative evidence. The influence of the CLAHRC was important here in formalising and legitimising this collaboration between clinical academics and targeted groups in the NHS.

Without CLAHRC, we would have some of those connections but I think the momentum, thrust and energy that’s going into current programme really wouldn’t be there . . . associating with individuals from other fields, groups that we wouldn’t normally be part of. This has really allowed us to reflect more objectively on work, and the direction we’re going. BLUETOWN022

Structural features of the CLAHRC were used to communicate the overarching objectives of central management to the clinical project teams. This involved regular interactions between the centre and projects, management representation at project team meetings, and programmed meetings for project leaders and project managers. The positions which project members held in other environments (i.e. outside of their own team environment) were typically construed as ‘honorary’ – that is, not part of the main role which project members perform within their clinical team or central management group ( Box 1 ).

Case example: organisational processes by which the CLAHRC vision is distributed Observation of the interactions within a project meeting illustrated how the vision of the overall initiative is emphasised through the presence of a member of the core management (more...)

Although the majority of clinical project team members share similar types of disciplinary expertise, with most having clinical–academic experience, the structural organisation of the initiative provides access to other types of expertise. The extent of the CLAHRC-wide resources means that individuals with expertise such as health economics, statistics, systematic reviewing, sociology and communication are easily available for project teams to access. With the sociology theme, for example, each project team allocated a small proportion of their own resources to support the employment of a select number of people with this type of expertise. Although these team members come from different working cultures from the majority of the CLAHRC members, it is clear to the clinical project teams that the director values and respects the expertise that these individuals can provide. This helps to legitimise their contribution within the teams, even in sociological territory, which such teams would not normally view as part of their remit. At the start of CLAHRC, the cross-cutting activity for sociology was an undefined programme of work, but this provided an opportunity for these members to liaise with the clinical project teams to identify how they could support their programme of work. As relationships were built up, they quickly identified certain project teams where they could add value to the other work that was already planned by the team lead.

We are officially termed as a cross-cutting theme but we’re also embedded in the individual research, as in our jobs are paid out of individual projects. BLUETOWN003

This cross-cutting work has become an embedded part of a proportion of the clinical project teams. Although they provide a different type of expertise to the clinical projects, the members of this cross-cutting theme enact their role in such a way as to fit in with the overall work programme. While, overall, the cross-cutting theme constitutes only a small part of the CLAHRC, resources were deliberately allocated so that the members of this group would be highly skilled and experienced, and therefore able to achieve this. They have also been able to contribute guidance to more junior members of the project teams who are involved with areas that overlap with their area of expertise, such as qualitative components. Observation from in-depth studies of the four clinical themes indicates that this approach has facilitated the ‘embedding’ of the cross-cutting theme members within the project teams.

Networks and collaboration

The qualitative interviews demonstrated that from the early stages of the CLAHRC’s development, a clear objective was understood to focus on working with stakeholder groups, such as collaborating with NHS practitioners and managers within the clinical project work. There was also acknowledgement that this required some compromise with established academic work practices, with some effort being required to produce work that is suitable for practitioners.

Getting researchers to understand practitioners is a covert aim of CLAHRC. So that you don’t go away for five years and then tell them what they should have done in the first place because practitioners don’t want to hear that. CMBLUETOWN007

The activity of each of the clinical project teams means that they create links to defined health-care organisations involved in the CLAHRC partnership. The interaction between members of the project team (e.g. the project lead) is integral to fostering the relationships among the official partner organisations of the CLAHRC. As many senior CLAHRC members had pre-existing collaborative relationships with NHS trusts, they were able to enact ‘senior’ boundary-spanning roles. Many of the theme leads were in clinical–academic dual activity roles and held honorary contract positions with NHS organisations. However, their leadership typically reflected the wider ‘epistemic’ community of a university setting, emphasising academic values rather than the practical concerns seen in the health service environment. For university-based teams, the collaborative interaction was framed by the values of the academic community, with high-level academic publication considered as important for demonstrating value to these groups. This was seen as consistent with the vision of the CLAHRC, in that the collaboration is seen as creating a culture within health-care settings which is more receptive to high-quality scientific evidence.

It’s nonsense to say . . . the PCT health, local authority or the voluntary sector don’t consider evidence. They do. They just consider evidence perhaps in a different way than you or I perhaps might consider evidence . . . The CLAHRC process is about the better, the optimal decision making that we can bring, the greater rigour, to set different parameters for making the decision. That is the value. BLUETOWN014

Thus, the CLAHRC emphasises clinical–academic evaluation of service delivery in terms of producing high-quality evidence. As a result, the CLAHRC’s applied health research is conducted on the terms set by the clinical–academic community, to which other groups must be able to fit in. At the same time, the CLAHRC’s strong scientific reputation within certain fields helps it to build links with communities that value this type of evidence, such as national policy groups and certain local clinical groups. Certain groups of health-care managers and policy makers were perceived as valuing exactly this type of evidence.

Publishing all this information in top quality journals as absolutely, absolutely key. Not just to the academic credibility of CLAHRC but to the managerial credibility of CLAHRC . . . dealing with managers, when they want to know how good somebody is the first thing they do is see whether other academics respect that person. And one method of that is you publish in the top journals. They don’t want to deal with somebody who’s not up there at the cutting edge. They want to be with the front people. BLUETOWN001

The work taking place within these themes tends to be dominated by the traditions of the theme lead and the culture where the theme is physically located. Non-health care-based teams do use ‘in-built boundary spanners’, pre-existing contacts and mechanisms such as advisory boards to draw on insights about the local health-care context ( Box 2 ). This approach enables the teams to focus on their own academic areas of expertise but perhaps supports depth rather than breadth of approach.

Case example: clinical boundary spanner within a university-based team Although this CLAHRC did not have a formalised structure within its functional design to facilitate connections between clinical project teams, the flexibility provided for each subgroup (more...)

Bluetown CLAHRC also includes a number of themes based directly in health-care organisations. As the teams working on these themes are closer to the issues of practice, their work has the potential to more easily impact on health-care practice. In ‘speaking the same language’ as the practice and community groups they intend to impact, they are in a better position to integrate the perspectives of these groups. This should facilitate the implementation of findings and local impact that these groups will have. However, as these teams are further away from the core CLAHRC, greater attention has been required to ensure that these themes feel part of the Bluetown CLAHRC community.

Knowledge translation

Bluetown CLAHRC was not built on an explicit CLAHRC-wide strategy for KT. However, as each project team was provided with extensive flexibility in how they organised their clinical study, each individual theme has developed their own strategy for dissemination of outputs, with a flexibility to interpret the aims of the CLAHRC to fit their own clinical context. As a result, the themes have developed their own tailored approaches to relating their findings to local health-care practice and policy. These are not, however, related to an overall CLAHRC plan or strategy for this approach to the work. Additionally, these approaches do not appear to be shared between the themes, and their context-specific design may potentially limit wider application.

Overall, the Bluetown CLAHRC is formed from members who represent both academic disciplines and health-care professional groups. This means that the cumulative work of Bluetown CLAHRC has the potential to innovatively incorporate many different perspectives and draw from different types of expertise. However, currently, these tend to focus on project–team connections, which limit the potential of a co-ordinated Bluetown CLAHRC effect across the region. The lack of a co-ordinated strategy to link with the different types and levels of the Bluetown partners may have limited the capacity-building of the CLAHRC as a whole, notwithstanding the benefit of the strong relationships fostered by each individual team.

As the CLAHRC developed, a new theme of knowledge management was developed by the central CLAHRC management team. This was designed as a high-level cross-cutting theme. The activity was separate from the clinical project work.

But having said all that I am very keen to in addition add a specific knowledge management function to the CLAHRC but I am very clear this is not based on discoveries made in the CLAHRC, although I would not exclude those, but it’s not based on that, it’s based on the knowledge out there in the world, what can we make of that. So knowledge exchange if you like. BLUETOWN001

However, it drew on the infrastructure that the teams had used and fostered during the early stages of the CLAHRC. In particular, it was felt that, as the clinical project teams had demonstrated activity within the NHS organisations at an early stage, NHS managers and executives valued the work of the CLAHRC, and that this facilitated buy-in for this new venture.

Due to the financial model of the CLAHRC, no specific funding was allocated to this area. However, NIHR Flexibility and Sustainability Funding money was allocated to this activity. As part of this, the core management team was expanded to include support for the clinical teams and CLAHRC as a whole with external engagement and communication and dissemination activities. In addition, a knowledge-exchange forum was developed. This was targeted at high-level managers within NHS and local authority organisations. The meetings acted as a place where NHS organisations could discuss issues that they considered important areas for further work, and the CLAHRC team developed these ideas into discrete programmes of work in which they provided the resource for tailored evidence to be produced.

In this sense, as led by the director, this CLAHRC has evolved to incorporate new objectives as it has developed over time. However, the original vision of the CLAHRC model has been central to supporting the development of these new components. In particular, the knowledge-exchange forum has drawn on the connections fostered by the clinical teams, and the reputation established within partner organisations and beyond. This has allowed them to generate a membership of executive-level personnel who are in decision-making and management positions within their own organisations. Overall, the conceptual vision of the CLAHRC has helped to expand the CLAHRC programme of work beyond the initial set of clinical projects ( Box 3 ).

Case example: evolving collaborative relationships to provide additional services Theme 1 was built on what they describe as ‘a unique opportunity offered by these changes to carry out longitudinal studies into the interaction between changing (more...)

Reflections on the Bluetown Collaboration for Leadership in Applied Health Research and Care model and its development over time

The Bluetown CLAHRC’s vision and structure enables it to collaborate readily with those communities that are more aligned with the working practices of its members. The partner organisations and the members involved in the initiative, therefore, tend to support the principle that only rigorous evidence should be used to inform service developments. However, within this constraint, the Bluetown initiative does support new operational approaches, and in particular emphasises that project teams need to develop collaborative relationships with external communities, especially management and decision-makers.

With no overarching CLAHRC-wide strategy to support KT activity, each theme has developed approaches tailored to their own local communities and clinical context to support the mobilisation of the knowledge produced through their programme of work. However, as the CLAHRC has progressed over time, central management have augmented the original structure to develop new aspects to support overall Bluetown CLAHRC work. For example, they identified that CLAHRC-wide support was required to support the dissemination activities of the individual project teams. As a result, new central support was established to facilitate engagement of the project teams with end-users of their research, and to support the translation of research findings through a CLAHRC-wide communication strategy within the region.

Greentown Collaboration for Leadership in Applied Health Research and Care

The Greentown CLAHRC is led by a mental health trust, and the core of the initiative builds on established academic-research links between this health-care trust, a university hospital acute trust, and a university institution. However, an aim of this CLAHRC is to spread beyond the organisations that have traditionally been involved with research in order to build research capacity in localities further away from this core. As such, partner organisations are spread over a large geographical area, comprising a mix of urban and rural areas. The overall aim of the CLAHRC is to use an organisational learning model to facilitate a change in how research is conducted and utilised within the region. One key component of the model of this CLAHRC is about using the research experience of members from the ‘core’ organisations as a foundation from which this expertise can be dispersed and built on in other areas that have not traditionally worked in this way.

One of the things that CLAHRC was trying to do is move outside traditional university clinical centres, that would be located in this region . . . So it was not just about getting research into practice per se but broadening research into practice . . . In [another area] it’s red neck territory . . . best practice isn’t as evident over there as it is around the university, the trusts closely located to the university. GREENTOWN001

The CLAHRC model is built on an organisational learning approach which aims to close the gap between academia and practice. Within this approach, the vision of this CLAHRC is to develop the initiative in such a way that it can bring about a ‘step-change’ in how research is delivered and services are designed by facilitating a change in how the different communities involved conceptualise and undertake these types of activities. From the outset, the Greentown CLAHRC model created a number of structural features which were intended to embed this vision into its operational organisation. Key features include the clustering of work programmes within a small number of defined clinical themes, which support the building of communities around these clinical areas. There was also resourcing of dedicated ‘knowledge broker’ roles, through which a selected group of practitioners would support KT from project teams to the wider NHS. Cross-cutting themes were formed with the aim of providing clinical project team members with specialist forms of expertise in areas such as KT, synthesis of evidence, external engagement and communication, and statistical support. A CLAHRC-wide approach guided a similar constitution for all project teams, which included explicit mechanisms to support boundary spanning between different communities, through incorporating links within the structure of the CLAHRC to support the contact academics have with practitioners and managers in health services. This illustrates a key attribute of the Greentown vision for the CLAHRC in which the model that is being developed is designed to close the gap between research and practice by changing the working culture of the various stakeholder groups involved. However, as the CLAHRC has progressed, issues with the original approach were recognised, and amendments to this vision have been undertaken.

Greentown CLAHRC has had several changes in leadership since the decision to apply for a CLAHRC was made, with each one bringing different types of professional expertise to the role, ranging from clinical–academic, through business school academic, to health-services executive management. These changes in leadership are reflected in the ways in which the vision and approach of the CLAHRC has evolved from its conception and funding application through to its latter stages. Each new director has contributed a particular characteristic to the CLAHRC through their leadership. As the first director of the CLAHRC observed, the novelty of the role itself created a need for it to be ‘interpreted’ and ‘enacted’:

Even if they’d had a visible leadership role before the structured things were set up the brokering, engagement, it can be quite intangible. These sort of things have come to the fore . . . I am doing a leadership role that’s much more strategic and autonomous and I think there will be a degree of variability and interpretation of what the role is and how it’s enacted. My first port of call was to get practice on board. Those chief execs are quite frightening people sometimes. So get practice on board. So I went round every trust board that was a partner in CLAHRC and presented the CLAHRC. GREENTOWN001

As this suggests, the agency demonstrated by the leadership of the CLAHRC has been important in shaping its approach to KT. The original head of the CLAHRC bid was a clinical academic with a strong reputation in mental health research. A change in leadership was made to a specialist in organisational studies, with the aim of emphasising that the CLAHRC model was about a different way of working compared with traditional, standalone clinical–academic projects.

Overall, however, Greentown CLAHRC is structured around a set of clinical research programmes of work designed by clinical academics (i.e. typically a professor from one of the medical school clinical subdisciplines). These focus on applied health research issues to do with the delivery of services for chronic and mental health conditions. Although the basic form of the clinical themes persisted over time, they were eventually complemented by the creation of explicit structures for cross-cutting work. A considerable proportion of the finance was reallocated away from clinical research into implementation science to emphasise the integral role of this approach to their proposal. This process of evolving the planned model for the CLAHRC has generally been viewed as a positive process that enabled the CLAHRC strategy to be well defined by the time it started, supporting earlier progress.

And I mean, that letter and the feedback, you know, it was fairly explicit and it provided a platform for the reworking in the bid. You know, along implementation lines and gave me legitimacy to lead it . . . And I think that referral process was really useful for us. I think we were able to hit the ground running to a much greater extent than the other CLAHRCs. GREENTOWN001

Initiative-wide structures connected each clinical project team to members who provided specialist academic expertise, such as KT or statistical support. These fitted in with CLAHRC-wide activities, and were incorporated into the Greentown CLAHRC organisational model as a way of facilitating the sharing of different types of expertise with members from varied disciplinary and professional backgrounds.

This incorporation of this greater emphasis on implementation work was included after the majority of the core individuals had already ‘signed up’ to be part of the bid, and at a point when much of the focus for the clinical research projects had already been decided. In effect, the new KT strategy was grafted onto a CLAHRC structure that had evolved around a more traditional clinical–academic research model. Therefore, this new emphasis on an explicit implementation strategy had to be adopted by CLAHRC members with established interpretations of their roles, and where much of the content of the CLAHRC’s work programme had already been specified.

The majority of CLAHRC members are employed by the university, and many are co-located. However, as the CLAHRC spans multiple university departments, bringing together academics from a clinical–academic background within community health sciences, and social sciences from business and sociology departments, it created significant challenges for members with different types of expertise trying to work together.

For the clinical scientists this is a completely new way for them to do any work . . . They’ve never thought about the wider implementation aspects and actually how do you physically get research into practice. GREENTOWN002

As Greentown CLAHRC is built on a cross-disciplinary academic collaboration, this CLAHRC has faced additional challenges of working across the academic norms and practices of several different academic disciplines, including clinical sciences, nursing and allied health, and management and social sciences. In practice, it has sometimes been difficult to align these different spheres, especially in relating the conceptual remit of the cross-cutting themes. A further change to the leadership was made in the middle phase of the CLAHRC’s time frame, bringing in a director with a background in NHS executive management. This move helped to bring about a shift towards greater engagement with different types and levels of NHS organisations, in order to make the CLAHRC more NHS facing. At the same time, a key part of the restructuring from the mid-term review of Greentown was designed to combat uncertainty about the role of different programme components, and particularly the cross-cutting themes. In particular, as the CLAHRC’s vision emphasised new ways of working, it had been difficult for individuals to comprehend what their role should involve, or to fit this into traditional career trajectories.

As part of this restructuring, roles were divided into academic and non-academic parts, with the aim of allowing each member to focus on their own form of expertise, and to provide clear access to other types of skills. As a result, the CLAHRC was able to become more NHS facing, with a clearly defined team to assist with the delivery of research to practitioner and policy communities.

A typical configuration for the arrangement of positions within project teams had been designed by central management and was used across the initiative. Each core team was established around the team leader, which generally involved other colleagues from within the same academic subdivisions, and the employment of other team members who had trained within similar academic areas to fill designated roles for research and management of the programme of work. Additionally, management created a team structure that aimed to create connections between the core members of each project team, and other team members who could contribute different forms of expertise. These included ‘knowledge broker’ roles aimed at facilitating externally directed ties within health-care or community organisations. These acted as an explicit mechanism to support KT between different communities. An account provided by one team member who had taken on one such externally focused ‘knowledge brokering’ position describes some of her responsibilities within the team, and highlights how working across boundaries was achieved. She describes how an important part of this aspiration is for the team members in the designated brokering positions to spend time with external groups who are relevant stakeholders for to the intervention they are studying.

I did a lot of meetings etc., doing a presentation, explaining about the project. You need to tell them what’s happening with the project and how it’s going to be implemented locally, what the practice can have on them. And they’re a key part of making it work. Whether you . . . take their ideas up or we’re bringing ideas from the [initiative] to them, I just think it works both ways. So that won’t work or this won’t work and what about these participants, how is that going to work? Is there any money for that and then have we got stuff for that. Stuff that people in the university don’t understand.

Members in defined boundary-spanning roles within academic-centred project teams describe how they use team meetings to, for example, bring in insights about public health issues to the academic core team members. We observed in one discussion how project meetings were used as a place where the implications of the information provided by external groups was incorporated into a discussion on developing a sustainable implementation of the intervention which the project team were researching. Senior academic members of the team integrated this information by aligning it with the scientific and methodological approach for the project work, such as considering how this related to the study design, and the implications changes to the protocol would have on demonstrating the academic rigour required for high-quality journal publications.

I think a CLAHRC is about doing things differently to what’s been done before. I think the only way to do that is to bring in people who have different backgrounds and different experiences, who understand the world in a different way. Because I think one of the problems that the CLAHRCs are set up to address is that academic research is done for academics and clinical research is done for clinicians and the twain don’t meet. And I think this CLAHRC has been sensible in bringing in people from different backgrounds. GREENTOWN002

The structure of Greentown is centred on themes defined by related clinical areas. This supports the achievement of collaboration between CLAHRC members and relevant stakeholders in the local area. The commonality of many activities covering mental health, and related projects within the stroke rehabilitation theme, has provided an opportunity for CLAHRC members to develop communities around these clinical areas. In building on the formal roles to link project teams with external groups, efforts were made from the project team leadership to develop relationships with communities relevant to their research topic. With the senior leaders already having a reputation within their field, this provided a platform for connecting with stakeholders from within the local region, and in presenting a body of ‘CLAHRC-type’ work to national clinical groups.

As part of the CLAHRC-wide strategy, the building of ‘communities of practice’ is actively promoted as an approach which can ultimately support the implementation of evidence into local policy and practice. Four groups are perceived as particularly important: academics, clinical practitioners, health services decision-makers (managers and commissioners) and service user representatives. In particular, creating connections and building on links of existing networks of practitioners is viewed as a strategy to support this aim. In addition, the importance of developing relationships with opinion leaders within the local area has been described as an important part of the implementation process. The CLAHRC has developed an inclusive register of associates, where anyone who is interested in the CLAHRC work can sign up to receive updates about the CLAHRC work and are invited to events. Many of the activities and events are formed around the clinical topics that are of mutual interest, which forms an emergent community for people within the local area to connect to certain groups within the CLAHRC.

Greentown adopted an explicitly translational approach for informing external communities, such as commissioners, decision-makers and clinical practitioners, about the results of the clinical teams’ programme of work. This was based on a standard template and style of writing which emphasises the implications for policy and practice. These ‘bite-sized’ outputs operate as a tool to support KT of the work of the CLAHRC to the local practitioner and commissioning community. They require the academic teams (with assistance from specialist support members of the CLAHRC, and those with insight into practice) to tailor the way in which their work is presented for different types of audiences ( Box 4 ).

Case example: using a workshop event to discuss interim findings and facilitate KT A clinical project team organised a workshop to share interim findings from their programme of work. This both acted as a strategic tool for the dissemination of the study (more...)

In addition to organisational-level mechanisms, roles performed by individuals acted as bridges to support KT between different communities. Members in defined boundary-spanning roles within academic-centred project teams describe how they use team meetings to bring insight to the academic core team members relating to issues about using the public health intervention in a community setting:

I add an ability to look at things from an outsider’s perspective and say, ‘why are you doing it that way?’ And I think there’s as much challenge to academia as there is to the NHS. I think this CLAHRC along with the others were set up with ‘we’re the academics, we’ve got the knowledge, we’re going to tell you what you need to know’. And actually one of the biggest shifts that’s happening here is that academics have to get a sort of understanding of a new process around the democratisation of research. GREENTOWN009

Ultimately, these individuals were able to work with the academic team by enacting roles, such as ‘translating’ how information should be presented for different audiences. They also acted as ‘interpreters’ when providing insights into the practical implications of particular implementations of interventions, and helped to negotiate or legitimise the CLAHRC’s work in non-academic settings:

One of the goals was to try and encourage evidence based practice, and it’s using people like [the clinical practitioner who is a team member] to try and overcome some of the barriers. He’s very useful, as being a clinician he would command quite a lot of respect. GREENTOWN018

However, this KT occurred very much at the periphery of the project team’s work, with little impact on academic work practices. The creation of explicit knowledge-broker roles provided a formalised link for the team to work with those with academic expertise, and we observed how the project team meetings were used by its members as a focused time and space in which the insight and knowledge of those from beyond the community of the core team, such as academic advisors, and those representing the vision of the central management of the initiative, could be considered.

Reflections on the Greentown Collaboration for Leadership in Applied Health Research and Care model and its development over time

As noted, this CLAHRC has explicitly aimed at developing a model in which its members work in new and different ways. However, the qualitative data suggest that, in practice, there have been issues with the effectiveness of the CLAHRC’s original model. Some members (including leads) have failed to fully engage with the work of the CLAHRC (a key objective of the CLAHRC model), as they have struggled to understand the purpose and remit of certain elements of this CLAHRC’s structure (e.g. what the purpose of the implementation theme is; what the role of knowledge brokers is), and how they can integrate the CLAHRC model into achieving clinical sciences programmes of work.

The changes that took place in the mid-term of the CLAHRC’s life cycle were designed to take these challenges into account. Overall, the vision of the CLAHRC was reaffirmed, including the organisational learning model and its structural features and roles. However, it was recognised that the original CLAHRC model had led to some confusion about the contribution of particular roles and themes. As a result, the restructuring involved redefining roles to emphasise the specialisms of particular members, while providing greater resources for individuals with the expertise to make the CLAHRC more ‘NHS facing’.

Browntown Collaboration for Leadership in Applied Health Research and Care

Browntown CLAHRC is based on a partnership between the universities and health-care organisations within a region that comprises several metropolitan boroughs. The core activity of the initiative is centred on organisations based within the same city that have historically been engaged with research activity. Many of the CLAHRC members are employed either by the universities or by the acute health-care organisation within this city, but the CLAHRC was also designed to build extensive numbers of new collaborative relationships between different communities based across these organisations. In particular, the initiative brings together academics from across different departments and universities who have not previously worked together. In addition, a range of health-care organisations are involved as partners, including acute hospital trusts, primary trusts and mental health services.

This vision of the CLAHRC is described as bringing about a step-change in the way research evidence is used, so as to influence the design of health-care services within the region and to improve their quality and effectiveness.

I initially thought the initiative would have been that the content and the research questions that were there, although soon I began to realise that although they’re important, it was about a much bigger transformation in the way that things are done. To get a paradigm shift really. BROWNTOWN014

The metropolitan area has a high level of health inequalities, and the CLAHRC programme of work is structured around groupings of clinical research projects for various long-term conditions which are undertaken using an applied health approach. In addition, there are a number of separate activities that use KT approaches to undertake later-stage implementation programmes of work designed to directly interact with and impact current health-care policy and services. There is a strong emphasis on capacity building within the various partner organisations across the region in relation to developing expertise on how evidence is handled. Overall, both the clinical research projects and the KT programmes of work are based on a model of integrating members from both research and practice by embedding a focus on practice-based issues.

It’s about addressing the second gap in translation. So it’s about getting research very close to practice or as part of practice. So it’s about undertaking applied research or making sure that research is implemented into practice . . . I don’t think it’s on practice, it’s research with practice . . . really integrating research as practice almost to improve services as you go along through reflection and action. The implementation arm is exactly the same, it’s really trying to get research so close to practice that you can’t really see a difference. So I think it’s about the full bridge really. So it’s about not saying research is one place and practice is another, it’s about trying to make things a lot more connected and integrated. BROWNTOWN021

The CLAHRC’s leadership is largely from an allied health and nursing background, with the CLAHRC membership including a high percentage of academic researchers and health-care practitioners with an allied health background. The vision of this CLAHRC is consequently informed by the practice-based approaches traditionally used within allied health professions, including an operating model centred on applied activities that aim to seamlessly integrate research and practice. However, while the approach of this CLAHRC fits well with the working practices of the allied health professions (both research and practice), it faces greater challenges to involve other groups, such as academics from other disciplines.

Browntown CLAHRC is built around a novel collaboration between the two main academic centres within the region: one which focuses on traditional forms of clinical science work, and another with expertise in allied health. This allied health ethos is reflected in the types of partnerships that are being built with the NHS, with strong links with senior and middle-level management in nursing and allied health within the partner trusts. These have been influential in informing the Browntown programmes of work.

This is not centric about the university. This is about an NHS collaboration that is distributed across a health environment, a health economy . . . It is about long-term conditions, and about knowledge mobilisation. BROWNTOWN002

In practice, this CLAHRC model faced challenges in creating a coherent overall programme of work that integrated members from a wide range of professional and disciplinary backgrounds, including different types of academics, and different groups of health-care practitioners. Nevertheless, especially at the core management level, the overall emphasis of the CLAHRC is to develop integrated work programmes involving both academic and NHS groups, and for these connections to be across different levels (i.e. to create links at high- and medium-level health-care management, and also NHS practice-level participation), and also to build the work of the CLAHRC across the whole Browntown region. In particular, the capacity-building objective of the CLAHRC is about building up the skills and expertise in all partner organisations, and ultimately bringing about an evidence-based applied health research culture across the Browntown region.

Overall, Browntown CLAHRC is formed from members of a wide mixture of academic disciplines and different groups of health-care professionals. This heterogeneous composition means that the work of Browntown CLAHRC has the potential to innovatively incorporate many different perspectives and draw from different types of expertise. This provides this CLAHRC with a strong foundation to develop a novel approach for an inclusive and collaborative model of applied research – one better able to span the boundaries between the ‘producers’ and ‘users’ and research. The clinical project work is structured into a small number of clusters which each constitute a programme of work within a common clinical topic. This deployment of members into relatively large subcommunities helps to foster collaboration between members who come from different departments and organisations. On being involved in a project that was one of a set within a larger programme of work, one respondent comments about the benefits of belonging to the translational initiative, as opposed to doing standalone project work:

It was a group of like-minded people where we could work together, because often we would all be doing independent things and not working together. So it was an opportunity for people to work together in some sort of funded activity which would have more power and influence than an individual academic working on their own. BROWNTOWN010

It was felt that having an interlinked set of projects could potentially have a greater impact. The overall programmes of work were often designed to inform different levels or aspects of health services for the same clinical areas. This more ‘holistic’ package of activity was perceived to have the potential to have a greater impact. In belonging to a larger team, there could be a co-ordinated presentation of activities to policy groups, with team members able to draw on the established connections with other groups to legitimise their own work through the high reputation of other colleagues. However, as members remain part of their ‘home’ organisation, this presents some operational challenges, as limited day-to-day interaction can mean that some members cannot easily access tacit information, or do not have a day-to-day reinforcement of the CLAHRC ‘approach’.

Many of the team members have several roles across different parts of the initiative, such as being members of clinical project teams while holding positions within the core management of the initiative. The central management team comprises a large group of CLAHRC members, meaning that internally the CLAHRC adheres to a distributed leadership style. This helps to support the diffusion of the values and aspirations of the central management team within the project work, and helps to reinforce the vision of the CLAHRC across the whole work programme. Many senior CLAHRC members, both from within the core management and the theme leads, are implicit boundary spanners – sometimes by dint of having ‘dual contracts’ with both NHS and university bodies – who contribute hybrid expertise and ‘belong’ to more than one community. They help to support the aim that the various programmes of work should incorporate different perspectives. The overlap between a large core management group and those in positions of leadership within the project teams helps to spread this vision. A smaller core group co-ordinates the overall CLAHRC-wide organisation, and presents the external-facing view of this CLAHRC model, and is influential in driving the vision throughout the CLAHRC. Overall, the onus is on project leadership to co-ordinate the different types of knowledge into one coherent programme. The leaders of the CLAHRC itself view their role as one of facilitating a new form of collaboration, rather than providing specific scientific or methodological expertise ( Box 5 ).

Case example: the role of a project team leader The role of the project leader is to co-ordinate different areas of work that are producing knowledge aligned to different disciplines, with the aim of producing one coherent programme of work. In working (more...)

The work taking place within these themes or project work is not dominated by the vision or traditions of one individual (e.g. the theme lead), but a culture has been created where individuals can contribute from their own perspective. As there is no one dominant culture influencing the approach of the work programmes, members with ‘specialist’ types of expertise are integrated members of project teams, allowing different types of knowledge to routinely inform the programme of work.

In [this translational initiative] you’re going into situations all the time where everyone in the room has got lots of different roles. That can be a bit of a challenge at times with people having to approach things from lots of different perspectives. It’s very much going in and out of roles sometimes. BROWNTOWN013

Members within the Browntown CLAHRC typically evolved more flexible and overlapping roles, reflecting the need for expertise to support different aspects of the work programme across the initiative.

Although the overall theme of each programme of work remained largely unchanged during the study period, the CLAHRC model and leadership in Browntown has allowed different groups to shape the focus and direction of the work packages. By collaboratively working with other stakeholder groups, the work packages were shaped by the values and insight of different communities, in what one respondent describes as an ‘organic process’.

It’s a tool for facilitating research, applied healthcare research. To enable patients and clinicians and commissioners to make sense of decisions about what to, about what types of treatment to provide . . . The overall structure of the research design didn’t change but it was such an organic process really, what we set out to do is what we’re doing, but their support and interest and feedback was important. CMBROWNTOWN002

In describing the work programme within the clinical theme, the participant highlights the flexibility of the plans for the project work, and how this allowed the integration of insights from different groups to inform and shape the direction of the work ( Box 6 ).

Case example: collaboration with different types of communities In this example, we observed a situation where a project team responded to external groups’ requests for outputs to inform their service development by refocusing their research from (more...)

The project teams across the CLAHRC were composed of a mix of academics from different disciplines and clinical practitioners. The senior management group actively encouraged teams to continue developing their original proposals based on discussion and dialogue with stakeholder groups. This more emergent approach was enabled by certain features of the CLAHRC model and membership. Within the project team, for example, several of the team members were what we will term ‘hybrid’ individuals, that is, they were affiliated to both academic and practitioner communities, and they helped to foster an environment where no one group dominated the direction of work programmes. Instead, all team members were encouraged to actively interact with other groups, and to be flexible in doing their project work. Thus, the vision of the CLAHRC fostered an environment where members were encouraged to develop new work practices and build relationships, rather than to conform to particular disciplinary approaches.

Across the Browntown CLAHRC, many of the members were able to act as boundary spanners precisely by virtue of their ‘hybrid’ academic and health practitioner background. This supported a more fluid integration between research and practice and the building of sustainable relationships, as the overlapping roles conferred membership of both the CLAHRC community and of external groups of managers and commissioners. At the same time, those in leadership positions helped to create an environment where knowledge from different perspectives was routinely shared across teams. Boundary-spanning mechanisms, such as project meetings, were used to support the fluid integration of different perspectives into the various components of work involved.

You see everyone has got a different perspective. Whether you’re a commissioner, you know, perhaps coming from a public health or social services background, but you’re commissioning. Or a manager in the NHS, perhaps social services seconded to NHS. Or a doctor or a nurse or a psychologist or a GP or a service user. You’ve all got a different understanding of what the care pathway is and what needs to be done to improve it. And so very much we deliberately wanted to incorporate a collaborative project between all those different groups. BROWNTOWN008

This CLAHRC’s KT approach drew from an established implementation model, the Canadian ‘knowledge into action’ cycle. In particular, many of the members of Browntown CLAHRC come from the NHS partner organisations, and many of the academics involved with this CLAHRC also hold NHS contracts and have been practically involved with roles at the local NHS organisations. In this sense, the CLAHRC organisation itself acts as a key mechanism to support the translation of knowledge between different communities.

I think CLAHRC is a boundary spanner. That’s its job, that’s what it is. Because the organisations, the NHS organisations, I mean, they do talk to each other because of, you know, Department of Health policy and stuff but they all have different ways of implementing policy. And so they don’t necessarily talk to each other but through us there’s work happening that can be, you know, translated across the different organisations. So we do act as kind of a, it’s almost like a phone exchange. BROWNTOWN017

The Browntown CLAHRC model included a number of work programmes which were designed from the outset to focus on explicit late-stage implementation activity that would produce tangible impact at an early stage in the CLAHRC time frame. These themes were not designed to produce new research evidence, but were intended to align with the NIHR aim of learning more about KT by conducting implementation activity.

We need to demonstrate progress with implementation from the start of CLAHRC. They are implementation projects using research methods, as well as making a difference to practice, and we’re very much committed to adding to the body of knowledge about knowledge translation . . . Implementation work is really a cross between action research and participatory research, and you need to shape the projects as you work with the key stakeholders. BROWNTOWN001

The implementation programmes of work were designed to produce results and impact on practice at an early stage. Thus, although they drew on established research expertise, they also emphasised collaboration with the local partners, including at all levels (executives, middle-management and ground-level staff) with whom the activities were taking place. These strands of work thus helped to reinforce and promote the expectation that all programmes of work, including the research themes, would generate outputs that could be applied to inform health-care practice.

The KT themes, in particular, focus on developing evidence that will help to make a practical difference to local health-care services. The clinical priorities for implementation are identified collaboratively, and the project work is seen as socially embedded in the organisations where change is happening. This facilitates the effective translation of knowledge into action by individuals and teams.

There’s a sense in which often researchers come to the NHS with their research ideas and then you try and get sign-up from them to take a project forward. This is turning the coin over completely and it’s saying, ‘we’re a resource; we want to work with you. What are your priorities?’ It’s been getting that ownership that I think has meant that we work in a different way, but also we get a different response back from NHS managers and clinicians. But also seeing, I guess it’s the role of brokers in all of this. BROWNTOWN001

The main focus of the work of these themes is on piloting and evaluating innovative strategies for implementation, which are then planned to be rolled out across the NIHR CLAHRC for Browntown partnership (with further evaluation of their impact). One key mechanism in this effort involves focusing resources on individuals who are employed by the health-care trusts. A role was designed for these members to act as ‘facilitators’ to build up research activity within their organisations based on the priorities and general ethos of Browntown CLAHRC-type work.

We have what are called ‘research and development facilitators’. The model which was developed was to actively engage each partner healthcare organisation by having a person working within them. So we would bring CLAHRC to these organisations. My role is to bring research evidence to my organisation, and encourage people to use the research evidence much more determining the way that work is completed. And also to help people here to articulate some of their, some of the issues which they have which could have a research solution. They could find a solution through research or at least some preliminary studies. BROWNTOWN022

It is clear from our analysis that members from throughout the CLAHRC recognise that there is an underlying strategy for this initiative to facilitate KT, and that this is conceptualised as involving an integrated, collaborative approach between academics, health-care practitioners and managers in order to facilitate implementation work. Thus, although the CLAHRC does designate certain work packages as ‘implementation’ projects, the vision enacted throughout the CLAHRC emphasises the need to bridge the second translational gap, and not limit KT activity to discrete programmes of work.

It’s not that simple as just having an implementation arm in CLAHRC . . . I think that a lot of people have been practitioners and have done research, there are very few pure academics who have never really linked in and have been in practice or not in the NHS . . . if you look at nearly every lead they’ve either been a practitioner or had a role in the NHS before as well as doing research. They’re all boundary spanners. BROWNTOWN021

However, while this priority given to KT is very apparent at the core management level of the CLAHRC, it is perhaps more difficult for this type of approach to radically influence all areas of the CLAHRC work, and in particular for innovation approaches to inform the approach of the research-focused clinical theme work. In addition, the challenges of conducting implementation research are also highlighted, as the inductive co-production approach here differs from the design of conventional academic projects. Thus, while achieving KT through the seamless integration of research and practice is an important part of the Browntown CLAHRC vision, it depends heavily on the contribution of those occupying ‘hybrid roles’. Crucially, the individuals within these roles are not deemed peripheral to the project teams, but are well positioned to incorporate insights from different community perspectives into the work of the teams.

I work between a number of different organisations, so principally the NHS and academia. It was useful that I am actually from an academic background myself. It makes it a little bit easier in terms of understanding what academic opportunities there might be which the NHS might be able to tap into . . . I work with the initiative really because I work for the NHS and ensure that the CLAHRC work is embedded within this NHS organisation. So it’s very much that boundary-spanning role, I have two identities. BROWNTOWN022

Reflections on the Browntown Collaboration for Leadership in Applied Health Research and Care model and its development over time

The vision of the Browntown CLAHRC collaboration aims to foster a change in the culture of members across the partner organisations by building the capacity of its members to engage with applied health activities. The fact that the core of the CLAHRC is not university-centric, but is instead based on the traditions of allied health academics and practitioners, has helped to privilege health services’ concerns in shaping the programme of work. Although discrete KT activities were established at its inception, the vision of the Browntown CLAHRC is for all programmes of work to engage with diverse perspectives and traditions. In this way, the CLAHRC builds capacity for innovation through a work environment where work practices are able to draw on a diverse range of perspectives.

The Browntown CLAHRC has evolved incrementally over time as new activities have been developed in response to partner need. From its inception, the CLAHRC has emphasised the scope for such incremental growth both through grafting on new programmes of work and through the expansion of the CLAHRC community to include new types of partners. Although not emphasised in the original bid, collaboration with industry has also emerged as an important strand of this evolution. One result of this approach has been the ability of the CLAHRC Browntown model to adapt to a changing policy landscape, as the ‘organisational memory’ of relationships with the primary care trusts has been used to forge relationships with new commissioning organisations.

Comparative analysis of Collaboration for Leadership in Applied Health Research and Care models and their enactments

The CLAHRCs were given extensive flexibility in interpreting the NIHR remit. They thus represent a ‘natural experiment’ in how to focus, organise and manage applied health research, which will have an impact on a local health-care environment. Our study of three CLAHRCs has highlighted how it has been necessary for each model to be tailored to their own local context.

The senior management of Bluetown CLAHRC strongly emphasises a common vision throughout its work, and contributes technical scientific support to work programmes. The ambition here is to produce high-quality scientific evidence through a rigorous methodological approach. Within this broad remit, each project team has extensive flexibility in the operational management of their work programmes. Instead of drawing on a CLAHRC-wide approach for KT, each project team here developed their own approach to translating the findings from their work programmes into practice. In this sense, the Bluetown model for KT is about supporting the operational autonomy of each project team to develop its own locally tailored approach.

Greentown CLAHRC draws on an explicit CLAHRC-wide organisational structure to facilitate KT activity. This structure emphasises a common operational management championed by the core leadership. The overall approach draws on a cross-disciplinary conceptual model which integrates different types of knowledge, including both clinical and social science academic traditions. However, each project team develops its own approach to accessing and developing requisite scientific and technical expertise, which allows team members to retain their pre-existing working practices.

The Browntown CLAHRC model was based on adapting the explicit Canadian framework for KT. Operationally, the CLAHRC work was situated within heterogeneous teams embedded within the local partner organisations. This, together with features such as overlapping community memberships and hybrid roles, helped to support the fluid, and often tacit, integration of different types of knowledge across all work programmes.

Notably, all three of the CLAHRCs we studied were able to develop and adapt their model over the 5-year funding time frame. The focus of these developments, and the extent to which modifications occurred, varied depending on each CLAHRC context. Bluetown CLAHRC started with a conventional model of the relationship between research and practice, which allowed work activity to commence straight away, and did not require radical changes to the working practices of its members. However, as the CLAHRC developed over time, new activities were introduced to support KT and knowledge management and engagement activities. Importantly, the established relationships of the early CLAHRC model are credited with helping to gain support for these new types of activities.

Greentown CLAHRC has experienced several changes in leadership since the initial formation of its model. Its development over time has particularly focused on refining the original organisational learning model in order to improve effectiveness. As such, this CLAHRC has engaged in changes to its operational management by restructuring the groups within the CLAHRC, and, in particular, making adaptations to the work of the specialist support services to support the clinical project teams more effectively.

The model of Browntown CLAHRC has evolved incrementally and has maintained consistent support for capacity building across local health-care communities. In particular, this CLAHRC has sought to develop and integrate new work programmes reflective of its overall vision into its CLAHRC community. It has continually expanded its engagement with its original health-care partners, and also new types of stakeholder groups, such as industry. In keeping with its distributed leadership style, the central management team itself grew over time, so as to assimilate representatives of different work components and incorporate their views into the organisation of the CLAHRC’s work. Our study of the three different CLAHRC helps to explain the way in which the broad CLAHRC remit has been appropriated in distinctive ways, according to the social networks and local contexts which have shaped the CLAHRCs’ development. In the process, we have observed also the generative effect of leadership and vision. These variations in the interpretation and enactment of the CLAHRC mission underlines the importance of their differing network structures and sense-making cognitions as addressed through the other research strands in our study (and succeeding sections of this report). In respect of KT, it is clear that each CLAHRC has developed its own distinctive approach, some aspects of which are managed and articulated at senior management level, while others (e.g. the implications of hybrid roles) make a more implicit contribution.

USA and Canada qualitative analysis

The next part of the report will describe, analyse and discuss the three North American cases. The first case is the Canada-Coordination, an initiative involving a number of health-care players in the Ottawa district, Ontario (Canada), and aiming to improve the co-ordination and quality of health-care delivery. The initiative is specifically addressed to a small number of children with complex care needs (these children have at least five different specialists who follow them). At the time of our fieldwork, the Canada-Coordination initiative included 23 such children. The second case is the Canada-Translation, an initiative involving a community hospital (Com-Hospital) and a large university (Uni-Canada) in the same city in Quebec, aiming to promote KT processes from academic (Uni-Canada) to practitioners (Com-Hospital) and, more generally, aiming to increase collaboration and cross-fertilisation activities between the hospital and the university. The third case is US-Health, an initiative involving a number of universities, hospitals and consultant companies specialising in health-care management and applied research and aiming to promote implementation research across the USA.

All three initiatives are different to the CLAHRCs in terms of size, being either somewhat smaller (e.g. the Canada-Translation) or larger (US-Health). In addition, their thematic focus and governance arrangements are necessarily different to the CLAHRCs’ (e.g. the Canada-Coordination is more focused on KT and collaboration across existing health-care organisations). However, these three cases were chosen because they are all organised to promote implementation research and KT processes on a networked basis, by exploiting existing networks and/or facilitating the creation of new collaborative networks.

The qualitative analysis of the North American cases, in line with the CLAHRCs analysis, is structured as follows (for each case): firstly, we introduce the case; secondly, we break down the analysis into the three main theoretical elements (or dimensions) of the framework supporting this study (governance and management aspects, networks and collaborations, and KT); and, thirdly, we discuss the implications of the case. As with the CLAHRCs qualitative analysis, each case involves three case examples, one for each dimension of the framework. We conclude this section with a discussion of the three initiatives and a comparison between these (North American) cases and the UK CLAHRCs.

Canada-Coordination pilot project

Canada-Coordination is a pilot project housed at the White Hospital, located in Ottawa, ON, Canada, and involves the hospital itself (a world-class tertiary paediatric centre), and several paediatric organisations and agencies in the Ottawa community.

The pilot project involves four main players (organisations): (1) the Regional Community Care Access Centre (RCAC), which is a community health provider that organises home, school, and hospital care, developing customised ‘care plans’ and providing support from health-care professionals, nurses, physiotherapists, social workers, registered dieticians, occupational therapists, speech therapists, and personal support workers to provide a range of care and support services; (2) the Ottawa Association to Support Children (OASC), which is another community health provider that provides specialised care for children and youth in Ontario with multiple physical, developmental, and associated behavioural needs; (3) the social services (SS), which is an agency that develops case resolution mechanisms to provide recommendations and referrals for families with children with complex care needs who are experiencing difficulties accessing support and services in the community; and (4) the White Hospital, which is the ‘hub’ of the project in that the children with complex care needs are patients of the hospital and, therefore, the main treatments are provided at the White Hospital.

The pilot project funds three key people to manage the project: (1) a project manager, (2) the most responsible physician and (3) the nurse co-ordinator. The project manager supervises the pilot project: she ensures that processes, communication pathways and flow maps have been developed; conducts staff training sessions; co-ordinates the meetings and presentations for the steering and advisory committees; and prepares reports. The most responsible physician reviews the overall complex medical needs of each child and co-ordinates communication with all the specialists at the White Hospital, other tertiary paediatric centres specialists, and the community physicians. The nurse co-ordinator works very closely with the most responsible physician, interfacing between the doctors, nurses, and managers at the White Hospital, and the other agencies; the nurse co-ordinator is the link person for all of the families of the children in the project. Interestingly, along with a solid governance structure, informal relationships played a central role in the pilot project, as is outlined in the example below ( Box 7 ).

Case example: governance structure and informal relationships The governance structure of the pilot project is relatively formal including steering and advisory committees that meet monthly in addition to an external entity – the White Hospital (more...)

From the case example in Box 7 , it is clear that informal relationships facilitated tight collaborations and promoted trust among the players involved in the pilot project. The development of trust, as we will show below, was also a relevant element in supporting the health-care network of the Ottawa community.

The pilot project exploits existing networks between the players involved including RCAC, OASC, SS, independent paediatricians, and the White Hospital personnel (doctors, nurses and staff). In fact, while the project involved hiring some key people who could facilitate collaboration among the players, many of the relationships between, for example, social services (RCAC) and the nurses and doctors in the hospital (the White Hospital) were already tight. This aspect (prior networks) has positively affected the overall project because while formal networks are relatively easy to establish, it takes time for people to begin working together productively. Interestingly, the pilot project network developed collaborations aimed at improving the quality of health-care delivery that were not limited to the players that were involved in the initial project. In fact, the managers (of the four agencies) soon realised that in order to clearly identify the needs of the children involved in the pilot project, it was important to involve the patients directly. Therefore, the project manager, in accordance with the directors of RCAC, OASC, and SS, decided to involve the parents of two children involved in the project. This involvement included having the parents sitting in the steering committee of the project that meets monthly and makes decisions regarding how the co-ordination of care at the White Hospital and across its network can be improved.

As the project manager highlighted regarding the evaluation process of the project: ‘So the two parents from family forum that also sit on our steering committee for this Pilot Project reviewed our questionnaires and helped us get to the questions we wanted so that it’s more a participatory evaluation approach’. This quote underlines a collaborative climate where actors belonging to different networks are willing to bring their contributions and are supported by a common aim: to identify ways to improve the quality of health-care delivery services for children with complex care needs. One of the most relevant issues that emerged from the feedback with the (two) families who sit in the steering committee was the difficulty of having all of the different community services up to date with the most recent changes regarding the children’s condition – this problem was made very challenging by the fact that each child is frequently seen by a number of specialists.

Knowledge translation within Canada-Coordination was focused on relations between clinicians and with family members of the children involved. It was facilitated not only by direct interactions among these groups, but also by the development of artefacts that could help span the boundaries between them. In this context, the introduction of the Single Point of Care (SPOC) document is an important example because it radically improved the relationship between the White Hospital and the health-care networks. The SPOC is a paper-based medical sheet including all basic information about a child’s health, such as current health status, current treatments (medications), and any other detail that can be helpful at school (e.g. current allergies) or in emergency situations (particular drugs that the child needs to take if his/her condition suddenly becomes severe or life-threatening). The SPOC is issued by the White Hospital and is carried by the families, who now no longer have the difficult and at times confusing task of collating themselves all the medical information related to their children produced by different specialists. The SPOC is also shared with a number of organisations in the Ottawa community, such as police and schools. In particular, it is very relevant that, for example, if the child develops a new allergy or changes one medication, the school nurse is aware of the changes. While the creation of the SPOC will be broadly discussed in the next section – the SPOC being a KT tool – the following case is meaningful in highlighting how SPOC contributed to promoting networks and collaboration across different players in the Ottawa community ( Box 8 ).

Case example: SPOC as a tool for KT The SPOC originated from discussions between the families of the children involved in the pilot project and the doctors and managers during steering committee sessions. Its value is highlighted here through the example (more...)

The SPOC also helped to reduce redundant examinations because the parents show the medical sheet to each specialist who would edit it as appropriate and gather information about forthcoming tests. In sum, the introduction of the SPOC improved efficiency (being a co-ordination mechanism for different specialists) and provided the families with more awareness about the conditions of their children. In fact, while on the one hand the SPOC is acknowledged by any doctor as an official document because it is issued by a hospital, on the other hand, the (simple) way the SPOC is structured allows the family to interpret (in general terms) the health status of their child.

In sum, according to the project founders (the leaders of RCAC, OASC and SS), the involvement of the parents had produced significant benefits. This point was also confirmed by a number of interviews that we conducted with the families of the children involved in the pilot project because a number of issues of the families in terms of co-ordination emerged that could be brought up for discussion in the project meetings (steering committee).

Reflections on the pilot project model and its development over time

The pilot project is an example of how informal networks are effective in promoting KT and collaboration across community partners, including health-care partners such as a hospital and the SS, yet also including also non-health-care partners such as the police department and the schools. The management of the project includes periodic controls undertaken by an independent entity that is the White Hospital Research Institute. The White Hospital Research Institute surveys doctors and families of the children involved in the project and makes sure that co-ordination and health-care delivery services are continuously improved. This is evidenced by feedback from both clinicians and patient families.

Canada-Translation Centre

The Canada-Translation Centre is an initiative that originates at Com-Hospital, a community and university affiliated health centre in Quebec, Canada, and that serves a multicultural population in southern Quebec.

The Canada-Translation Centre started in 2010 with the aim to promote and co-ordinate clinical research carried out by clinicians who work at Com-Hospital and are also appointed by Uni-Canada, a university in Quebec. According to the regulatory framework of the Canada-Translation Centre, it carries out clinical, epidemiological, and health services research studies, provides consultation to other researchers in the hospital, and provides educational services, including seminars and workshops, related to research.

The Canada-Translation Centre is led by Johanna, Associate Professor at Uni-Canada and the vice president (VP) of Academic Affairs at Com-Hospital. The Canada-Translation Centre organises monthly meetings (last Thursday of every month) that are held in the hospital. As at the time of our research the Canada-Translation Centre was in its initial stage of development, the main objective of the meetings that we observed involved the establishment of guidelines and systems.

From a governance perspective, the three main bodies that collaborate with the Canada-Translation Centre are (a) the REC, which is responsible for reviewing the scientific and ethical aspects of all research projects involving human subjects; (b) the research review office, which is co-ordinated by the research administrative secretary and provides administrative support to both the EC and the REC; and (c) the Quality Assessment (QA) Unit, which provides assistance to hospital staff on various aspects of QA analysis and evaluation, that is, projects that assess current performance or practice.

The governance aspects of the Canada-Translation Centre are extremely formalised, reflecting the interest of the academics at Uni-Canada to secure control of the development of the project, especially in its early stages. The board of directors supervises all research activities, while the VP of Academic Affairs (who is also the Canada-Translation Centre’s Director) supervises all main research committees. The Quality and Risk Management Committee is an independent body chaired by the VP of Professional Services. According to an interview with Johanna, the rationale of this design lies in the desire to have objective control of research activities by an independent body (the Quality Committee).

The network of the Canada-Translation Centre is formed by people who work in the hospital who also have at least a teaching appointment or, more often, a professorial appointment, at Uni-Canada. The design of the three key bodies of the centre sought to promote collaboration and cross-fertilisation between the hospital and Uni-Canada. In particular, within Family Medicine at Uni-Canada there are four departments that have been always very independent and loosely coupled; however, with the start of the Canada-Translation Centre, members of these four departments started meeting twice a month to try and pursue common research objectives. In sum, the main objectives of the Canada-Translation Centre are to (1) tighten the collaboration between Uni-Canada and Com-Hospital by promoting networks and (2) bring in expertise from external collaborations.

In terms of improving the network within the Canada-Translation Centre (Com-Hospital and Uni-Canada) one of the initial challenges was to try to build relationships between key actors who had no experience of working together. For instance, quality and risk management staff rarely interacted with academics prior to the start of the project. This group quickly became committed to collaborating with the academic groups, as highlighted by the director of the quality and risk management at Com-Hospital:

And I convinced Johanna that the uniqueness of the relationship between Quality and Research here has to live somehow and has to be formalised in whatever plan she does. And I think she saw that as an opportunity. If it were someone else here than me I don’t know if it would work the same. It’s just because I started out working in Research and I, you know, I did that for ten, twelve years and I know the language and I know their challenges and I know, you know, how they think and how they . . . operate.

While it is important that people within Com-Hospital are able to work together (e.g. the research team and the quality and risk management department, as per what was highlighted above), it is also relevant that the (more practice-oriented) researchers at Com-Hospital collaborate and develop networks with the professors at Uni-Canada. The associate dean of Inter-Hospital Affairs plays a role in doing this by trying to promote fruitful collaborations between the hospital and the university. As he highlighted to us:

It was a natural thing to develop research along these lines. Again my role has been to facilitate communication between the hospital and the university, both with the Dean of Medicine and with other research leaders within the university. I’m not a researcher myself. My role is mainly to put people together. And to use the links that we have with the Ministries to help support what the hospitals do. The other way in which I interplay with the hospital is I’m on the board of directors. So being on the board of directors of course some of these initiatives to fund this research infrastructure comes to the board and at times I speak to it in a supportive fashion in order to help promote this venture for the hospital.

Included in the Canada-Translation Centre mission for the period 2010–15 there are five main domains of research to be pursued:

to support and conduct high quality clinical and health services research relevant to the patients and services provided by Com-Hospital
to promote KT and exchange activities to support evidence-informed decision-making in practice, management and policy
to provide decision support for clinical and management leaders through high-quality rapid systematic reviews of scientific evidence
to support the application of evidence through quality improvement and other implementation initiatives
to provide a high-quality training programme and environment for students interested in research careers.

From the above it is clear that the Canada-Translation Centre has a specific focus on KT. In fact, each research member (i.e. a professor) must also be a clinician (i.e. he/she needs to spend a minimum number of hours per week in the hospital), a rule which is aimed at promoting applied research. As outlined by the case example below ( Box 9 ), one of the strategies that the Canada-Translation Centre adopts for promoting implementation research is to work on small projects whose short-term tangible results are directly testable in the hospital environment.

Case example: short-term implementation research One example of how the Canada-Translation Centre promotes implementation research is to try to develop very small projects where implementation requires months if not just weeks. Through the exploitation (more...)

Reflections on the Canada-Translation Center model and its development over time

In contrast with the pilot project in Ottawa, this initiative is much more complex and involves more than 50 people including Com-Hospital physicians, Uni-Canada’s academics, and administrative personnel. Staff involved are fully aware of the barriers between academics and practitioners and between people who work in different departments (in the case of Com-Hospital) and in different institutions (at the hospital and at Uni-Canada). Therefore, specific boundary spanners – such as the associate dean of Inter-Hospital affairs – were identified to connect people with different background, professional and personal interests.

US-Health is a model of field-based research designed to promote innovation in health-care delivery by promoting the diffusion of research into practice. The US-Health initiative promotes innovation in health-care delivery by speeding up the development, implementation, diffusion, and uptake of evidence-based tools, strategies, and findings. In particular, US-Health develops and aims to disseminate scientific evidence to improve health-care delivery systems.

The US-Health network includes a number of large partnerships (the ‘contractors’) and collaborating organisations that provide health care to more than 100 million Americans and is a 5-year implementation model of research that is field based and that fosters public–private collaboration aiming to provide concrete results in the short term. The US-Health partnerships involve most US states and provide access to large numbers of providers, major health plans, hospitals, long-term care facilities, ambulatory care settings, and other health-care structures. Each partnership includes health-care systems with large, robust databases, clinical and research expertise, and the authority to implement health-care innovations.

US-Health focuses on a wide variety of demand-driven, practical, applied topics of interest to the partnerships’ own operational leaders as well as the project funders. The programme emphasises projects that are addressed to user needs and operational interests and which, ideally, are expected to be generalisable across a number of settings.

US-Health partnerships operate under multi-year contracts. Proposals are bid on a rolling basis throughout each 5-year cycle. Projects need to be undertaken in the short term; they are awarded under separate task orders and are completed within 12–24 months. Also, the US-Health network is promoted by a national health agency called Federal-Health. Federal-Health’s mission is to improve the quality, safety, efficiency, and effectiveness of US health care. Federal-Health supports research that helps people make more informed decisions and improves the quality of health-care services.

US-Health’s research has two main characteristics: it is practice based and implementation oriented. Thus, it supports field-based research to explore practical, applied topics that are responsive to diverse user needs and operational interests. By testing innovations directly in the practical settings in which they are intended to be adopted, US-Health increases the likelihood of their eventual successful uptake. US-Health research is also designed to increase knowledge about the process of implementing innovations and the contextual factors influencing implementation. It aims to promote understanding of how and why specific strategies work or fail.

The governance structure of US-Health is relatively flat. Federal-Health is the government organisation that manages the tendering process for contracts, and US-Health (the network) is one of the recipients of these contracts. Informal relationships between Federal-Health and its collaborations over time, however, help to ensure that contracts are tailored to the strengths of members of the US-Health network. For example, Federal-Health frequently discusses potential research projects with the contractors of previous bids to elicit their interest.

Once a contract is signed, a project officer is assigned to each contractor; there are few project officers who manage multiple contracts nationwide. The main task of the project officer is to make sure that all milestones are met during the very short period of the contract. Moreover, the project officer can review ongoing documents, can come to visit a contractor to see how the research project progresses, and can provide suggestions and indications. The project officers need to write periodic reports for Federal-Health; therefore, Federal-Health can closely monitor each contractor (and each research project). The way a contractor (e.g. a member of the US-Health network) manages the research project is very subjective. While a proposal on how they will reach the objectives needs to be provided to Federal-Health, no specific guidelines on how to undertake the research are given. However, the contracts (and the research projects) are generally very specific in their objectives and concrete results. Very often, the research output is a ‘toolkit’, that is, a document with specific recommendations on how to manage a health-care problem in practice.

Many of the people whom we interviewed and who were involved in one or more US-Health research projects (i.e. contracts) highlighted that the success of the project depended to a large extent on the project officer. The effects of the project officer role can be both positive and negative, as shown by the example below ( Box 10 ).

Case example: the role of project officers in US-Health This interview was undertaken with a professor in a department of family medicine who has been involved in a Federal-Health project for several years. She describes with examples points of strength (more...)

US-Health has a very complex network including, as we previously noted, a number of large partnerships. In this section we provide some insights that focus on two main partnerships where we were able to conduct interviews: Health-partnership and Health-Consulting. We chose these two networks because they are very different (one is a partnership whose participants are academics while the other is a consultant company with expertise in health care). Although collaboration on bid writing between partners was limited by a lack of funding, some collaboration did take place across US-Health contractors.

Health-partnership (primary contractor) is a partnership led by a US university (name not disclosed) which managed some 10 contracts with Federal-Health within US-Health. The contracts of Health-partnership involve themes such as improving hepatitis C virus-screening practices and testing uptake in select primary care providers, preventing pressure ulcers in hospitals, co-ordinating care across primary care practices, using innovative communication technology to improve the health of minorities, avoiding readmissions in hospitals using technology, and reducing infections caused by particular bacteria.

Health-Consulting is a much smaller entity, being a private consultancy company with some 15 senior consultants. As a result, it is not in a position to develop clinical research involving patients. Health-Consulting’s strategy within US-Health was, therefore, to find collaborators (subcontractors) who could undertake implementation research in health-care structures. To do this, they drew on a wide network of subcontractors. The contracts managed by Health-Consulting focused on the relationship between patient information management in hospitals and risks of complications and mortality while patients are hospitalised (this contract investigates both electronic and paper-based medical records) and on the development of performance measures for injurious falls in nursing homes and rehospitalisation of patients discharged from hospitals to home care. Although collaboration on bid writing between partners was limited by a lack of funding, some collaboration did take place across US-Health contractors.

With the overall goal of translating research into practice, US-Health links many of the largest health-care systems in the USA with top health services researchers who are identified through a tendering process and are managed through short- to medium-term contracts.

It provides a network of delivery-affiliated researchers and sites with a means of testing the application and uptake of research knowledge. US-Health is the successor to another large-scale initiative which was completed in 2005. All of the large partnerships (i.e. the prime contractors who work with a specified range of other organisations) have a demonstrated capacity to turn research into practice for proven interventions, targeting those who manage, deliver or receive health-care services. As per the above, both Health-partnership and Health-Consulting develop research that is focused on a wide variety of demand-driven, practical, applied topics which are of interest to the partnerships’ own operational leaders as well as to the project funders. The overall programme (US-Health) emphasises projects that are broadly responsive to user needs and operational interests and which are expected to be generalisable across a number of settings. An example of implementation research conducted by Health-Consulting is outlined in the case example below ( Box 11 ).

Case example: implementation research at Health-Consulting Health-Consulting developed a tool to improve pharmacists’ communications with patients. This was informed by evidence that only 12% of US adults understand and use health information (more...)

Reflections on the US-Health model and its development over time

The US-Health case, if compared with the two other North American cases, involves a number of partnerships, each partnership involving a number of organisations and players. Moreover, the funding model is quite unique, depending on bids for contracts (very often agreed between parties – e.g. Federal-Health and, in our case, US-Health). Even though there was little interaction across the US-Health network as a whole, collaborations proliferated within partnerships. Moreover, most projects have been successful and some projects were adopted nationwide.

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Cite this Page Scarbrough H, D’Andreta D, Evans S, et al. Networked innovation in the health sector: comparative qualitative study of the role of Collaborations for Leadership in Applied Health Research and Care in translating research into practice. Southampton (UK): NIHR Journals Library; 2014 May. (Health Services and Delivery Research, No. 2.13.) Chapter 4, Empirical analysis and findings: qualitative investigation.
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Scarbrough H, D'Andreta D, Evans S, et al. Networked innovation in the health sector: comparative qualitative study of the role of Collaborations for Leadership in Applied Health Research and Care in translating research into practice. Southampton (UK): NIHR Journals Library; 2014 May. (Health Services and Delivery Research, No. 2.13.)

Empirical Research: Definition, Methods, Types and Examples

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Chapter 1. Introduction

Why an Open Access Textbook on Qualitative Research Methods?

What is Research?

What is Qualitative Research?

Examples of Qualitative Research

Example 1 : The End Game (ethnography + interviews)

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

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

How Is This Book Organized?

Chapter Descriptions

Recommended Reading: Other Qualitative Research Textbooks

Patton’s Ten Suggestions for Doing Qualitative Research

Empirical Research: Quantitative & Qualitative

Introduction: What is Empirical Research?

Quantitative Research

Qualitative Research

Empirical Research: Defining, Identifying, & Finding

Characteristics of Empirical Research

Characteristics of Quantitative Research

Characteristics of Qualitative Research

Qualitative and Quantitative Research

Methodical Basics of Empirical Research

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Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period

Conclusions

Sample size in qualitative research: Conceptual developments and empirical investigations

Objectives of the present study

Study design

Search strategy to identify studies

Eligibility criteria

Data extraction and analysis

Sample size justifications: Results from the quantitative and qualitative content analysis

Pragmatic considerations

Qualities of the analysis

Meet sampling requirements

Sample size guidelines

In line with existing research

Richness and volume of data

Meet research design requirements

Researchers’ previous experience

Nature of study

Further sampling to check findings consistency

Thematic analysis of passages discussing sample size

Characterisations of sample size sufficiency

‘Small’ but why and for whom?

‘Good enough’ sample sizes

‘Large’ sample sizes - Promise or peril?

Threats from sample size insufficiency

Generalizability

Strengths and limitations of the present study

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