characteristics of a qualitative research study

Qualitative Research: Characteristics, Design, Methods & Examples

Lauren McCall

MSc Health Psychology Graduate

MSc, Health Psychology, University of Nottingham

Lauren obtained an MSc in Health Psychology from The University of Nottingham with a distinction classification.

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Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Associate Editor for Simply Psychology

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“Not everything that can be counted counts, and not everything that counts can be counted“ (Albert Einstein)

Qualitative research is a process used for the systematic collection, analysis, and interpretation of non-numerical data (Punch, 2013). 

Qualitative research can be used to: (i) gain deep contextual understandings of the subjective social reality of individuals and (ii) to answer questions about experience and meaning from the participant’s perspective (Hammarberg et al., 2016).

Unlike quantitative research, which focuses on gathering and analyzing numerical data for statistical analysis, qualitative research focuses on thematic and contextual information.

Characteristics of Qualitative Research 

Reality is socially constructed.

Qualitative research aims to understand how participants make meaning of their experiences – individually or in social contexts. It assumes there is no objective reality and that the social world is interpreted (Yilmaz, 2013). 

The primacy of subject matter 

The primary aim of qualitative research is to understand the perspectives, experiences, and beliefs of individuals who have experienced the phenomenon selected for research rather than the average experiences of groups of people (Minichiello, 1990).

Variables are complex, interwoven, and difficult to measure

Factors such as experiences, behaviors, and attitudes are complex and interwoven, so they cannot be reduced to isolated variables , making them difficult to measure quantitatively.

However, a qualitative approach enables participants to describe what, why, or how they were thinking/ feeling during a phenomenon being studied (Yilmaz, 2013). 

Emic (insider’s point of view)

The phenomenon being studied is centered on the participants’ point of view (Minichiello, 1990).

Emic is used to describe how participants interact, communicate, and behave in the context of the research setting (Scarduzio, 2017).

Why Conduct Qualitative Research? 

In order to gain a deeper understanding of how people experience the world, individuals are studied in their natural setting. This enables the researcher to understand a phenomenon close to how participants experience it. 

Qualitative research allows researchers to gain an in-depth understanding, which is difficult to attain using quantitative methods. 

An in-depth understanding is attained since qualitative techniques allow participants to freely disclose their experiences, thoughts, and feelings without constraint (Tenny et al., 2022). 

This helps to further investigate and understand quantitative data by discovering reasons for the outcome of a study – answering the why question behind statistics. 

The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively (Busetto et al., 2020).

To design hypotheses, theory must be researched using qualitative methods to find out what is important in order to begin research. 

For example, by conducting interviews or focus groups with key stakeholders to discover what is important to them. 

Examples of qualitative research questions include: 

• How does stress influence young adults’ behavior?
• What factors influence students’ school attendance rates in developed countries?
• How do adults interpret binge drinking in the UK?
• What are the psychological impacts of cervical cancer screening in women?
• How can mental health lessons be integrated into the school curriculum? 

Collecting Qualitative Data

There are four main research design methods used to collect qualitative data: observations, interviews,  focus groups, and ethnography.

Observations

This method involves watching and recording phenomena as they occur in nature. Observation can be divided into two types: participant and non-participant observation.

In participant observation, the researcher actively participates in the situation/events being observed.

In non-participant observation, the researcher is not an active part of the observation and tries not to influence the behaviors they are observing (Busetto et al., 2020). 

Observations can be covert (participants are unaware that a researcher is observing them) or overt (participants are aware of the researcher’s presence and know they are being observed).

However, awareness of an observer’s presence may influence participants’ behavior. 

Interviews give researchers a window into the world of a participant by seeking their account of an event, situation, or phenomenon. They are usually conducted on a one-to-one basis and can be distinguished according to the level at which they are structured (Punch, 2013). 

Structured interviews involve predetermined questions and sequences to ensure replicability and comparability. However, they are unable to explore emerging issues.

Informal interviews consist of spontaneous, casual conversations which are closer to the truth of a phenomenon. However, information is gathered using quick notes made by the researcher and is therefore subject to recall bias. 

Semi-structured interviews have a flexible structure, phrasing, and placement so emerging issues can be explored (Denny & Weckesser, 2022).

The use of probing questions and clarification can lead to a detailed understanding, but semi-structured interviews can be time-consuming and subject to interviewer bias. 

Focus groups 

Similar to interviews, focus groups elicit a rich and detailed account of an experience. However, focus groups are more dynamic since participants with shared characteristics construct this account together (Denny & Weckesser, 2022).

A shared narrative is built between participants to capture a group experience shaped by a shared context. 

The researcher takes on the role of a moderator, who will establish ground rules and guide the discussion by following a topic guide to focus the group discussions.

Typically, focus groups have 4-10 participants as a discussion can be difficult to facilitate with more than this, and this number allows everyone the time to speak.

Ethnography

Ethnography is a methodology used to study a group of people’s behaviors and social interactions in their environment (Reeves et al., 2008).

Data are collected using methods such as observations, field notes, or structured/ unstructured interviews.

The aim of ethnography is to provide detailed, holistic insights into people’s behavior and perspectives within their natural setting. In order to achieve this, researchers immerse themselves in a community or organization. 

Due to the flexibility and real-world focus of ethnography, researchers are able to gather an in-depth, nuanced understanding of people’s experiences, knowledge and perspectives that are influenced by culture and society.

In order to develop a representative picture of a particular culture/ context, researchers must conduct extensive field work. 

This can be time-consuming as researchers may need to immerse themselves into a community/ culture for a few days, or possibly a few years.

Qualitative Data Analysis Methods

Different methods can be used for analyzing qualitative data. The researcher chooses based on the objectives of their study. 

The researcher plays a key role in the interpretation of data, making decisions about the coding, theming, decontextualizing, and recontextualizing of data (Starks & Trinidad, 2007). 

Grounded theory

Grounded theory is a qualitative method specifically designed to inductively generate theory from data. It was developed by Glaser and Strauss in 1967 (Glaser & Strauss, 2017).

 This methodology aims to develop theories (rather than test hypotheses) that explain a social process, action, or interaction (Petty et al., 2012). To inform the developing theory, data collection and analysis run simultaneously. 

There are three key types of coding used in grounded theory: initial (open), intermediate (axial), and advanced (selective) coding. 

Throughout the analysis, memos should be created to document methodological and theoretical ideas about the data. Data should be collected and analyzed until data saturation is reached and a theory is developed. 

Content analysis

Content analysis was first used in the early twentieth century to analyze textual materials such as newspapers and political speeches.

Content analysis is a research method used to identify and analyze the presence and patterns of themes, concepts, or words in data (Vaismoradi et al., 2013). 

This research method can be used to analyze data in different formats, which can be written, oral, or visual. 

The goal of content analysis is to develop themes that capture the underlying meanings of data (Schreier, 2012). 

Qualitative content analysis can be used to validate existing theories, support the development of new models and theories, and provide in-depth descriptions of particular settings or experiences.

The following six steps provide a guideline for how to conduct qualitative content analysis.

• Define a Research Question : To start content analysis, a clear research question should be developed.
• Identify and Collect Data : Establish the inclusion criteria for your data. Find the relevant sources to analyze.
• Define the Unit or Theme of Analysis : Categorize the content into themes. Themes can be a word, phrase, or sentence.
• Develop Rules for Coding your Data : Define a set of coding rules to ensure that all data are coded consistently.
• Code the Data : Follow the coding rules to categorize data into themes.
• Analyze the Results and Draw Conclusions : Examine the data to identify patterns and draw conclusions in relation to your research question.

Discourse analysis

Discourse analysis is a research method used to study written/ spoken language in relation to its social context (Wood & Kroger, 2000).

In discourse analysis, the researcher interprets details of language materials and the context in which it is situated.

Discourse analysis aims to understand the functions of language (how language is used in real life) and how meaning is conveyed by language in different contexts. Researchers use discourse analysis to investigate social groups and how language is used to achieve specific communication goals.

Different methods of discourse analysis can be used depending on the aims and objectives of a study. However, the following steps provide a guideline on how to conduct discourse analysis.

• Define the Research Question : Develop a relevant research question to frame the analysis.
• Gather Data and Establish the Context : Collect research materials (e.g., interview transcripts, documents). Gather factual details and review the literature to construct a theory about the social and historical context of your study.
• Analyze the Content : Closely examine various components of the text, such as the vocabulary, sentences, paragraphs, and structure of the text. Identify patterns relevant to the research question to create codes, then group these into themes.
• Review the Results : Reflect on the findings to examine the function of the language, and the meaning and context of the discourse. 

Thematic analysis

Thematic analysis is a method used to identify, interpret, and report patterns in data, such as commonalities or contrasts. 

Although the origin of thematic analysis can be traced back to the early twentieth century, understanding and clarity of thematic analysis is attributed to Braun and Clarke (2006).

Thematic analysis aims to develop themes (patterns of meaning) across a dataset to address a research question. 

In thematic analysis, qualitative data is gathered using techniques such as interviews, focus groups, and questionnaires. Audio recordings are transcribed. The dataset is then explored and interpreted by a researcher to identify patterns. 

This occurs through the rigorous process of data familiarisation, coding, theme development, and revision. These identified patterns provide a summary of the dataset and can be used to address a research question.

Themes are developed by exploring the implicit and explicit meanings within the data. Two different approaches are used to generate themes: inductive and deductive. 

An inductive approach allows themes to emerge from the data. In contrast, a deductive approach uses existing theories or knowledge to apply preconceived ideas to the data.

Phases of Thematic Analysis

Braun and Clarke (2006) provide a guide of the six phases of thematic analysis. These phases can be applied flexibly to fit research questions and data. 

Template analysis

Template analysis refers to a specific method of thematic analysis which uses hierarchical coding (Brooks et al., 2014).

Template analysis is used to analyze textual data, for example, interview transcripts or open-ended responses on a written questionnaire.

To conduct template analysis, a coding template must be developed (usually from a subset of the data) and subsequently revised and refined. This template represents the themes identified by researchers as important in the dataset. 

Codes are ordered hierarchically within the template, with the highest-level codes demonstrating overarching themes in the data and lower-level codes representing constituent themes with a narrower focus.

A guideline for the main procedural steps for conducting template analysis is outlined below.

• Familiarization with the Data : Read (and reread) the dataset in full. Engage, reflect, and take notes on data that may be relevant to the research question.
• Preliminary Coding : Identify initial codes using guidance from the a priori codes, identified before the analysis as likely to be beneficial and relevant to the analysis.
• Organize Themes : Organize themes into meaningful clusters. Consider the relationships between the themes both within and between clusters.
• Produce an Initial Template : Develop an initial template. This may be based on a subset of the data.
• Apply and Develop the Template : Apply the initial template to further data and make any necessary modifications. Refinements of the template may include adding themes, removing themes, or changing the scope/title of themes. 
• Finalize Template : Finalize the template, then apply it to the entire dataset. 

Frame analysis

Frame analysis is a comparative form of thematic analysis which systematically analyzes data using a matrix output.

Ritchie and Spencer (1994) developed this set of techniques to analyze qualitative data in applied policy research. Frame analysis aims to generate theory from data.

Frame analysis encourages researchers to organize and manage their data using summarization.

This results in a flexible and unique matrix output, in which individual participants (or cases) are represented by rows and themes are represented by columns. 

Each intersecting cell is used to summarize findings relating to the corresponding participant and theme.

Frame analysis has five distinct phases which are interrelated, forming a methodical and rigorous framework.

• Familiarization with the Data : Familiarize yourself with all the transcripts. Immerse yourself in the details of each transcript and start to note recurring themes.
• Develop a Theoretical Framework : Identify recurrent/ important themes and add them to a chart. Provide a framework/ structure for the analysis.
• Indexing : Apply the framework systematically to the entire study data.
• Summarize Data in Analytical Framework : Reduce the data into brief summaries of participants’ accounts.
• Mapping and Interpretation : Compare themes and subthemes and check against the original transcripts. Group the data into categories and provide an explanation for them.

Preventing Bias in Qualitative Research

To evaluate qualitative studies, the CASP (Critical Appraisal Skills Programme) checklist for qualitative studies can be used to ensure all aspects of a study have been considered (CASP, 2018).

The quality of research can be enhanced and assessed using criteria such as checklists, reflexivity, co-coding, and member-checking. 

Co-coding 

Relying on only one researcher to interpret rich and complex data may risk key insights and alternative viewpoints being missed. Therefore, coding is often performed by multiple researchers.

A common strategy must be defined at the beginning of the coding process  (Busetto et al., 2020). This includes establishing a useful coding list and finding a common definition of individual codes.

Transcripts are initially coded independently by researchers and then compared and consolidated to minimize error or bias and to bring confirmation of findings. 

Member checking

Member checking (or respondent validation) involves checking back with participants to see if the research resonates with their experiences (Russell & Gregory, 2003).

Data can be returned to participants after data collection or when results are first available. For example, participants may be provided with their interview transcript and asked to verify whether this is a complete and accurate representation of their views.

Participants may then clarify or elaborate on their responses to ensure they align with their views (Shenton, 2004).

This feedback becomes part of data collection and ensures accurate descriptions/ interpretations of phenomena (Mays & Pope, 2000). 

Reflexivity in qualitative research

Reflexivity typically involves examining your own judgments, practices, and belief systems during data collection and analysis. It aims to identify any personal beliefs which may affect the research. 

Reflexivity is essential in qualitative research to ensure methodological transparency and complete reporting. This enables readers to understand how the interaction between the researcher and participant shapes the data.

Depending on the research question and population being researched, factors that need to be considered include the experience of the researcher, how the contact was established and maintained, age, gender, and ethnicity.

These details are important because, in qualitative research, the researcher is a dynamic part of the research process and actively influences the outcome of the research (Boeije, 2014). 

Reflexivity Example

Who you are and your characteristics influence how you collect and analyze data. Here is an example of a reflexivity statement for research on smoking. I am a 30-year-old white female from a middle-class background. I live in the southwest of England and have been educated to master’s level. I have been involved in two research projects on oral health. I have never smoked, but I have witnessed how smoking can cause ill health from my volunteering in a smoking cessation clinic. My research aspirations are to help to develop interventions to help smokers quit.

Establishing Trustworthiness in Qualitative Research

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability.

Credibility in Qualitative Research

Credibility refers to how accurately the results represent the reality and viewpoints of the participants.

To establish credibility in research, participants’ views and the researcher’s representation of their views need to align (Tobin & Begley, 2004).

To increase the credibility of findings, researchers may use data source triangulation, investigator triangulation, peer debriefing, or member checking (Lincoln & Guba, 1985). 

Transferability in Qualitative Research

Transferability refers to how generalizable the findings are: whether the findings may be applied to another context, setting, or group (Tobin & Begley, 2004).

Transferability can be enhanced by giving thorough and in-depth descriptions of the research setting, sample, and methods (Nowell et al., 2017). 

Dependability in Qualitative Research

Dependability is the extent to which the study could be replicated under similar conditions and the findings would be consistent.

Researchers can establish dependability using methods such as audit trails so readers can see the research process is logical and traceable (Koch, 1994).

Confirmability in Qualitative Research

Confirmability is concerned with establishing that there is a clear link between the researcher’s interpretations/ findings and the data.

Researchers can achieve confirmability by demonstrating how conclusions and interpretations were arrived at (Nowell et al., 2017).

This enables readers to understand the reasoning behind the decisions made. 

Audit Trails in Qualitative Research

An audit trail provides evidence of the decisions made by the researcher regarding theory, research design, and data collection, as well as the steps they have chosen to manage, analyze, and report data. 

The researcher must provide a clear rationale to demonstrate how conclusions were reached in their study.

A clear description of the research path must be provided to enable readers to trace through the researcher’s logic (Halpren, 1983).

Researchers should maintain records of the raw data, field notes, transcripts, and a reflective journal in order to provide a clear audit trail. 

Discovery of unexpected data

Open-ended questions in qualitative research mean the researcher can probe an interview topic and enable the participant to elaborate on responses in an unrestricted manner.

This allows unexpected data to emerge, which can lead to further research into that topic. 

Flexibility

Data collection and analysis can be modified and adapted to take the research in a different direction if new ideas or patterns emerge in the data.

This enables researchers to investigate new opportunities while firmly maintaining their research goals. 

Naturalistic settings

The behaviors of participants are recorded in real-world settings. Studies that use real-world settings have high ecological validity since participants behave more authentically. 

Limitations

Time-consuming .

Qualitative research results in large amounts of data which often need to be transcribed and analyzed manually.

Even when software is used, transcription can be inaccurate, and using software for analysis can result in many codes which need to be condensed into themes. 

Subjectivity 

The researcher has an integral role in collecting and interpreting qualitative data. Therefore, the conclusions reached are from their perspective and experience.

Consequently, interpretations of data from another researcher may vary greatly. 

Limited generalizability

The aim of qualitative research is to provide a detailed, contextualized understanding of an aspect of the human experience from a relatively small sample size.

Despite rigorous analysis procedures, conclusions drawn cannot be generalized to the wider population since data may be biased or unrepresentative.

Therefore, results are only applicable to a small group of the population. 

Extraneous variables

Qualitative research is often conducted in real-world settings. This may cause results to be unreliable since extraneous variables may affect the data, for example:

• Situational variables : different environmental conditions may influence participants’ behavior in a study. The random variation in factors (such as noise or lighting) may be difficult to control in real-world settings.
• Participant characteristics : this includes any characteristics that may influence how a participant answers/ behaves in a study. This may include a participant’s mood, gender, age, ethnicity, sexual identity, IQ, etc.
• Experimenter effect : experimenter effect refers to how a researcher’s unintentional influence can change the outcome of a study. This occurs when (i) their interactions with participants unintentionally change participants’ behaviors or (ii) due to errors in observation, interpretation, or analysis. 

What sample size should qualitative research be?

The sample size for qualitative studies has been recommended to include a minimum of 12 participants to reach data saturation (Braun, 2013).

Are surveys qualitative or quantitative?

Surveys can be used to gather information from a sample qualitatively or quantitatively. Qualitative surveys use open-ended questions to gather detailed information from a large sample using free text responses.

The use of open-ended questions allows for unrestricted responses where participants use their own words, enabling the collection of more in-depth information than closed-ended questions.

In contrast, quantitative surveys consist of closed-ended questions with multiple-choice answer options. Quantitative surveys are ideal to gather a statistical representation of a population.

What are the ethical considerations of qualitative research?

Before conducting a study, you must think about any risks that could occur and take steps to prevent them. Participant Protection : Researchers must protect participants from physical and mental harm. This means you must not embarrass, frighten, offend, or harm participants. Transparency : Researchers are obligated to clearly communicate how they will collect, store, analyze, use, and share the data. Confidentiality : You need to consider how to maintain the confidentiality and anonymity of participants’ data.

What is triangulation in qualitative research?

Triangulation refers to the use of several approaches in a study to comprehensively understand phenomena. This method helps to increase the validity and credibility of research findings. 

Types of triangulation include method triangulation (using multiple methods to gather data); investigator triangulation (multiple researchers for collecting/ analyzing data), theory triangulation (comparing several theoretical perspectives to explain a phenomenon), and data source triangulation (using data from various times, locations, and people; Carter et al., 2014).

Why is qualitative research important?

Qualitative research allows researchers to describe and explain the social world. The exploratory nature of qualitative research helps to generate hypotheses that can then be tested quantitatively.

In qualitative research, participants are able to express their thoughts, experiences, and feelings without constraint.

Additionally, researchers are able to follow up on participants’ answers in real-time, generating valuable discussion around a topic. This enables researchers to gain a nuanced understanding of phenomena which is difficult to attain using quantitative methods.

What is coding data in qualitative research?

Coding data is a qualitative data analysis strategy in which a section of text is assigned with a label that describes its content.

These labels may be words or phrases which represent important (and recurring) patterns in the data.

This process enables researchers to identify related content across the dataset. Codes can then be used to group similar types of data to generate themes.

What is the difference between qualitative and quantitative research?

Qualitative research involves the collection and analysis of non-numerical data in order to understand experiences and meanings from the participant’s perspective.

This can provide rich, in-depth insights on complicated phenomena. Qualitative data may be collected using interviews, focus groups, or observations.

In contrast, quantitative research involves the collection and analysis of numerical data to measure the frequency, magnitude, or relationships of variables. This can provide objective and reliable evidence that can be generalized to the wider population.

Quantitative data may be collected using closed-ended questionnaires or experiments.

What is trustworthiness in qualitative research?

Trustworthiness is a concept used to assess the quality and rigor of qualitative research. Four criteria are used to assess a study’s trustworthiness: credibility, transferability, dependability, and confirmability. 

Credibility refers to how accurately the results represent the reality and viewpoints of the participants. Transferability refers to whether the findings may be applied to another context, setting, or group.

Dependability is the extent to which the findings are consistent and reliable. Confirmability refers to the objectivity of findings (not influenced by the bias or assumptions of researchers).

What is data saturation in qualitative research?

Data saturation is a methodological principle used to guide the sample size of a qualitative research study.

Data saturation is proposed as a necessary methodological component in qualitative research (Saunders et al., 2018) as it is a vital criterion for discontinuing data collection and/or analysis. 

The intention of data saturation is to find “no new data, no new themes, no new coding, and ability to replicate the study” (Guest et al., 2006). Therefore, enough data has been gathered to make conclusions.

Why is sampling in qualitative research important?

In quantitative research, large sample sizes are used to provide statistically significant quantitative estimates.

This is because quantitative research aims to provide generalizable conclusions that represent populations.

However, the aim of sampling in qualitative research is to gather data that will help the researcher understand the depth, complexity, variation, or context of a phenomenon. The small sample sizes in qualitative studies support the depth of case-oriented analysis.

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4.2 Definitions and Characteristics of Qualitative Research

Qualitative research aims to uncover the meaning and understanding of phenomena that cannot be broken down into measurable elements. It is based on naturalistic, interpretative and humanistic notions. 5 This research method seeks to discover, explore, identify or describe subjective human experiences using non-statistical methods and develops themes from the study participants’ stories. 5 Figure 4.1 depicts major features/ characteristics of qualitative research. It utilises exploratory open-ended questions and observations to search for patterns of meaning in collected data (e.g. observation, verbal/written narrative data, photographs, etc.) and uses inductive thinking (from specific observations to more general rules) to interpret meaning. 6 Participants’ voice is evident through quotations and description of the work. 6 The context/ setting of the study and the researcher’s reflexivity (i.e. “reflection on and awareness of their bias”, the effect of the researcher’s experience on the data and interpretations) are very important and described as part of data collection. 6 Analysis of collected data is complex, often involves inductive data analysis (exploration, contrasts, specific to general) and requires multiple coding and development of themes from participant stories. 6

Reflexivity- avoiding bias/Role of the qualitative researcher

Qualitative researchers generally begin their work with the recognition that their position (or worldview) has a significant impact on the overall research process. 7 Researcher worldview shapes the way the research is conducted, i.e., how the questions are formulated, methods are chosen, data are collected and analysed, and results are reported. Therefore, it is essential for qualitative researchers to acknowledge, articulate, reflect on and clarify their own underlying biases and assumptions before embarking on any research project. 7 Reflexivity helps to ensure that the researcher’s own experiences, values, and beliefs do not unintentionally bias the data collection, analysis, and interpretation. 7 It is the gold standard for establishing trustworthiness and has been established as one of the ways qualitative researchers should ensure rigour and quality in their work. 8 The following questions in Table 4.1 may help you begin the reflective process. 9

Table 4.1: Questions to aid the reflection process

Philosophical underpinnings to qualitative research

Qualitative research uses an inductive approach and stems from interpretivism or constructivism and assumes that realities are multiple, socially constructed, and holistic. 10 According to this philosophical viewpoint, humans build reality through their interactions with the world around them. 10 As a result, qualitative research aims to comprehend how individuals make sense of their experiences and build meaning in their lives. 10 Because reality is complex/nuanced and context-bound, participants constantly construct it depending on their understanding. Thus, the interactions between the researcher and the participants are considered necessary to offer a rich description of the concept and provide an in-depth understanding of the phenomenon under investigation. 11

An Introduction to Research Methods for Undergraduate Health Profession Students Copyright © 2023 by Faith Alele and Bunmi Malau-Aduli is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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The word qualitative implies an emphasis on the qualities of entities and on processes and meanings that are not experimentally examined or measured [if measured at all] in terms of quantity, amount, intensity, or frequency. Qualitative researchers stress the socially constructed nature of reality, the intimate relationship between the researcher and what is studied, and the situational constraints that shape inquiry. Such researchers emphasize the value-laden nature of inquiry. They seek answers to questions that stress how social experience is created and given meaning. In contrast, quantitative studies emphasize the measurement and analysis of causal relationships between variables, not processes. Qualitative forms of inquiry are considered by many social and behavioral scientists to be as much a perspective on how to approach investigating a research problem as it is a method.

Denzin, Norman. K. and Yvonna S. Lincoln. “Introduction: The Discipline and Practice of Qualitative Research.” In The Sage Handbook of Qualitative Research . Norman. K. Denzin and Yvonna S. Lincoln, eds. 3 rd edition. (Thousand Oaks, CA: Sage, 2005), p. 10.

Characteristics of Qualitative Research

Below are the three key elements that define a qualitative research study and the applied forms each take in the investigation of a research problem.

• Naturalistic -- refers to studying real-world situations as they unfold naturally; non-manipulative and non-controlling; the researcher is open to whatever emerges [i.e., there is a lack of predetermined constraints on findings].
• Emergent -- acceptance of adapting inquiry as understanding deepens and/or situations change; the researcher avoids rigid designs that eliminate responding to opportunities to pursue new paths of discovery as they emerge.
• Purposeful -- cases for study [e.g., people, organizations, communities, cultures, events, critical incidences] are selected because they are “information rich” and illuminative. That is, they offer useful manifestations of the phenomenon of interest; sampling is aimed at insight about the phenomenon, not empirical generalization derived from a sample and applied to a population.

The Collection of Data

• Data -- observations yield a detailed, "thick description" [in-depth understanding]; interviews capture direct quotations about people’s personal perspectives and lived experiences; often derived from carefully conducted case studies and review of material culture.
• Personal experience and engagement -- researcher has direct contact with and gets close to the people, situation, and phenomenon under investigation; the researcher’s personal experiences and insights are an important part of the inquiry and critical to understanding the phenomenon.
• Empathic neutrality -- an empathic stance in working with study respondents seeks vicarious understanding without judgment [neutrality] by showing openness, sensitivity, respect, awareness, and responsiveness; in observation, it means being fully present [mindfulness].
• Dynamic systems -- there is attention to process; assumes change is ongoing, whether the focus is on an individual, an organization, a community, or an entire culture, therefore, the researcher is mindful of and attentive to system and situational dynamics.

The Analysis

• Unique case orientation -- assumes that each case is special and unique; the first level of analysis is being true to, respecting, and capturing the details of the individual cases being studied; cross-case analysis follows from and depends upon the quality of individual case studies.
• Inductive analysis -- immersion in the details and specifics of the data to discover important patterns, themes, and inter-relationships; begins by exploring, then confirming findings, guided by analytical principles rather than rules.
• Holistic perspective -- the whole phenomenon under study is understood as a complex system that is more than the sum of its parts; the focus is on complex interdependencies and system dynamics that cannot be reduced in any meaningful way to linear, cause and effect relationships and/or a few discrete variables.
• Context sensitive -- places findings in a social, historical, and temporal context; researcher is careful about [even dubious of] the possibility or meaningfulness of generalizations across time and space; emphasizes careful comparative case study analysis and extrapolating patterns for possible transferability and adaptation in new settings.
• Voice, perspective, and reflexivity -- the qualitative methodologist owns and is reflective about her or his own voice and perspective; a credible voice conveys authenticity and trustworthiness; complete objectivity being impossible and pure subjectivity undermining credibility, the researcher's focus reflects a balance between understanding and depicting the world authentically in all its complexity and of being self-analytical, politically aware, and reflexive in consciousness.

Berg, Bruce Lawrence. Qualitative Research Methods for the Social Sciences . 8th edition. Boston, MA: Allyn and Bacon, 2012; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 2nd ed. Thousand Oaks, CA: Sage Publications, 1995; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Basic Research Design for Qualitative Studies

Unlike positivist or experimental research that utilizes a linear and one-directional sequence of design steps, there is considerable variation in how a qualitative research study is organized. In general, qualitative researchers attempt to describe and interpret human behavior based primarily on the words of selected individuals [a.k.a., “informants” or “respondents”] and/or through the interpretation of their material culture or occupied space. There is a reflexive process underpinning every stage of a qualitative study to ensure that researcher biases, presuppositions, and interpretations are clearly evident, thus ensuring that the reader is better able to interpret the overall validity of the research. According to Maxwell (2009), there are five, not necessarily ordered or sequential, components in qualitative research designs. How they are presented depends upon the research philosophy and theoretical framework of the study, the methods chosen, and the general assumptions underpinning the study. Goals Describe the central research problem being addressed but avoid describing any anticipated outcomes. Questions to ask yourself are: Why is your study worth doing? What issues do you want to clarify, and what practices and policies do you want it to influence? Why do you want to conduct this study, and why should the reader care about the results? Conceptual Framework Questions to ask yourself are: What do you think is going on with the issues, settings, or people you plan to study? What theories, beliefs, and prior research findings will guide or inform your research, and what literature, preliminary studies, and personal experiences will you draw upon for understanding the people or issues you are studying? Note to not only report the results of other studies in your review of the literature, but note the methods used as well. If appropriate, describe why earlier studies using quantitative methods were inadequate in addressing the research problem. Research Questions Usually there is a research problem that frames your qualitative study and that influences your decision about what methods to use, but qualitative designs generally lack an accompanying hypothesis or set of assumptions because the findings are emergent and unpredictable. In this context, more specific research questions are generally the result of an interactive design process rather than the starting point for that process. Questions to ask yourself are: What do you specifically want to learn or understand by conducting this study? What do you not know about the things you are studying that you want to learn? What questions will your research attempt to answer, and how are these questions related to one another? Methods Structured approaches to applying a method or methods to your study help to ensure that there is comparability of data across sources and researchers and, thus, they can be useful in answering questions that deal with differences between phenomena and the explanation for these differences [variance questions]. An unstructured approach allows the researcher to focus on the particular phenomena studied. This facilitates an understanding of the processes that led to specific outcomes, trading generalizability and comparability for internal validity and contextual and evaluative understanding. Questions to ask yourself are: What will you actually do in conducting this study? What approaches and techniques will you use to collect and analyze your data, and how do these constitute an integrated strategy? Validity In contrast to quantitative studies where the goal is to design, in advance, “controls” such as formal comparisons, sampling strategies, or statistical manipulations to address anticipated and unanticipated threats to validity, qualitative researchers must attempt to rule out most threats to validity after the research has begun by relying on evidence collected during the research process itself in order to effectively argue that any alternative explanations for a phenomenon are implausible. Questions to ask yourself are: How might your results and conclusions be wrong? What are the plausible alternative interpretations and validity threats to these, and how will you deal with these? How can the data that you have, or that you could potentially collect, support or challenge your ideas about what’s going on? Why should we believe your results? Conclusion Although Maxwell does not mention a conclusion as one of the components of a qualitative research design, you should formally conclude your study. Briefly reiterate the goals of your study and the ways in which your research addressed them. Discuss the benefits of your study and how stakeholders can use your results. Also, note the limitations of your study and, if appropriate, place them in the context of areas in need of further research.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Heath, A. W. The Proposal in Qualitative Research. The Qualitative Report 3 (March 1997); Marshall, Catherine and Gretchen B. Rossman. Designing Qualitative Research . 3rd edition. Thousand Oaks, CA: Sage, 1999; Maxwell, Joseph A. "Designing a Qualitative Study." In The SAGE Handbook of Applied Social Research Methods . Leonard Bickman and Debra J. Rog, eds. 2nd ed. (Thousand Oaks, CA: Sage, 2009), p. 214-253; Qualitative Research Methods. Writing@CSU. Colorado State University; Yin, Robert K. Qualitative Research from Start to Finish . 2nd edition. New York: Guilford, 2015.

Strengths of Using Qualitative Methods

The advantage of using qualitative methods is that they generate rich, detailed data that leave the participants' perspectives intact and provide multiple contexts for understanding the phenomenon under study. In this way, qualitative research can be used to vividly demonstrate phenomena or to conduct cross-case comparisons and analysis of individuals or groups.

Among the specific strengths of using qualitative methods to study social science research problems is the ability to:

• Obtain a more realistic view of the lived world that cannot be understood or experienced in numerical data and statistical analysis;
• Provide the researcher with the perspective of the participants of the study through immersion in a culture or situation and as a result of direct interaction with them;
• Allow the researcher to describe existing phenomena and current situations;
• Develop flexible ways to perform data collection, subsequent analysis, and interpretation of collected information;
• Yield results that can be helpful in pioneering new ways of understanding;
• Respond to changes that occur while conducting the study ]e.g., extended fieldwork or observation] and offer the flexibility to shift the focus of the research as a result;
• Provide a holistic view of the phenomena under investigation;
• Respond to local situations, conditions, and needs of participants;
• Interact with the research subjects in their own language and on their own terms; and,
• Create a descriptive capability based on primary and unstructured data.

Anderson, Claire. “Presenting and Evaluating Qualitative Research.” American Journal of Pharmaceutical Education 74 (2010): 1-7; Denzin, Norman. K. and Yvonna S. Lincoln. Handbook of Qualitative Research . 2nd edition. Thousand Oaks, CA: Sage, 2000; Merriam, Sharan B. Qualitative Research: A Guide to Design and Implementation . San Francisco, CA: Jossey-Bass, 2009.

Limitations of Using Qualitative Methods

It is very much true that most of the limitations you find in using qualitative research techniques also reflect their inherent strengths . For example, small sample sizes help you investigate research problems in a comprehensive and in-depth manner. However, small sample sizes undermine opportunities to draw useful generalizations from, or to make broad policy recommendations based upon, the findings. Additionally, as the primary instrument of investigation, qualitative researchers are often embedded in the cultures and experiences of others. However, cultural embeddedness increases the opportunity for bias generated from conscious or unconscious assumptions about the study setting to enter into how data is gathered, interpreted, and reported.

Some specific limitations associated with using qualitative methods to study research problems in the social sciences include the following:

• Drifting away from the original objectives of the study in response to the changing nature of the context under which the research is conducted;
• Arriving at different conclusions based on the same information depending on the personal characteristics of the researcher;
• Replication of a study is very difficult;
• Research using human subjects increases the chance of ethical dilemmas that undermine the overall validity of the study;
• An inability to investigate causality between different research phenomena;
• Difficulty in explaining differences in the quality and quantity of information obtained from different respondents and arriving at different, non-consistent conclusions;
• Data gathering and analysis is often time consuming and/or expensive;
• Requires a high level of experience from the researcher to obtain the targeted information from the respondent;
• May lack consistency and reliability because the researcher can employ different probing techniques and the respondent can choose to tell some particular stories and ignore others; and,
• Generation of a significant amount of data that cannot be randomized into manageable parts for analysis.

Research Tip

Human Subject Research and Institutional Review Board Approval

Almost every socio-behavioral study requires you to submit your proposed research plan to an Institutional Review Board. The role of the Board is to evaluate your research proposal and determine whether it will be conducted ethically and under the regulations, institutional polices, and Code of Ethics set forth by the university. The purpose of the review is to protect the rights and welfare of individuals participating in your study. The review is intended to ensure equitable selection of respondents, that you have met the requirements for obtaining informed consent , that there is clear assessment and minimization of risks to participants and to the university [read: no lawsuits!], and that privacy and confidentiality are maintained throughout the research process and beyond. Go to the USC IRB website for detailed information and templates of forms you need to submit before you can proceed. If you are  unsure whether your study is subject to IRB review, consult with your professor or academic advisor.

Chenail, Ronald J. Introduction to Qualitative Research Design. Nova Southeastern University; Labaree, Robert V. "Working Successfully with Your Institutional Review Board: Practical Advice for Academic Librarians." College and Research Libraries News 71 (April 2010): 190-193.

Another Research Tip

Finding Examples of How to Apply Different Types of Research Methods

SAGE publications is a major publisher of studies about how to design and conduct research in the social and behavioral sciences. Their SAGE Research Methods Online and Cases database includes contents from books, articles, encyclopedias, handbooks, and videos covering social science research design and methods including the complete Little Green Book Series of Quantitative Applications in the Social Sciences and the Little Blue Book Series of Qualitative Research techniques. The database also includes case studies outlining the research methods used in real research projects. This is an excellent source for finding definitions of key terms and descriptions of research design and practice, techniques of data gathering, analysis, and reporting, and information about theories of research [e.g., grounded theory]. The database covers both qualitative and quantitative research methods as well as mixed methods approaches to conducting research.

SAGE Research Methods Online and Cases

NOTE :  For a list of online communities, research centers, indispensable learning resources, and personal websites of leading qualitative researchers, GO HERE .

For a list of scholarly journals devoted to the study and application of qualitative research methods, GO HERE .

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Qualitative Research : Definition

Qualitative research is the naturalistic study of social meanings and processes, using interviews, observations, and the analysis of texts and images.  In contrast to quantitative researchers, whose statistical methods enable broad generalizations about populations (for example, comparisons of the percentages of U.S. demographic groups who vote in particular ways), qualitative researchers use in-depth studies of the social world to analyze how and why groups think and act in particular ways (for instance, case studies of the experiences that shape political views).   

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What Is Qualitative Research? | Methods & Examples

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

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

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

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

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

Table of contents

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

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

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

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

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

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

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

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

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

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

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

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

• Flexibility

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

• Natural settings

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

• Meaningful insights

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

• Generation of new ideas

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

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

• Unreliability

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

• Subjectivity

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

• Limited generalisability

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

• Labour-intensive

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

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

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

There are five common approaches to qualitative research :

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

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

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

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

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

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Home » Qualitative Research – Methods, Analysis Types and Guide

Qualitative Research – Methods, Analysis Types and Guide

Table of Contents

Qualitative Research

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

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

Qualitative Research Methods

Qualitative Research Methods are as follows:

One-to-One Interview

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

Focus Groups

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

Ethnographic Studies

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

Text Analysis

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

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

Process of Observation

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

Record Keeping

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

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

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

Qualitative Research Analysis Methods

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

Thematic Analysis

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

Content Analysis

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

Discourse Analysis

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

Grounded Theory Analysis

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

Narrative Analysis

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

Phenomenological Analysis

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

Comparative Analysis

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

Applications of Qualitative Research

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

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

How to Conduct Qualitative Research

Here are some general steps for conducting qualitative research:

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

Examples of Qualitative Research

Here are some real-time examples of qualitative research:

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

Purpose of Qualitative Research

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

Qualitative research can serve multiple purposes, including:

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

When to use Qualitative Research

Here are some situations where qualitative research may be appropriate:

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

Characteristics of Qualitative Research

Qualitative research is characterized by several key features, including:

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

Advantages of Qualitative Research

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

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

Limitations of Qualitative Research

Qualitative research also has some limitations, including:

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

Also see Research Methods

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Affiliations.

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

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

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

Examples of Qualitative Research Approaches

Ethnography

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

Grounded Theory

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

Phenomenology

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

Narrative Research

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

Research Paradigm

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

Positivist vs Postpositivist

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

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

Constructivist

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

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

Data Sampling

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

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

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

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

Extreme case sampling- targeted selection of rare cases.

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

Data Collection and Analysis

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

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

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

Dissemination

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

Examples of Application

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

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

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

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

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

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

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

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

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

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

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

Publication types

• Study Guide

Research Design Review

A discussion of qualitative & quantitative research design, 10 distinctive qualities of qualitative research.

Researchers conduct qualitative research because they acknowledge the human condition and want to learn more, and think differently, about a research issue than what is usual from mostly numerical quantitative survey research data.  Not surprisingly, the unique nature of qualitative inquiry is characterized by a distinctive set of attributes, all of which impact the design of qualitative research one way or the other.  The 10 unique attributes of qualitative research* are the:

• Absence of “truth” With all the emphasis in qualitative research on reality and the human condition, it might be expected that qualitative inquiry is in the business of garnering “the truth” from participants.  Instead of “truth,” the qualitative researcher collects information from which some level of knowledge can be gained.  The researcher does not acquire this information and knowledge in a vacuum but rather in a context and, in this way, the research data are a product of various situational factors.  For this reason, qualitative researchers do not talk about the “truth” of their findings but rather the “plausibility” of their interpretations. Plausibility is derived from achieving accuracy in the data collection process , accuracy in the absence of absolute “truth.”
• Importance of context A relevant factor in the elusiveness of “truth” is the central and significant role context plays in qualitative research.  Whether it be the physical environment or mode by which an in-depth interview (IDI), group discussion, or observation is conducted the outcomes in qualitative research hinge greatly on the contexts from which we obtain this data.
• Importance of meaning Although the goal of all research is to draw meaning from the data, qualitative research is unique in the dimensionality of this effort.  Qualitative researchers derive meaning from the data by way of multiple sources, evaluating any number of variables such as: the context, the language, the impact of the participant-researcher relationship, the potential for participant bias, and the potential for researcher bias. Several articles in Research Design Review discuss the importance of meaning, including “Words Versus Meanings.”
• Researcher-as-instrument Along with the emphases on context, meaning, and the potential for researcher subjectivity, qualitative research is distinguished by the fact it places the researcher at the center of the data-gathering phase and, indeed, the researcher is the instrument by which information is collected.  The closeness of the researcher to the research participants and subject matter instills an in-depth understanding which can prove beneficial to a thorough analysis and interpretation of the outcomes; however, this intimacy heightens concerns regarding the researcher’s ability to collect (and interpret) data in an objective, unbiased manner. Mitigating these effects is discussed here .
• Participant-researcher relationship Closely associated with the idea that the researcher is the tool by which data are gathered is the important function of the participant-researcher relationship in qualitative research and its impact on research outcomes.  This relationship is at the core of IDIs, group discussions, and participant observation, where participants and researchers share the “research space” within which certain conventions for communicating (knowingly or not) may be formed and which, in turn, shapes the reality the researcher is capturing in the data. A discussion of this attribute along with two other unique attributes — importance of context and importance of meaning — can be found here .
• Skill set required of the researcher Qualitative research requires a unique set of skills from the researcher, skills that go beyond the usual qualities of organization, attention to detail, and analytical abilities that are necessary for all researchers.  Techniques to build rapport with participants and active listening skills are only two examples.  Qualitative researchers also need a special class of analytical skills that can meet the demands of contextual, multilayered analysis (see below) in qualitative inquiry where context, social interaction, and numerous other inter-connected variables contribute to the realities researchers take away from the field. Qualitative research involving multiple methods requires a special set of skills, as discussed in “Working with Multiple Methods in Qualitative Research: 7 Unique Researcher Skills.”
• Flexibility of the research design A defining characteristic of qualitative research is the flexibility built into the research design .  For instance, it is not until a focus group moderator is actually in a group discussion that he or she understands which topical areas to pursue more than others or the specific follow-up (probing) questions to interject.  And, a participant observer has little control over the activities of the observed and, indeed, the goal of the observer is to be as unobtrusive and flexible as possible in order to capture the reality of the observed events.
• Types of issues or questions effectively addressed by qualitative research Qualitative research is uniquely suited to address research issues or questions that might be difficult, if not impossible, to investigate under more structured, less flexible research designs.  Qualitative inquiry effectively tackles: sensitive or personal issues such as domestic violence and sexual dysfunction; intricate topics such as personal life histories; nebulous questions such as “Is the current school leadership as effective as it could be?”; and contextual issues such as in-the-moment decision-making.  Similarly, qualitative research is useful at gaining meaningful information from hard-to-reach or underserved populations such as children of all ages, subcultures, and deviant groups.
• Contextual, multilayered analysis Without a doubt, the analysis of qualitative data does not follow a straight line, where point ‘A’ leads to point ‘B’, but rather is a multilayered, involved process that continually builds upon itself until a meaningful, contextually-derived, and verifiable interpretation is achieved.  The interconnections, possible inconsistencies, and interwoven contextual input reaped in qualitative research demand that researchers embrace the tangles of their data from many sources.  A large contributor to the complexity of the analytical process is the inductive method.  Qualitative researchers typically analyze their outcomes from the inside out, deriving their interpretations from the themes they construct from the data gathered. Qualitative Data Analysis is a compilation of 16 articles discussing various facets of qualitative analysis.
• Unique capabilities of online and mobile qualitative research Online and mobile technology offer unique enhancements to qualitative research design.  In large part, this technology has shifted the balance of power from the researcher to the online or mobile participant who is given greater control of the research process by way of more flexibility, convenience, and ways to respond in greater detail and depth to the researcher’s questions.

* Adapted from Applied Qualitative Research Design: A Total Quality Framework Approach (Roller, M. R. & Lavrakas, P. J., 2015. New York: Guilford Press).

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36 comments

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Would like know more about Qualitative research design

For an alternative approach to qualitative research design, see my book–JA Maxwell, Qualitative Research Design: An Interactive Approach (SAGE publications, 3rd ed., 2011).

For more on qualitative research design, see my book Qualitative Research Design: An Interactive Approach (3rd ed., Joseph Maxwell, SAGE Publications, 2013); there are reviews on Amazon.com.

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Thank you…it really helps me a lot in understanding of qualitative research which I am embarking now.

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This is a really nice summary. The one point I would add is that qualitative research is much better than quantitative research at identifying the processes by which events or outcomes occur. Quantitative research is very good at showing WHETHER A influenced B, but can tell us very little about HOW it did so. Qualitative methods can get inside the “black box” of experimental and statistical designs and reveal the mechanisms (mental as well as physical) that caused the result. See J.Maxwell, “Causal explanation, qualitative research, and scientific inquiry in education,” Educational Researcher 33(2), 3-11, March 2004.

Thank you for this addition, and my apologies for not responding sooner. I have read your paper in Educational Researcher as well as your very good book “A Realist Approach for Qualitative Research.” I agree wholeheartedly with your discussions of a process approach to causation, and the idea that social and cultural contexts are essential to understanding “causal mechanisms.” This is the important role that qualitative methods play and, as you say, why we are comfortable identifying causation from single case studies.

Let me add that I also appreciate your long discussion of validity in your 2012 book, including the three distinctions you make, e.g., separating accounts of phenomena from the accounts of meaning that can only come from individuals’ “conceptual framework.”

Thanks, again. And, again, sorry for the delay.

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It is good I liked it, keep posting more on qualitative research method and practices

Reblogged this on Anthropologizing .

Reblogged this on Elodie Crespel .

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10 Characteristics Of Qualitative Research, Its Applications, Advantages and Disadvantages

 We explain what a qualitative research is and its applications. Also, what are its characteristics, advantages and disadvantages.

What is a qualitative research?

It differs from quantitative research, which looks for measurable and comparable data such as percentages, quantities, and probabilities.

Qualitative research is a method used mainly in the social sciences  to study human phenomena  that require complex analysis for their understanding.

The researcher  approaches the subjects he wants to study and shares his daily life with them  , in some cases conducting interviews to inquire about their emotions , ideas and expectations.

Qualitative investigations can be complemented with other quantitative ones.

Characteristics of a qualitative research  :

Qualitative research is an approach to research that focuses on understanding the subjective experiences, perspectives, and meanings of individuals and groups. Some of the key characteristics of qualitative research include:

Emphasis on context

Qualitative research focuses on the context in which people experience and interpret events, rather than just the events themselves. This means that researchers seek to understand the social, cultural, and historical factors that shape people's experiences.

Data collection through interviews, observations, and other qualitative methods

Qualitative researchers typically collect data through methods such as interviews, observations, focus groups, and other techniques that allow for detailed exploration of people's experiences and perspectives.

In-depth analysis

Qualitative research involves a detailed and in-depth analysis of data, with a focus on identifying themes, patterns, and relationships that emerge from the data.

Subjectivity

Qualitative research acknowledges the subjectivity of the researcher and the participants, and recognizes that multiple perspectives and interpretations are possible.

Flexibility

Qualitative research is often flexible and iterative, allowing the researcher to adjust their methods and approach based on the data they collect and the insights they gain.

Interpretive and exploratory

Qualitative research is often exploratory and interpretive, seeking to understand and make sense of complex phenomena rather than testing specific hypotheses.

Generalizability

Qualitative research does not seek to generalize findings to a larger population in the same way that quantitative research does. Instead, qualitative research seeks to provide rich and detailed descriptions of the experiences and perspectives of individuals and groups.

Inductive reasoning is  one that goes from the particular to the general  . It is different from deductive reasoning, which draws a conclusion about a particular case from a general law .

Qualitative research  is inductive because it does not start from general laws or principles  that apply to particular cases but, on the contrary, is dedicated to collecting data from which it can later make generalizations.

However, inductive reasoning  is used with reservations in qualitative research  since the generalizations are not applicable to any society studied but to societies that have certain characteristics.

In addition, they  are raised as hypotheses that can be refuted  by other qualitative research.

Interaction with the subjects studied

In addition to  studying processes in society  , the researcher takes into account the way his own research progresses.

The researcher  can interact directly through the interview  or through participation in activities in the community he studies.

But even if it is limited to observation , its mere presence already  affects the behavior of the subjects

Process oriented

One of the reasons why qualitative research does not seek universal generalizations is because it  does not focus on fixed situations or invariant states  of a society, but rather studies processes.

Qualitative research  looks at the way a society transforms  and not the initial or final state of change.

It also studies its own process, this means that it is recursive: it refers to itself.

The subject in its own frame of reference

When studying a social group or a society far from his own, the qualitative researcher  does not judge the attitudes and thoughts of that group from his own point of view  but tries to understand it within the framework of values , norms , practices and beliefs of the group studied.

The subjective aspect is always present in this type of research, but an  attempt is made to identify one's own opinions and prejudices  , to avoid affecting the research.

These investigations  never study an isolated event  but, to understand each event, behavior or customs, they adopt a holistic position, that is, they take into account the experience of the subject as a whole.

For this, the subjects studied  are considered within the framework of their past  , their expectations for the future and their location within their specific context.

Complex data

When studying a human group qualitatively,  the measurable and expressible factors in numbers or proportions are minimal  . Rather, non-measurable data are observed and described.

For this reason, these investigations  do not usually allow statistical analysis  and the conclusions of each investigation depend to a great extent on the interpretation of the data obtained.

Flexible and evolutionary

By not having a fixed methodology, qualitative research  is adapted to the realities studied  .

Depending on the phenomena the researcher encounters, he can hypothesize and correct concepts as he goes along.

Variety of study objects

Qualitative research  takes into account all the participants of an event  and all the factors involved, regardless of whether they participate from a central or peripheral place.

For example, when studying a social phenomenon, it  does not only study the leaders  but also the behavior of all the members of the social group.

Advantages of Qualitative Research

Compared to a quantitative research, the advantages of a qualitative research are:

• Allows communication with the subjects studied
• Facilitates a horizontal relationship with the investigated groups
• It allows a description and a complex analysis of the phenomena
• The large amount and variety of data it offers allows other scholars to reach different conclusions and even continue the investigation

Disadvantages of Qualitative Research

Compared to quantitative research, the disadvantages of qualitative research are:

• It is difficult to process and compare the information obtained since it does not present quantifiable data
• The results lose objectivity because they depend on the interpretation of the researcher

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MA student of the TransAtlantic Masters program at UNC-Chapel Hill. Political Science with a focus on European Studies. Expressed ideas are open to revision. He not only covers Technical articles but also has skills in the fields of SEO, graphics, web development and coding. .

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11 Characteristics of Qualitative Research

June 12, 2023 | By Hitesh Bhasin | Filed Under: Marketing

Qualitative research is scientific research used to collect non-numerical data through different qualitative research methods like observational methods, Face-to-Face interviews, case studies. Qualitative research methods are used to obtain detailed answers to the questions. Participants of the research are asked open-ended questions rather than asking close-ended questions through surveys and questionnaires .

In qualitative research, a researcher gives more importance to the concepts, definitions, meanings, and detailed description of things and give less stress to figures and numbers. Qualitative research methods explain how and why something happens and do not answer what and how much happens.

For example, if a store manager wants to know the reason behind the declined daily sales rate, then hr should conduct qualitative research such as face-to-face interviews of potential customers , observing the behavior of customers in the store. You can select random customers and can request them to take part in the interview process.

By conducting qualitative research, you would know about the reason behind the declined sales rate, such as high prices, lack of items, etc. By knowing these reasons, you can work on them and boost your sales again. The answers to such questions can only be determined through interaction with potential customers and observational study.

Therefore, in market situations, qualitative research methods play a crucial role. In this article, you will learn about the different characteristics of qualitative research.

Table of Contents

1. Real-world Setting

The real-world setting is the first characteristic of qualitative research. In qualitative research methods like observation method , ethnographic research , focus group , one-to-one interviews, the behavior of the participants of study is observed, and the conclusion is drawn based on their answers and their behavior.

For example, A teacher will conduct qualitative research if he wants to know about the reason for the declining performance of students in the class. Qualitative research is conducted in natural settings to get real information.

2. Researcher Plays an important role

A researcher is a person who performs qualitative research. Qualitative research can be conducted by a group of people or by an individual. The purpose of a researcher is essential in qualitative research. The researcher of qualitative research is responsible for choosing the research method and for making a plan to conduct effective research.

The researcher is also responsible for participating in the study to make the right observations. He participates in the research and engages the participants in the study. He also explains the procedure of research to the participants and answers their queries.

3. Different Research methods

Another vital characteristic of qualitative research method is the various methods of research. For example, focus group, face-to-face interview, observation research methods, case study, content analysis, ethnography, phenomenology, ground theory , group discussions.

Each qualitative research method has different significance and is used for different scenarios and research situations. Sometimes, researchers make the use of more than one qualitative research method to obtain the accurate output.  Research methods like a case study and Content analysis are also used to compare the results of quantitative research.

4. Complex reasoning

An essential characteristic of the qualitative research method is that it is beneficial for complex reasoning. Sometimes, there are search situations which are required to have complex rationale to get the right results rather than direct statistical answers.

For example, if a restaurant owner wants to know about what kind of entertainment people prefer at different hours of the day and why then he is required to adopt one of the qualitative research methods to understand the psychology of customers behind the choice of their entertainment.

In addition to this, qualitative research methods are also used to explain the outcome of quantitative research methods.

5. Participants meanings

In qualitative research, like the researcher, the role of a participant is also very important. During the whole research process , the focus of a researcher is to understand and determine the meaning that a participant brings to the research rather than the definition given or thought by the researcher based on the literature reviews.

Based on the different perspectives of participants, different meaning of research is observed.

6. Flexible

Qualitative research is flexible. It can change at any stage of the research and based on the change, the course of research might also get changed. Therefore, qualitative research is used in such a scenario where the flexible nature of research is acceptable.

7. Reflexivity

In qualitative research, the researchers share everything about themselves like their background and their purpose of research with the participants. Reflexivity also makes them participate In the research openly and willingly.

8. Holistic Account

The purpose of conducting qualitative research is to paint the larger picture. While doing qualitative research, the researcher focuses on different perspectives and determine various factors involved in the research.

The research works to develop a complex description of the research problem. A researcher should not try to identify a cause and effect type relationship between two or more factors but should try to establish a complex cause and relationship between different elements.

9. Ongoing data analysis

The analysis of data in qualitative research does not take place at the end of the completion of the research process. Data analysis is an on-going process in the qualitative research method.

The researcher can analyze as well as draw conclusions, and based on the outcome of the research process is modified.

10. Purposeful selection of participants

In qualitative research, participants are selected randomly from a carefully chosen segment of potential participants. The persistent range of participants increases the accuracy of the outcome of the research.

Therefore, the selection of participants is an important stage of qualitative research, unlike quantitative research, where participants are chosen randomly.

11. Emergent Design

A unique characteristic of qualitative research is its new design. That means a qualitative research method can remain the same as decided by the researcher at the beginning of the research process. The research process changes at every stage of the research. Sometimes, change in the research process changes when the researcher starts collecting data for the research problem.

This can result in the difference in the methods being used for the research and sometimes, the research problem is altered and results in a completely new research problem. Because of this, the researcher is required to be ready to change in the whole research process at any time or phase of the research.

The primary purpose of qualitative research methods is not to determine a quantitative answer but to be able to establish an understanding of the problem and to find out in detail about it.

Liked this post? Check out the complete series on Market research

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Hitesh Bhasin is the CEO of Marketing91 and has over a decade of experience in the marketing field. He is an accomplished author of thousands of insightful articles, including in-depth analyses of brands and companies. Holding an MBA in Marketing, Hitesh manages several offline ventures, where he applies all the concepts of Marketing that he writes about.

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Uses of Qualitative Research

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• Published: 11 May 2024

Nurses’ and patients’ perceptions of physical health screening for patients with schizophrenia spectrum disorders: a qualitative study

• Långstedt Camilla 1 ,
• Bressington Daniel 2 , 3 &
• Välimäki Maritta 1 , 4  

BMC Nursing volume  23 , Article number:  321 ( 2024 ) Cite this article

Metrics details

Despite worldwide concern about the poor physical health of patients with schizophrenia spectrum disorders (SSD), physical health screening rates are low. This study reports nurses’ and patients’ experiences of physical health screening among people with SSD using the Finnish Health Improvement Profile (HIP-F) and their ideas for implementation improvements.

A qualitative exploratory study design with five group interviews with nurses ( n  = 15) and individual interviews with patients with SSD ( n  = 8) who had experience using the HIP-F in psychiatric outpatient clinics. Inductive content analysis was conducted.

Two main categories were identified. First, the characteristics of the HIP-F were divided into the subcategories of comprehensive nature, facilitating engagement, interpretation and rating of some items and duration of screening. Second, suggestions for the implementation of physical health screening consisted of two subcategories: improvements in screening and ideas for practice. Physical health screening was felt to increase the discussion and awareness of physical health and supported health promotion. The HIP-F was found to be a structured, comprehensive screening tool that included several items that were not otherwise assessed in clinical practice. The HIP-F was also considered to facilitate engagement by promoting collaboration in an interactive way. Despite this, most of the nurses found the HIP-F to be arduous and too time consuming, while patients found the HIP-F easy to use. Nurses found some items unclear and infeasible, while patients found all items feasible. Based on the nurses’ experiences, screening should be clear and easy to interpret, and condensation and revision of the HIP-F tool were suggested. The patients did not think that any improvements to the HIP-F were needed for implementation in clinical settings.

Conclusions

Patients with schizophrenia spectrum disorders are willing to participate in physical health screening. Physical health screening should be clear, easy to use and relatively quick. With this detailed knowledge of perceptions of screening, further research is needed to understand what factors affect the fidelity of implementing physical health screening in clinical mental health practice and to gain an overall understanding on how to improve such implementation.

Peer Review reports

The physical health state of people diagnosed with schizophrenia spectrum disorder (SSD) is a global problem [ 1 ]. Typically, poor physical health results from a range of issues, including the impact of psychiatric symptoms on health behavior, adverse effects of prescribed medication, difficulties observing physical health concerns, lifestyle, diagnostic overshadowing, and patient unwillingness to report health problems [ 2 , 3 ]. These factors may lead to obesity, metabolic syndrome, coronary vascular disease, diabetes, hypertension, or cancer [ 4 , 5 , 6 ]. High rates of infectious diseases such as hepatitis and HIV [ 7 ] and COVID-19 [ 8 ] have also been reported in patients with SSD. As an outcome of physical health issues, physical comorbidity is associated with psychiatric readmission [ 9 ] and high treatment costs. In Finland, the total healthcare costs caused by schizophrenia are approximately 700–900 million euros per year, mostly as a result of inpatient treatment costs [ 10 ]. Due to poor physical health, the life expectancy of persons with schizophrenia is approximately 20 years less than that of the general population [ 11 , 12 ]. Therefore, it is crucial that physical health screening is conducted regularly for patients with SSD. Improving regular screening helps to support earlier detection of risk factors that can, without detection and intervention, have deleterious effects on the physical health of patients with SSD [ 10 ].

Several international clinical guidelines have recommended how physical health screening for patients with SSD should be conducted [ 10 , 13 , 14 , 15 , 16 ]. According to guidelines persons with SSD who have been prescribed antipsychotic medication should have annual health checks focusing on full blood count, lipids, plasma glucose, prolactin, blood pressure, urea, electrolytes, liver function tests, weight, waist circumference measurement and electrocardiogram examination (ECG) [ 16 ]. Being aware of patients’ lifestyle habits, including smoking and use of other substances [ 10 , 13 , 15 ] is important for directing appropriate behavioral interventions to promote healthy lifestyles. In addition, a variety of screening instruments have been developed to assess physical health among people with SSD. Lamontagne-Godwin et al. [ 17 ] identified in their systematic review 44 intervention studies aiming to increase access to or uptake of physical health screening. Examples of monitoring tools in the included studies were Physical Health Check (PHC) [ 18 ]; physical health monitoring sheet [ 19 ]; systematic computerized cardiovascular health screening [ 20 ]; the Metabolic Syndrome Screening Tool (MSST) [ 21 ]; quality improvement (QI) [ 22 ] to increase rates of metabolic syndrome screening and the Health Improvement Profile (HIP), which is a comprehensive nurse-led profiling tool that assesses physical health risks, identifies unhealthy lifestyle behaviors, and provides associated recommended actions for health promotion [ 23 ]. Despite the abundance of available instruments, physical health screening is still poorly implemented in clinical mental health services [ 24 , 25 ].

To better understand this rationale for poor physical health screening, a quantitative study in Uganda [ 26 ] showed, that more than 75% of 28 nurses had a positive attitude towards metabolic screening and associated interventions. The same study reported that more than 50% of nurses were confident in providing physical activity and smoking cessation advice and nutritional counseling. However, 57% stated that their heavy workload prevented them from doing health screening. Voort et al. [ 27 ] reported in their qualitative study in Netherlands, that most nurses perceived physical health screening to be an important part of their professional role, but identified a discrepancy between their perceptions and actual clinical practice. Happell et al.’s qualitative study [ 28 ] reported in Australia that although nurses recognize their responsibility with respect to the physical health of patients with severe mental illness, they experienced factors such as staff shortages and lack of knowledge that prevented them from conducting screening properly. Further, Mwebe [ 29 ] reported in his UK study that nurses shared a clear commitment regarding their role in physical health screening in mental health care settings. Four themes emerged as follows: features of current practice and physical health monitoring; perceived barriers to physical health monitoring; education and training needs; and strategies to improve physical health monitoring. In the UK, Butler et al.’s qualitative study [ 30 ] revealed that patients varied in their awareness of the association between mental and physical health, but were engaged in physical health screening.

Moreover, Bressington et al. [ 31 ] revealed in their qualitative study, that nurses working in Hong Kong psychiatric care settings found the HIP (the Health Improvement Profile) to be comprehensive and perceived positive changes in their patients’ wellbeing, for example, by increasing motivation for patients to improve their health. HIP was developed to increase patient engagement in screening their physical health in collaboration with a nurse [ 32 ]. Earlier studies in the UK [ 33 ], Hong Kong [ 34 ], and Thailand [ 35 ] have reported patient acceptability and clinical utility of the HIP in identifying health risks where interventions are needed. These findings show that HIP may be feasible in engaging patients in discussions about physical health and in identifying areas of health risk [ 34 , 35 ]. Although Hardy et al. [ 33 ] found support for the usability of the HIP in clinical practice in a study in the UK, a subsequent RCT study conducted in the UK revealed that nurses found the use of the HIP unfeasible in a clinical setting due to its length [ 36 ]. In contrast, nurses in Hong Kong [ 31 ] found the HIP to be acceptable, feasible, and potentially useful in clinical practice. In Finland, our validation study of the Finnish Health Improvement Profile (HIP-F) supported this finding by detecting 399 areas of health and health behavior risk in a sample of 47 patients [ 37 ].

Previous international studies have only reported nurses’ and patients’ general attitudes toward health checks without detailed perceptions of the importance of comprehensively assessing different health parameters together with ideas for improvements. Implementation of physical health screening is influenced by services users’ perceptions and experiences. It is of paramount importance to involve potential users in the design and implementation of new procedures [ 38 ], and thus, when developing physical health screening for patients with SSD, the perceptions of both nurses and patients are vital [ 38 , 39 ]. Reconciling patients’ and nurses’ perceptions of physical health and its screening is an important step in promoting collaborative care and improving physical health screening rates [ 40 ]. Little detailed information is known about how nurses and patients perceive physical health screening; particularly, the assessment target areas and parameters, and how would nurses and patients improve screening so that it is more likely to regularly conducted in clinical practice. No previous studies have aimed to understand detailed perceptions and ideas for improvements of physical health screening by combining both nurses’ and patients’ perspectives using qualitative methods. The contrasting results regarding HIP instrument highlight that the acceptability and feasibility of HIP might be culturally and clinically context specific, and more research on patients’ and nurses’ perceptions of HIP in clinical practice is needed. To fulfill this knowledge gap, the current study sought to explore nurses’ and patients’ perceptions of physical health screening using the HIP-F profile as an example of physical health screening among patients with SSD in psychiatric settings in Finland and identify possible areas for improvement in the HIP-F tool and screening procedures.

The aim of this study was to explore (1) nurses’ and patients’ perceptions of physical health screening using the HIP-F profile as an example and (2) possible areas of improvement for implementation of physical health screening among patients with SSD in psychiatric settings in Finland. The information can be used to identify possible areas to be improved regarding implementation of systematic physical health screening activities as a part of treatment process among patients with SSD.

Study design

A qualitative exploratory study design, with focus group interviews for nurses and individual interviews for patients, was used to gain a better understanding of the real-life experiences of the study participants [ 41 , 42 ]. The qualitative exploratory design was appropriate for defining the terms of the research problem and to gain background information on a topic that little is known about [ 42 , 43 ]. For nurses, focus group interviews were used not only as a way of obtaining individual answers but also with the group interaction of participants to allow participants to explore and clarify individual and shared perspectives of specific phenomena in an open and flexible way [ 43 , 44 ]. For patients, individual interviews were chosen to receive deep insight into the respondent’s personal thoughts and feelings but also to ensure privacy, confidentiality, and a comfortable atmosphere, with concern for the vulnerability of patients with SSD [ 13 ] Moreover, individual interviews for patients were conducted to pursue personal disclosure and with consideration of the possible cognitive disabilities, such as attention and memory issues of patients with SSD [ 45 ]. Despite the potential for cognitive dysfunction, there is several benefits, such as receiving patients’ perspectives affecting engagement, involving consumers in developing interventions [ 46 ]. An exploratory approach was selected to obtain more detailed descriptions of the experiences of the participants. With this approach, we aimed to identify the phenomenon by using open-ended questions to allow nurses and patients to freely express their perceptions so that we could perform an inductive content analysis on the data without any theoretical framework or previously produced codes and categories [ 42 , 47 ].

We adhered to the consolidated criteria for reporting qualitative studies (COREQ) [ 48 ] when reporting the current study.

The study was conducted in five psychiatric outpatient clinics in Southern Finland. These clinics were selected because they offer a desirable representativeness of the study population, being part of the largest hospital area in Finland with a population of approximately 460,000 inhabitants [ 49 ]. The clinics provide mental health care for approximately 2,300 patients who have been diagnosed with a range of schizophrenia spectrum disorders (F20–29) [ 50 ]. The clinics provide both crisis and long-term mental health care and focuses on recovery and rehabilitation provided by multidisciplinary teams (psychiatrists, social workers, mental health nurses) as well as counseling and psychiatric examinations [ 51 ]. The patients’ frequency of attendance at the clinics depends on their individual treatment plan.

For nurses, a purposive sampling method was used to recruit enough participants and generate enough rich data to understand the studied phenomenon [ 52 ]. All 47 nurses who had previously been asked to use the HIP-F to assess the physical health of their patients, were invited to join the focus group interviews. These nurses had diverse backgrounds of various ages, education, and length of working experience and had the potential to provide relevant and diverse data pertinent to the research question [ 53 , 54 ]. The inclusion criteria for nurses were that they had professional education (registered nurse, mental health nurse), that they had permanent or long-term temporary employment and that they were currently working in mental health clinical practice as a patient’s primary nurse in coordinating and providing care. The exclusion criterion was being a nursing student. We aimed to sample a total of 5 focus groups, one from each study clinic, with 6–10 nurse participants in each focus group, which is close to an optimal size in focus groups to promote discussion. The sample size estimation was based on previous literature suggesting that at least four focus groups would be sufficient to identify new issues (code saturation), but more groups may be needed to completely understand these issues (meaning saturation)” [ 52 ].

For patients, a purposive sampling method was used to recruit eligible participants for the individual interviews. To be eligible to be invited to participate, the patients needed to have a diagnosis of a schizophrenia spectrum disorder, to have been treated as an outpatient in a clinic and to have been previously targeted for physical health screening with the HIP-F to elicit feedback on their experiences and perceptions [ 55 ]. We aimed to recruit 10 patients for the individual interviews since this number of interviews in qualitative content analysis was believed to allow us to reach a saturation of themes [ 56 ]. The inclusion criteria for patients were a minimum age of 18 years, being treated in outpatient clinics, having the ability to understand and speak Finnish, and a diagnosis of schizophrenia or another schizophrenia spectrum disorder F20-29 (ICD10) [ 50 ]. The exclusion criteria were having an acute psychosis or a very disturbed mental state, where participation would distress the patient or put nurses at risk.

Interview questions

Participants were asked to give their responses to open-ended questions, which focused on physical health screening with the HIP-F. The original HIP instrument, a physical health screening tool, was developed in the UK [ 32 ] and validated in Finland [ 37 ]. The HIP is a 27-item (28 for females) gender-specific profiling tool focusing on physical health and health behavior items (see Table  1 ). It enables nurses and patients to work together to assess physical health among patients with SSD. Health items (e.g., smoking status) are evaluated by categorizing them as green (e.g., nonsmoker) or red (e.g., passive smoker/smoker) depending on the result. If the health item is assessed as red, recommended actions (e.g., advice that all smoking is associated with health risks, refer to smoking cessation service) can be selected to produce a health care plan. The HIP is intended to be completed at least annually, which is the recommended frequency of screening for patients with SSD [ 12 , 50 ]. This assessment together with regular discussions with a nurse familiar with the patient might decrease barriers, for example, in talking about sensitive topics [ 17 ]. In this study, the perceptions of recommended actions have not been reported because we aimed to study only the nurses’ and patients’ experiences and perceptions of the screening procedure.

The interview questions were based on the process observation method used in a UK-based cluster-randomized controlled trial with HIP [ 36 ] and a qualitative descriptive HIP study in Hong Kong [ 31 ]. An overview of the open-ended questions is as follows:

How did you experience the physical health screening with the HIP-F?

What did you think about the physical health screening?

Which elements of assessing physical health with the HIP-F did you find most and least feasible?

How long did it take to complete the HIP-F?

What improvements could be made to physical health screening?

Recruitment

First, for potential nurse participants, one researcher (CL) provided information sessions about the study to each study clinic twice via Teams meetings. Information was given about the rights, voluntariness and confidentiality, and purpose of the study, as well as the process and the risks and benefits of participating. The main risk of participating would be the time spent participating in the research. The research would not produce immediate benefits for the nurse participants, but it would give an opportunity to influence the improvement of the usability of the HIP-F profile by giving feedback and suggestions for changes. Nurses were informed about what to expect from the focus group interviews to increase the likelihood of honesty. Participants also received written information by email before they gave their written informed consent. Nurses expressed verbally their possible desire to participate to the researcher during the information sessions and the researcher collected the consent form from the participating nurses from the study clinics at the agreed time. Of the 47 eligible nurses, 16 agreed to participate. However, one of the agreed nurses withdrew before the interview. The researcher regularly visited the study clinics (once a week), obtained informed consent from participants, and contacted the participating nurses to agree on dates for the focus groups.

Second, patients were recruited by nurses during their regular meetings in study clinics after they had been screened with the HIP-F. Nurses informed patients about the voluntariness and confidentiality as well as the purpose of the study, the process, and the risks and benefits of participating. There would be no direct benefit to the patients from participating, and no other disadvantages than the time spent on the interview. It was deemed unlikely that patient participants would experience any distress as a result of participating. Patients were given both oral and written information from nurses that participation or refusal to participate would affect their treatment in the clinic or their relationship with the clinical staff. Since cognitive problems may be associated with SSD [ 13 ], we aimed to ensure that each nurse would recruit familiar patients using an assessment of their cognitive ability and their capacity to give informed consent for participation [ 13 , 45 ]. Altogether, eight patients participated and gave their informed consent to a nurse who informed the researcher of the patient’s participation. The researcher contacted the patients to agree on dates for the individual interviews.

Data collection

Interviews were conducted using a semi-structured format to encourage participants to talk about issues that would answer the research question [ 57 , 58 ]. Before the interviews, participants gave their background information regarding gender and age. Nurses were also asked about their education and work experience in mental health care. The researcher guided the participants in the focus group interview and encouraged them to interact with each other [ 59 ]. The focus groups were preexisting work groups from clinics, and this facilitated open discussion and interaction with shared experiences in a comfortable and familiar setting [ 57 ].

All interviews were conducted between October and December 2022 by one female researcher (CL), a registered nurse (PhD student) with a long working experience with patients with SSD, who was working as a nurse manager in another unit. The researcher knew one nurse participant from an earlier HIP validation study. Participants knew that the research was a part of the researcher’s PhD study. Only the researcher and study participants were present during the interviews. Consent for recording was obtained from all participants. No pilot interviews were used. Altogether, four group interviews with nurses with two to six participants in each interview were conducted. One nurse was individually interviewed because the other consenting participant withdrew. Four of the nurses’ interviews occurred in clinic meeting rooms, and one was held via Microsoft Teams meeting. For the patients, eight individual interviews were conducted: seven by phone and one in Microsoft Teams meeting after the researcher called the patient with Microsoft Teams application. These approaches were chosen so that the subjects would experience as little harm as possible from participating in the study, for example an extra visit to the research outpatient clinic. When conducting the interviews, the current restrictions due to the COVID-19 pandemic also had to be taken into account. The duration of the interviews with nurses varied from 25 to 56 min, and the patients’ interviews lasted from 8 to 32 min. During the first two interviews, the researcher evaluated whether the questions were clear and relevant according to the information received. As no participant asked for clarification and the data were considered relevant, the questions were used in all interviews. No field notes were made during the focus group interviews and the patient interviews, but records were made about observations of nonverbal responses and reflections in the nurses’ interviews as soon as possible after each interview [ 60 ].

Data analysis

The data analysis was conducted concurrently with the interviews. The interviews, original transcriptions, and overall data analysis were in Finnish. An inductive content analysis method for audio-recorded interviews was chosen since there are no previous qualitative studies on the topic in Finland [ 61 ]. When conducting exploratory research in an area where little is known, content analysis might be suitable for the reporting of general issues in the data [ 62 ]. Furthermore, content analysis was well suited for analyzing our study topic, which is a sensitive, important, and multifaceted phenomenon of nursing [ 58 , 63 ]. Since we aimed to generate complementary perceptions and an enhanced understanding of the phenomenon, focus group and individual interview data were combined for analysis [ 64 ]. All interviews were transcribed in Word 2021 and analyzed using the five-step method by Graneheim and Lundman [ 65 ]. This approach enabled a systematic, reliable, and valid data analysis [ 58 ], which was led by research questions [ 66 ]. No software was used for coding in the analysis. First, all interviews were transcribed verbatim by one researcher (CL). Second, the researcher initially familiarized herself with the data through multiple careful readings of the transcripts to gain an understanding of the whole. Third, a sentence was selected as an analysis unit. Fourth, the text was distributed into meaning units, which were further condensed into sentences, and the condensed meaning units were abstracted and labeled with a code. Fifth, all 18 codes identified from the data were compared with each other for similarities and differences and sorted into six subcategories. The tentative categories were discussed between all authors and revised. A process of discussion and reflection resulted in an agreement on how to sort the codes.

Finally, the subcategories that were similar in terms of meaning and content were sorted into two main categories. Quotations from study participants were translated into English by one author (CL), checked by another bilingual researcher (MV) for equivalent meaning, and presented to illustrate the results (N as nurse, P as patient). From the first to the third nurses’ interview a total of 13 codes were added, and no further new codes were developed after the fourth interview. Based on code identification (88% of codes had been identified), code prevalence (90% of high-prevalence codes were identified) and codebook stability (94% of codebook changes were made), code saturation was reached after four interviews. Meaning saturation was reached at the last interview in which a new dimension of the code was identified. [52.] From patients’ interviews, code saturation was reached after the fourth individual interview and meaning saturation was achieved after the eighth interview as the repetition of content became obvious [ 52 , 67 ]. Examples of meaning units and codes are presented in Table  2 .

Demographic characteristics of study participants

A total of 15 nurses participated in the study (11 females and four males). The distribution of nurses was as follows: in the first interview there were three males and one female; in the second group there were two females; in group three there was one male and one female; the fourth interview contained one female and in the fifth interview there were six female nurses. The ages of the participants varied between 43 and 61 years, with a mean age of 49.47 years (SD 5.99). The majority were registered nurses. The length of their work experience in mental health nursing varied from one and a half years to 38 years, with a mean working experience of 21.73 years (SD 8.18). Among the patients, seven females and one male participated in the study. The ages of the participants varied between 21 and 65 years, with a mean age of 43.87 years (SD 17.27). The demographic characteristics of the study participants are presented in Table  3 .

Nurses’ and patients’ perceptions of physical health screening with the HIP-F and suggestions for improvement of screening in psychiatric settings

Both nurse and patient participants perceived physical health screening among patients with SSD to be important and the screening with HIP-F as an example screening tool to be comprehensive, but also highlighted some areas for improvement for conducting screening in psychiatric settings. Two main categories were identified from the analysis. First, the characteristics of the HIP-F were divided into subcategories: comprehensive nature , facilitating engagement , interpretation and rating of some items , and duration of screening . Second, suggestions for the implementation of physical health screening consisted of two subcategories: improvements in screening and ideas for practice . The summary of codes, subcategories and main categories is presented in Table  4 .

Characteristics of the HIP-F

Comprehensive nature.

The patients and nurses considered the HIP-F tool to be important, structured and able to comprehensively evaluate physical health. Patients found alcohol intake, activity and smoking status to be extremely important to assess among patients with SSD and expressed that it was the first time nurses had asked about several of the important items in HIP-F, including urine, caffeine intake and sexual satisfaction. Participants stated that the HIP-F includes several items, such as urine, caffeine intake, feet, and sexual satisfaction, which would not be assessed otherwise. Nurses expressed that in clinical practice a range of different nurses evaluate patients’ physical health parameters dependent on the clinical setting, however there is a current lack of appropriate structured, comprehensive screening tools. Based on the experiences of most nurses and all patient participants, all HIP-F items were considered feasible. Most of the nurses expressed that all items assessed with laboratory tests as well as body mass index (BMI), waist circumference, diet, activity, alcohol intake, teeth, smoking status, eyes, and caffeine intake were particularly feasible in physical health screening. However, despite the importance and feasibility, some HIP-F items were considered potentially challenging to talk about (e.g., sexual satisfaction) because of their sensitive nature.

The items are kind of structured here, because there is a lot, a lot of things we are asking, but they are being asked scattered in different situations, in different phases…yes, the comprehensiveness is good. (N5) Yes, there was the alcohol intake and smoking status and activity, they seemed essential. (P6) Yeah, well, it could be that for some people, the things related to their own sexual life are the same, which they don’t necessarily want to discuss. (P5) .

Facilitating engagement

All participants found the physical health screening with HIP-F to be an overall positive experience. Patients were fully aware of the significance of the relationship between physical health and mental health and were happy to have their physical health assessed. All study participants stated that physical health monitoring with the HIP-F on an annual basis is a relevant timespan for regular health checks. Based on the nurses’ and patients’ experiences, the participants felt that conducting the HIP-F together in an interactive way facilitates engagement with physical health screening and health promotion. The participants described this working model to be more desirable, making health checks easier and enabling patients to have feedback on their state of health immediately. Furthermore, nurses stressed the importance of engaging patients with SSD in their own care, something that is supported with HIP-F screening. The patients and most of the nurses expressed that the screening increased discussion in general, and discussion about physical health between nurses and patients in areas that would otherwise not be discussed. According to the study participants, screening improved information, raised some thoughts and increased awareness of physical health and health behavior in general and particularly about the items that affect patients with SSD. Nurses experienced that especially with patients with SSD it is more beneficial to conduct the screening together during a discussion because of patients’ potential cognitive challenges. The participants described that screening helped to identify physical health illnesses which helped them to start adequate treatment for the patient. Based on the participants’ experiences, screening might motivate patients to increase their activity, support physical health, and strengthen already healthy life behaviors.

Well, I wouldn’t mind if this assessment would be conducted once a year. (P5) Yes, it is very good, especially with our psychosis patients, that we are engaging them in treatment, especially in somatic health. (N5) Yes, it raised at least a little discussion about physical health. (P1) In fact, we caught quite a hypertension disease, so that was the end of it. (N2) .

Interpretation and rating of some items

Most of the nurse participants experienced HIP-F as arduous to conduct and challenging in screening, especially without routine. Nurses described the HIP-F to be too complicated and too precise and that some items were difficult to assess; for example, items pertaining to urine, fat intake (diet), five portions a day (diet), and activity were found to be difficult to assess. Nurses stated that the amount of urine passed is difficult to assess just by asking patients about it. Nurses also experienced that screening with HIP-F was too precise because nurses believed that their main work task is to evaluate mental health state, not physical health. Furthermore, some nurses were not familiar with the measurement units for some HIP-F items. However, patient participants expressed that HIP-F was easy to conduct. Moreover, nurses experienced that the HIP-F was ambiguous and partly difficult to interpret. Nurses described that some items, units of measure, and cutoff values were unclear; for example, the items for fluid, caffeine and alcohol intake, as well as the items concerning feet and urine, were overall experienced to be strange, and the significance of urine as an item remained unclear. Nurses stated that for some items, they could not find an adequate alternative to the cutoff values. This made most of the nurses consider the HIP-F to be ambiguous, which made conducting it frustrating. Some of the nurses experienced that the HIP-F also included items that were not feasible in physical health screening, such as safe sex, breast examination (men), body temperature, five portions a day (diet), caffeine intake, liver function, sexual satisfaction, BMI and feet check.

Some items felt weird, perhaps I didn’t quite understand why these were being asked so precisely in a mental health care context. (N10) I think one challenge was for example those…there are lipids or blood sugar, so, how was it, it’s quite a long time since you have done these…I had to check from the patient record how they are assessed in Finland, are they millimole or what, to find the congruent values and what are they then. (N1) The item alcohol intake is weird, there is no alternative to choose if you don’t use alcohol at all. (N9) It was a quite an easy questionnaire. Yes, it felt like that, and truly clear. (P6) .

Duration of screening

Nurses found the HIP-F too broad and time consuming to be used in clinical practice in a psychiatric setting and not feasible to be implemented in Finnish mental health services. Nurses described that although physical health screening among patients with SSD is crucial and the HIP-F includes important health items, it is too long to be used in clinical practice. Even those nurses who were first motivated to conduct screening, did not continue screening with several patients when they found out how long the screening took. Nurses reported the heavy workload of caring for many patients and their main tasks in the mental health treatment setting. Nurses experienced that the screening with HIP-F took all the time from the scheduled appointment and no time was left for discussion about the mental health of the patients, so they decided to choose to assess possible psychotic symptoms or patients’ functioning ability. Furthermore, nurses described that during screening, it was found that some health parameters, for example, annual laboratory tests, had not been conducted on patients, even if they should have been conducted according to the clinics’ regular procedures, and this challenged and delayed the screening. Nurses stated that conducting the HIP-F screening takes from 45 to 60 min, which they felt was too much for patient meetings, especially if patients only seldomly have appointments. Some nurses experienced the HIP-F to be easy to use but still too time consuming. Whereas, some of the patients had been prepared for a longer assessment and expressed that the HIP-F screening was suitable in length.

Well, I made one at the beginning, and when I noticed that it was arduous and how much time it takes, maybe that’s when the enthusiasm faded. (N9) I’m guessing 45–60 min, I haven’t recorded it, but usually we have 45-minute appointments and sometimes it takes slightly more, and it took me the whole time to do it. (N10) I was prepared for a longer questionnaire, but it wasn’t. (P5) .

Suggestions for the implementation of physical health screening

Improvements in screening.

Nurses suggested lightening and condensing the content of the HIP-F. They described that screening could be shorter and that some HIP-F items could be left out. For example, one nurse expressed that asking about temperature in physical health screening is pointless unless the patient has a cold. However, some of the nurses and all patients felt that no improvements were needed in screening for implementation. Some nurses suggested that the cutoff values could be removed, and the items could remain just as a checklist for discussion. However, other nurses thought that the cutoff values should be retained in screening and that there was nothing to develop or leave out. In addition, some nurses stated that items, such as blood pressure, could be assessed numerically but that there could be additional space for open narrative text. On the other hand, some nurse participants expressed that the assessment might be ineffective without cutoff values. Furthermore, participants expressed that some items could be assessed differently. Nurses suggested that, for example, instead of asking patients about their amount of urine output, patients could be asked about hematuria, and instead of asking about teeth checks, patients could be asked if they are brushing their teeth regularly. One patient suggested that instead of assessing activity levels, patients could be asked what kind of activity they prefer. Another patient suggested that sexual satisfaction could be assessed more broadly, taking sexual diversity into account. In addition, nurses suggested that the layout and order of the items could be different: the green and red areas could appear in green and red on the HIP-F form, and a yellow area could be added. This was considered to be more effective in demonstrating to patients their physical health state and highlighting possible areas which should be improved, rather than just discussing about the results of the HIP-F screening. Nurses stated, that adding yellow areas in HIP-F would show patients that although the result is still in a healthy area, if no improvements are made, subsequent physical health problems are likely.

I would remove temperature. It should be normal if you don’t have cold. (N12) I wouldn’t directly remove anything. (N5) Yes, I said that I could take all these cutoff values out of here and keep it just as a check list so these would be checked with a patient at least once a year. (N3) However, if there were no cutoff values for activity, sleep and smoking, then… I think these traffic light systems would be good if you could get it in color so that if it is shown to the patient who you now have this in red, that you should probably do something about it. (N1) Therefore, it could be three-part if there were the traffic light like you said just now, if it was the yellow light in between as well. (N4) .

Ideas for practice

Most of the nurses expressed that the HIP-F includes basic physical health items and that conducting health screening with the HIP-F in clinical practice does not require any additional training. However, one nurse expressed that education for talking about sensitive topics, such as safe sex and sexual satisfaction with patients, is needed. Some of the nurses suggested that the HIP-F could at least partly be completed beforehand by the patient before their clinic appointment so the screening would not take too much time from the appointment. One nurse suggested that this could happen by using an electronic version (i.e., a software application) instead of a paper questionnaire, especially for younger patients with technical skills. In addition, some of the nurses suggested a separate, longer appointment for patients in the clinics for physical health screening.

These are just basic things, there is no need for additional training. (N9) Yes, some could be doing it in advance, and some would be that who you would measure the blood pressure or something together…I think it would be reasonable, that it would already be…the patient would have already filled it in beforehand as best they could and perhaps thought about these things in peace at home, so that would speed it up in the appointment. (N10) .

As far we are aware, this study is the first study to explore perceptions among nurses and patients with SSD of physical health screening. We used the HIP-F profile as an example of a physical health screening tool. We aimed to identify possible areas for improvement in the tool and screening procedures. The study reveals several important aspects of how nurses and patients perceive physical health screening. At the same time, the HIP-F tool was also found to be arduous and time consuming, which led to recommendations on key improvements to the tool and physical health screening procedures.

Our study showed that nurses perceived physical health screening to be important [ 27 , 68 ] and that they appreciated the comprehensive physical health screening with HIP-F [ 28 , 31 ]. Nurses expressed that several HIP-F items were particularly feasible. Patients also found physical health screening beneficial in improving their awareness of physical health, which can potentially trigger health promotion conversations between nurses and patients [ 18 , 28 , 31 ]. Patients in our study were interested in and satisfied with having regular assessment of their health status [ 30 , 33 , 69 , 70 , 71 ]. Indeed, the theme ‘facilitating engagement’ was identified as a crucial factor for successful health screening in both nurses’ and patients’ data [ 26 , 27 , 30 ]. Our results are encouraging since previous studies have revealed that negative attitudes among nurses and a lack of support may restrict systematic health checks in mental health services [ 30 , 31 ]. In some countries, for example Turkey [ 72 ], nurses have stated that patients are not interested in participating in health checks. Positive perceptions among nurses towards any new intervention, including physical health screening, are important in facilitating the integration of new practices into patient care [ 73 , 74 ].

Some divergent perceptions were also found in nurses’ and patients’ perceptions in our study. Patients did not identify any infeasible or unclear items in their physical health assessment while nurses identified items regarding urine, caffeine intake, temperature, safe sex, or sexual satisfaction not meaningful or difficult to complete [ 37 ]. The finding regarding urine problems in patients with SSD is interesting as polydipsia may lead to water intoxication [ 75 ]. Patients with SSD are also 29 times more likely to get a urinary tract infection, which is a precipitating factor for acute psychosis [ 76 , 77 ]. Sometimes nurses perceive their subjective clinical view as more crucial in assessing patients’ health status than using the objective results of a standard screening tool [ 78 ]. In the future, the core reason for this discrepancy should be explored to fully understand nurses’ avoidant behavior in conducting systematic health screening with patients. This is important because our current results may be contradictory with the reality. For example, although health screening was seen as an important task in patient care, the nurses complained that using HIP-F took too much time, which made them avoid patient health screening. For example, in the current study out of 47 nurses who had been asked to conduct HIP-F screenings with their patients, only 16 were willing to use the HIP-F screening tool and monitor their patients’ physical health. This finding is interesting as it highlights the benefit of collaboration between nurses and patients when conducting screening together, as reported in previous studies [ 35 , 36 , 79 ]. At the same time, nurses expressed that the screening process was unclear and difficult to follow [ 17 , 29 , 80 ]. To adopt healthy lifestyles, e.g. physical activity and nutrition, nurses should integrate improvement initiatives for patient physical health into daily practice by making small changes [ 71 ]. In this study, however, nurses perceived assessment of patient physical health using HIP-F as a separate task, which caused double recording in patients’ health records. This finding concurs with earlier studies that health screening is poorly implemented into mental health practice [ 24 , 25 ].

In our study, nurses suggested condensation of the screening and revising the assessment with more culturally-understandable units of measurements. Item terminology should also be better suited into clinical practice [ 31 ]. To improve patients’ ability to understand the results of their health assessment, nurses suggested use of ‘a yellow traffic light’ as already used in the Chinese Health Improvement Profile (CHIP) [ 34 ]. Therefore, based on the data, some specific health components need a special effort, such as oral and general hygiene [ 72 ]. In addition, training in talking about such sensitive topics was suggested, such as topics around sexual health [ 81 , 82 ]. In addition, general training is needed to improve nurses’ understanding of the value of specific health screening items.

All these development ideas are feasible and realistic, but still leave us without a conclusion as to why these good ideas are not realized in daily practice. One reason for this may be nurses’ training needs [ 83 ]. For example, in our study, nurses had worked in mental health setting on average for over 20 years and still some health issues, e.g. adverse effects of medication, patients’ difficulties observing physical health concerns and lifestyle typical for patients with SSD, were unclear for nurses [ 2 , 3 ]. Furthermore, organizational culture can affect nurses’ self-confidence in conducting screenings [ 84 ] and our research results revealed that nurses have to prioritize the time used on an appointment between mental health and physical health assessment. Patients with SSD may not have the ability to fill the screening assessment by themself before the appointment [ 45 ] and may require the collaboration with a nurse. Moreover, possibilities of using digital technology [ 85 ] in physical health screening may be underrated.

Trustworthiness

We reflected on the trustworthiness of our study in terms of its credibility, dependability, conformability, and transferability [ 86 , 87 ] as follows. Credibility was confirmed by selecting the context and participants who had different experiences of the topic. By using focus groups and individual interviews in the data gathering, we gained knowledge of various experiences, which increased the possibility of shedding light on the research question from a variety of perspectives [ 40 ]. Credibility was further strengthened through presenting the coding process by illustrating how the meaning units from the interviews, extracted codes and categories were produced. The similarities and differences of the research findings are shown with representative quotations from the transcribed text. Dependability was improved through open dialogue among the authors and consistently during the data collection by asking all of the participants similar questions [ 63 ]. Conformability was achieved by reporting the research steps carefully. Transferability was increased by presenting a clear and distinct description of the context, recruitment and characteristics of the participants and of the data collection and data analysis.

Study strengths and limitations

The current study has some limitations that potentially impact the trustworthiness and transferability of the findings. Participants were recruited by a purposive sampling method, which likely caused bias by recruiting those more interested in discussing the topic [ 88 , 89 ]. Although nurses were trained to understand the meaning of specific inclusion and exclusion criteria for the patients, selection bias may still have occurred in the patient recruitment process and patient data may be biased toward those patients who are more motivated, capable and collaborative to join initiatives. All patient participants were diagnosed with a psychotic disorder (F20–29), but the sample size was relatively small and might limit the transferability of the findings to patients with SSD. Similarly, participants were recruited in one hospital only and due to their narrow ethnic background group, this may also may reduce the transferability of the findings outside Finland.

The qualitative study design itself might have imposed some limitations in several phases during the study. The researcher’s presence during the interviews may have affected the subjects’ responses, even if this is often unavoidable in qualitative research [ 88 , 90 ]. The researcher conducting the interviews had a deep understanding of the research topic based on her experience in working with persons with SSD. At the same time, having strong pre-assumptions may have caused bias due to a lack of openness to the topic, hence reducing the credibility. Furthermore, it is possible that the short duration of interviews limits the depth of understanding of the topic. Similarly, the small number of nurse participants in some of the focus groups is likely to have limited the potential for productive group discussion. Even though the interviews were conducted individually with patients, it is possible that the patients were hesitant to openly share their views to a person who represents a staff member. Moreover, the transcripts of the digitally recorded interviews were not returned to nurses or patient participants, so member checking of transcripts and categories was not carried out. Formal backtranslation was not conducted for the data, which might also decrease the credibility of the results. Regardless of these limitations, the study has some strengths and consists of rich and informative data regarding the perceptions of nurses and patients.

Our study results offer a novel diversity of perceptions from nurses and patients toward physical health screening in mental health settings. Patients with schizophrenia spectrum disorders are willing to participate in physical health screening. Although nurses found the HIP-F to be too long, they showed interest in assessing their patients’ physical health and suggested improvements to develop screening to improve its feasibility in clinical practice. Physical health screening should be clear, easy to use and relatively quick. Developing and improving health screening to better suit clinical practice, for example in their length, would further support professionals in conducting and encouraging patients to participate in physical health screening. With this detailed knowledge of perceptions of screening, further research is needed to understand what factors affect the implementation fidelity of physical health screening in clinical mental health practice and to gain an overall understanding on how to improve such implementation.

Implications

Several studies have emphasized the position of nurses in the assessment of physical health [ 28 , 68 , 73 ]. In order for patients to benefit from the results of physical health assessments in clinical practice, it is crucial that the treatment guidelines are followed, assessment results are available in patient record systems and actions are completed according to health promotion plans. Our findings can be used in supporting professionals to collaborate with patients to participate in physical health screening. Our results are also useful in planning curriculums in nursing education and clinical settings. Finally, our results should encourage nurses to implement regular physical health screenings for patients with SSD followed by appropriate effective health promotion interventions. For effective physical health screening and preventing physical comorbidity and premature deaths, the perceptions explored in our study can be taken into consideration by those who develop screening procedures and health screenings for clinical practice.

Data availability

Data generated during and/or analyzed during the study are not publicly available due to ethical restrictions and privacy.

Abbreviations

Body mass index

Chinese Health Improvement Profile

consolidated criteria for reporting qualitative studies

Coronavirus

electrocardiogram

Health improvement profile

Finnish health improvement profile

human immunodeficiency virus

Helsinki University Hospital

10th revision of the International Classification of Diseases and Related Health Problems

Metabolic Syndrome Screening Tool

metabolic syndrome

Nursing Research Center

The physical health check

Doctorate of Philosophy

quality improvement

randomized controlled trial

Standard deviation

schizophrenia spectrum disorder

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Acknowledgements

We would like to thank all patients and nurses for their indispensable assistance in conducting this research.

Helsinki University Hospitals (HUH) Nursing Research Center (NRC) and HUH Funding, Psychiatry supported this study by granting a paid research period for the first author (CL).

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CL designed the study, collected the data, contributed to data input, analyzed the data, and contributed to the writing of the manuscript and all tables. MV led the study design, data analysis, and writing of the manuscript. DB contributed to the study design, the data analysis, and writing of the final manuscript. All the authors have read and approved the final manuscript.

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The study was approved by the ethical committee (HUH/1556/2021) of the Helsinki University Hospital, and permission to conduct the study was obtained (HUH/153/2021) from the research organization. All participants received oral and written information about the study. All participants gave their written informed consent to participate. During the study, ethical principles regarding self-determination, harm avoidance, privacy and data protection and ethical considerations were considered and all methods were performed in accordance with the Declaration of Helsinki [ 89 , 90 , 91 , 92 ]. Confidentiality in reporting results was ensured by using codes instead of names in the quotations (e.g., nurse N1 and patient P1)

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Camilla, L., Daniel, B. & Maritta, V. Nurses’ and patients’ perceptions of physical health screening for patients with schizophrenia spectrum disorders: a qualitative study. BMC Nurs 23 , 321 (2024). https://doi.org/10.1186/s12912-024-01980-3

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Identifying gaps in healthcare: a qualitative study of Ukrainian refugee experiences in the German system, uncovering differences, information and support needs

• Kristin Rolke 1 ,
• Johanna Walter 1 ,
• Klaus Weckbecker 1 ,
• Eva Münster 1 &
• Judith Tillmann 1  

BMC Health Services Research volume  24 , Article number:  585 ( 2024 ) Cite this article

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The 5.8 million Ukrainian refugees arriving in European countries must navigate varying healthcare systems and different and often unknown languages in their respective host countries. To date, there has been little exploration of the experiences, perceived differences, information and support needs of these refugees regarding the use of healthcare in Germany.

We conducted ten qualitative interviews with Ukrainian refugees living in Germany from February to May 2023, using Ukrainian, English and German language. The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker with the MAXQDA software.

In general, participants consistently had a positive experience of the German healthcare system, particularly regarding the quality of treatments and insurance. Differences have been reported in the structure of the healthcare systems. The Ukrainian healthcare system is divided into private and state sectors, with no mandatory insurance and frequent out-of-pocket payments. Pathways differ and tend to focus more on clinics and private doctors. General practitioners, often working in less well-equipped offices, have only recently gained prominence due to healthcare system reforms. Initiating contact with doctors is often easier, with much shorter waiting times compared to Germany. Interviewees often found the prescription requirements for many medications in Germany to be unusual. However, the mentioned differences in healthcare result in unmet information needs among the refugees, especially related to communication, navigating the healthcare system, health insurance, waiting times and medication access. These needs were often addressed through personal internet research and informal (social media) networks because of lacking official information provided during or after their arrival.

Conclusions

Despite the positive experiences of Ukrainian refugees in the German healthcare system, differences in the systems and language barriers led to barriers using healthcare and information needs among refugees. The dissemination of information regarding characteristics of the German health care system is crucial for successful integration but is currently lacking.

Trial Registration

German Clinical Trials Register: DRKS00030942, date of registration: 29.12.2022.

Peer Review reports

Since the beginning of the war in Ukraine on 24th February 2022, more than 5.8 million people from Ukraine have been registered as refugees in European countries; in Germany, the number is estimated at more than one million in 2023 [ 1 ]. 80% of adult refugees in Germany are women, nearly half of them came to Germany with their minor children and live mostly in private accommodations [ 2 ]. Since June 2022, refugees from Ukraine are not required to go through an asylum procedure due to the Temporary Protection Directive (2001/55/EG), but receive temporary protection in the European Union for up to three years after registration in the Central Register of Foreigners. They are thus entitled to medical care according to the catalog of the statutory health insurance (SHI) [ 3 ]. In Germany, around 90% of the population is covered by SHI [ 4 ]. There is an obligation to be insured in a SHI up to a fixed income limit. Earners above this limit and some professional groups can opt for private health insurance. Healthcare is primarily financed by contributions from citizens and employers, as along with subsidies from tax revenue [ 5 ]. In Germany, the Standing Committee on Vaccination (STIKO) makes recommendations on the implementation of vaccinations in accordance with § 20 (2) of the Infectious Diseases Protection Act (IfSG). Vaccination is only compulsory for measles for all children aged one year and above who attend community facilities such as kindergartens or schools, as well as some occupational groups. The healthcare system in Germany is divided into outpatient care, the hospital sector and rehabilitation facilities. The general practitioner is often the first point of contact in case of health problems and refers patients to other specialists if necessary; patients can also consult other specialists directly without a referral.

Ukrainian refugees have rarely been prepared for the contact with healthcare in Germany, which can be attributed to the rapid outbreak of war and the sudden flight. German health professionals can often look back on a long history of experience in treating refugees. Nevertheless they now face new regulations due to the EU mass influx directive [ 3 ] and also a lack of information flow, e.g. in regard of information for practice teams and a lack of networking with psychotherapeutic services, contact points, medication databases and regional interpreter services [ 6 ]. Differences in the healthcare systems, such as their structure and initial contacts/pathways in case of illness, prescription rules of medication, and coping with diseases may play a role in becoming familiar with another healthcare system.

Differences in the healthcare system are rarely described in the literature or health data. Findings include, for example, corruption problems with procurement of medication [ 7 ], low vaccination coverage rates e.g. regarding polio or COVID-19, and one of the highest burdens in Europe of chronic infectious diseases such as tuberculosis and HIV in Ukraine [ 8 , 9 ]. Life expectancy at birth in Ukraine is on average 65.2 years for men (Germany: 78.6 years), significantly lower than for women with 74.4 years (Germany: 83.4 years) [ 10 , 11 ]. The Ukrainian healthcare system is underfunded, which leads to high out-of-pocket expenditure on the part of the population in order to achieve adequate care, although formally the healthcare system provides free care in public healthcare facilities. Besides, taking out health insurance is voluntary [ 12 , 13 ].

In 2018 the state healthcare system in Ukraine was reformed. The reform of general practitioner (GP) care in Ukraine has included a free choice of doctor and stronger gatekeeping by the GP in the form of a referral system-similar to that in Germany [ 7 , 13 ]. Literature from UK and Poland indicate that Ukrainian refugees are in need of healthcare services, especially for chronic diseases, gynecological and obstetric treatments as well as mental health [ 14 , 15 ].

Experiences and challenges in contact with Ukrainian refugees in Germany from the viewpoint ofGPs have been researched in 2022 in a quantitative study. Communication, lack of information on previous illnesses, refugees’ expectations of services to be provided (e.g. routine unsubstantiated blood tests, thyroid tests, prescription of multivitamin supplements), and drug prescription due to unavailable or unknown medication were mentioned by GPs as the most common challenges [ 6 ]. A publication from Poland on health system differences between Ukraine and Poland indicates differences in immunization programs and prevalence of some infectious diseases [ 16 ]. However, the experiences and needs of Ukrainian refugees themselves in other healthcare systems, especially the German one, have rarely been studied and are of high current relevance. They are essential to understand patients’ points of view and to develop solutions to improve care and facilitate the arrival and integration of refugees in the German healthcare system.

That is why we focus on this topic in the following study (RefUGe-P) and aim to answer the following research questions in this publication:

How do Ukrainian refugees experience healthcare in Germany regarding major differences to the system in Ukraine and which information and support needs can be identified?

The methodological elaboration of the study was carried out taking into account the COREQ guideline [ 17 ].

Study design

For this study, ten Ukrainian refugees from four cities in the German region of North-Rhine-Westphalia (NRW) were interviewed in person in German, English and Ukrainian. Theoretical saturation was reached after ten interviews were conducted, so no further interview participants were recruited. The two German and two English interviews were conducted by the project staff. The six interviews in Ukrainian were conducted with the help of interpreters who translated in the interview from Ukrainian to German and vice versa. The interpreters worked on a voluntary basis, but had a lot of experience in interpreting for Ukrainian refugees at medical appointments. Additionally, information materials and consent forms were translated into the respective languages and handed out before participation.

The interview participants were recruited in various ways, mostly face-to face, via multipliers (responsible municipal employees, employees of welfare organisations, people of Ukrainian origin who volunteer to translate for refugees in the federal state of North Rhine-Westphalia) known to the project staff in four cities. The multipliers received detailed information about the planned study as well as information about the necessary inclusion criteria for participation, both orally and through a project flyer and a study information sheet. The aforementioned information materials were made available to the multipliers for their workplace and they approached refugees about the project. Interested persons were then able to contact the project staff directly or informed the multipliers about their interest for participation. The prerequisite for participation was that the interviewees were at least 18 years old and had visited a general practitioner in Germany at least once after their arrival. Additionally, it was aimed to achieve diversity among participants in terms of age, gender, family situation and health status. One potential participant was excluded because he/she had not seen a GP himself/herself as a patient.

Participants received an information sheet about the study with information on data protection and filled in a short questionnaire about sociodemographic information. These documents were also explained to every participant in person by the interviewer. All participants were fully informed by the interviewers about the study, data protection and signed written informed consent forms.

The development of the interview guide was based on the guidelines developed by Helfferich [ 18 ] and began with open narrative stimuli (opening question Appendix 1) before progressing to more specific questions. Since the research interest included different topic-specific aspects, the interview form of the problem-centered interview according to Witzel [ 19 ] was considered during guide development.

Additionally, an expert advisory board consisting of five representatives from various disciplines (including general practice, local authorities, welfare organisations and interpreters) was established to accompany the project and was involved in the preparation of the interview guide and preparation and interpretation of results. The interview guide has been newly developed for this study and is available as supplementary material (appendix 1). The main topics of the semi-structured interviews are shown there. The interview guide was pretested in two interview situations. One pretest was conducted in German, one in English whereby no adjustments had to be made.

All interviews were conducted between February and May 2023 and lasted an average of 45 min (35 min to 1 h and 10 min). They were audio-recorded and fully transcribed by an external service provider in German and English and coded in these languages. Interview protocols were written after each interview, noting special incidents and details about the interview location and atmosphere which were included in the analyses.

Data analysis

The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker [ 20 ] with the computer software MAXQDA version 20 and 22. The content analysis according to Kuckartz and Rädiker can be carried out in three forms (to structure content, to evaluate it or to form types) [ 20 ]. The former was used for this project in order to be able to analyse the material in terms of content and topic.

The codes were developed through both deductive and inductive methods (Fig.  1 ). Deductive categories were formed by the subject areas that had already been recorded in the interview guide. Inductive categories were developed directly from the material.

Coding tree with relevant categories for this article, RefUGe-P

The interviews were independently coded by two authors and the results were subsequently compared and discussed. This process aimed to improve the quality of results and mitigate the influence of subjective perspectives. One of these authors is a public health scientist with a PhD and several years of work experience in the field of migration and health and the other is a psychologist and medical student.

Sample characteristics

A total of ten interviews were conducted with seven female and three male participants. The participants had an average age of 47.6 years (min. 29 years, max. 70 years). Additional participant characteristics are presented in Table  1 .

Refugees constitute a vulnerable group of people and this was considered during the study’s conception and research design. The interview questions were checked in advance to ensure that personal events and memories related to the flight experience were not discussed, thus minimizing the potential for retraumatization during the interviews. One interviewer was experienced in working with interview partners who had refugee experiences through prior project experience and workshops regarding this topic. The second interviewer received information and exchange of experiences via the project team. The multipliers assisting with recruitment had established positive relationships with the participants. They personally introduced the interviewers, contributing to the development of trust.

The Ethics Committee of the University Witten/Herdecke, Germany, granted approval for this study (reference number: S-219/2022).

In general, the participants’ experience of the German healthcare system was consistently positive. Interviewees positively mentioned the good and thorough treatment, as well as the extensive technical equipment of the doctors’ offices and health insurance. In particular, the inclusion of patients in treatment decisions and the information provided, for example in the case of upcoming surgical procedures, were positively emphasized in the interviews. Likewise, the reminder of the possibility to participate in preventive check-ups in old age was appreciated.

“So the first thing that comes to my mind and I think is very good, I got the insurance and immediately got the invitations for examinations. Mammography and colonoscopy. What I have never experienced in Ukraine like this.” (I5)

Differences between the German and the Ukrainian healthcare system

Pathways and structure of the healthcare system.

The interviewees reported that the healthcare system in Ukraine consists of a private and a state system, which exist side by side. Since there is no mandatory health insurance in Ukraine, according to the interviewees, citizens have the freedom to choose the services they want to use. Financial viability plays a major role in their decision-making. While many services provided by the state system are free of charge, those provided by private institutions must be paid for privately. The interviewees therefore reported different utilization patterns, which can be summarized in three scenarios: Exclusive use of the state system, exclusive use of the private system, or use of both systems.

“ I had a GP in Ukraine and then another private doctor and I communicated with both of them. Depending on the time (…) and then, because I had money, I got insurance also. ” (I5)

In case of illness, the participants in Ukraine usually went to a (poly)clinic containing many specialized medical fields, presented their concerns and were referred to the appropriate department. Some went to a physician assigned to them according to their place of residence. In urgent cases, private physicians could be visited directly on the same day. Home visits were also common in this context. Patients could request and pay for blood tests at laboratories and could immediately access their test results after processing.

“So suppose you call and it is said that the doctor can only come the day after tomorrow, but you urgently want him to come today, then you can pay money so that he comes today. Which is also not very expensive, so the equivalent of about ten euros.” (I6)

Some of the private institutions were considered to be of higher quality, both in medical treatment and in the equipment. Participants often had the mobile phone number of their doctors and could contact them around the clock. They got a diagnosis from remote and started treatment as suggested.

“If I have a fever or something then I can contact my doctor conveniently via Viber or WhatsApp. I text my doctor, my daughter is sick, she can’t eat and drink and she has a fever, what should I do, and the doctor writes what I should do. For example, you have to go to the hospital now, or go to the pharmacy and buy such tablets.” (I2)

In Ukraine a general practitioner system was also established in 2018. However, according to the interviewees, this has not yet been established everywhere across the country and private payments still exist.

Health insurance

Interviewees reported that health insurance covering major health treatment in case of illness likewise in Germany is not common in Ukraine and just a minority can afford it. Therefore, services are used when needed, often in the private sector, in order to be treated immediately. Surgeries in particular were described as very expensive and often unaffordable. Many Ukrainians save money for years in order to pay a medical treatment. The need for regular medication and its acquisition is described to be particularly challenging for elderly people due to the low pensions.

“(…) I don’t have this system in Ukraine because we don’t have obligatory health insurance. People in Ukraine don’t have this system. That’s why they can pay money for the first visit or for next visits and just came to the doctor and have health (…) treatment. (…) You just need to pay money and go to doctor.” (I1)

Some of the interviewees also reported that since the reform of the healthcare system in Ukraine, health insurance with fixed monthly rates has been introduced, but that it is not functioning effectively. However, state care is often described to be of lower quality and private payments to doctors are still frequent. In Germany, they experienced the insurance system as better and medical care as more affordable.

“Concerning the pediatrician. I can always call him and somehow ask him what medication I have to give my children now or what I should do when she feels ill. But I always send money in return. That means it’s always about money. And if you don’t do it, then nobody cares about you in the health system.” (I7)

Waiting times

All of the interviewees were initially surprised by the long waiting times in Germany. Waiting for months to get specialist appointments and long waiting times in doctor’s offices and clinics were unfamiliar to the refugees. Some found these long waiting times to be stressful and problematic. Furthermore, concerns were expressed about not receiving help quickly enough in case of emergency. Interviewees also reported difficulties in finding a GP who was not busy and still accepting new patients.

“(…) So this is long, long, long everywhere. You need to wait for an appointment, you need to wait in a waiting room. You will need to wait. Yeah, I understand. It’s different from Ukrainian system, but, yes, sometimes it’s exhausting.” (I1)

As a result, some of the interview participants thought about returning to Ukraine for treatment or knew other people who did this.

“She called several doctors nearby, dermatology yes, and the earliest appointment was only in three months. And what did she do? She went to Ukraine. We can go to Ukraine. And she bought a ticket in the bus, and went to city A by bus, and she did everything for one day. In the clinic she made laser, she had all blood tests. In the morning she had all the results.” (I2)

Prescription of medication and vaccination

The requirement for a prescription to obtain medication in Germany was unfamiliar to some interviewees. In Ukraine, various medicines were bought without a prescription, including antibiotics. The interviewees also observed that German doctors prescribe fewer medications than Ukrainian ones and they often recommend alternatives for symptoms like fever and headaches.

“But in Ukraine it is really common (…) when my kids are sick, I always got a prescription with total list of pills, even if it is like common fever or something like that.” (I1)

In addition to people who experienced this as positive, there were also negative statements, for example when antibiotics were not prescribed for infections and therefore then ordered in Ukraine. Additionally, individual reports highlighted differences in medication quality (better in Germany), and availability (certain Ukrainian combination medications were not available in Germany).

“She (the GP) said to me that my daughter must drink more tea and I will be honest with you, I called to my friends. They lived in (city in Germany) and I asked them to call my doctor in Ukraine so I can find an antibiotic.” (I9)

The mothers interviewed also wondered about the vaccinations given to their children, which they did not know from Ukraine. Most Ukrainian participants were also unaware of adult booster vaccinations. The majority was vaccinated only in childhood. Several interviewees reported that there is no structured approach to adult immunization in Ukraine. One person said that he/she did not know where to go as an adult to get vaccinations in Ukraine.

“But what I did here, for example, the doctor here immediately offered to do so and so many vaccinations. After sixty years. And we never got such an offer in Ukraine.” (I3)

Information and support needs

Most of the interviewees did not receive information about the German healthcare system, medical care and insurance in Germany. Instead, they had to seek information themselves, often by doing their own research on the internet. Frequently friends, relatives, hosts, language course teachers, interpreters, etc. were asked for information. Some of the interviewees described this process as difficult. Often they asked other Ukrainians in their place of residence, e.g. through Telegram or other online Ukrainian community groups. There, doctors were recommended, lists were shared, information was spread, questions were asked and translation help was offered or requested. Interpreters are searched for through these networks as well to overcome language barriers.

“We have some webs, there is this group in Telegram (…) and we have the big, big list and people ask maybe who knows some gynecologist or something like this and people help.” (I9)

Table  2 specifies frequently mentioned information needs and improvement requests from refugees in Germany, along with selected quotes.

Our study identified perceived differences between the German and Ukrainian healthcare systems with the Ukrainian system still being shaped by out-of-pocket payments, private care, no mandatory insurance, and a GP system only gaining prominence in the recent years before the war. Easier contact to doctors with shorter waiting times and less prescription requirements for some medications have been reported about Ukraine. These differences in combination with lacking official information provided during or after arrival lead to unmet information and support needs among Ukrainian refugees living in Germany.

The results are particularly relevant in light of the fact that many Ukrainians would like to live in Germany in the long term, recorded in current surveys [ 2 ]. Therefore, it is crucial to ensure the successful integration of this patient group and a mutual understanding of their needs to provide equal healthcare opportunities. Some of the results of this article may also be of interest to other countries, as the findings on the structure and characteristics of the Ukrainian healthcare sector can be compared regionally. In addition, the results show parallels to studies on refugees from other countries of origin in Germany, e.g. persisting communication problems [ 21 , 22 ].

Pathways in the healthcare system and waiting times

In Ukraine, fast access to healthcare, especially if the services are privately paid for, results in short waiting times and easy access to doctors. Therefore, Ukrainians in the German system are not used to experience long waiting times and not to have the ability to expedite the processes themselves. As reported from the interviewees in Ukraine, patients often commission, pay for and receive their own medical analyses. In the interviews it became clear that the different approach and the different circumstances in Germany can cause a feeling of loss of control and unpredictability. As patients in Ukraine, they were able to act in a self-determined manner and, for example, pay money in order to be treated more quickly. In Germany, faster access to care is particularly important in the case of acute or life-threatening conditions. It might be perceived as impatience or high expectations, but it primarily stems from differences in healthcare systems, habits and the lack of information dissemination. Ukrainian-language information on the German healthcare system should be provided to the refugees as soon as they arrive.

Prescription of medication and prevention

The respondents were often unfamiliar with preventive care services and booster vaccinations in adulthood. This lack of awareness may be attributed to the low vaccination rates in Ukraine prior to the war, which led to outbreaks of vaccine-preventable diseases such as measles and polio between 2017 and 2020 [ 23 ]. Despite a national vaccination schedule provided by the Ministry of health in Ukraine [ 24 ], vaccination rates are among the lowest in Europe. Preventive measures in Germany (e.g. cancer screening) were welcomed after information and explanation in our study. At the same time, people with a migration background have an on average lower level of health literacy with regard to preventive care services in Germany compared to people without a migration background [ 25 ]. Therefore, it can be useful to inform and educate patients about this approach to healthcare and to increase health literacy in general.

Participants also reported differences about how medication is prescribed and taken like quick prescription of medications by Ukrainian doctors. Since antibiotics were also sold over-the-counter in Ukraine until recently [ 26 ], self-medication occurred frequently. Having a large number of different medications were not rare in households. This old practice was criticized among some younger respondents and they appreciate the new reform regulations in Ukraine and feel comfortable with the treatment approach in Germany. It is essential for doctors and medical staff to be aware of these differences to address misconceptions and raise awareness about (in)effectiveness of medications.

Participants valued their membership in the German SHI as it provided them with a sense of security. However, not all participants were accustomed to this, as they often had to save up the required amount for healthcare. Because of this difference, the respondents wished to receive more information about the scope of medical services provided by the SHI, as it was not clear to them that most costs of necessary medication are included, whilst dental treatment, for example, partially requires private payment. This information should be made available upon arrival in Germany.

None of our interviewees received information about the German healthcare system or healthcare in general through official channels. The fact that information about the health care system is often obtained via informal channels is also reported in other (inter-)national studies [ 22 , 27 ]. This should be changed urgently to improve care and facilitate access for the refugees. As there is a lot of Ukrainian and Russian information online created for example by the Federal Office for Migration and Refugees ( www.germany4ukraine.de ), but it does not seem to reach the refugees, the distribution should be improved. This should already be done upon arrival, e.g. at registration at the Foreigners’ Registration Office or at the Citizens’ Registration Office in case of residence registration, but can also be useful in doctor’s offices.

As also identified in other studies [ 6 , 16 , 28 ], refugees in our study perceived some information and support needs to healthcare regarding communication. In many cases, the treating physicians demanded that an interpreting person must be present. Refugees, on the one hand, are therefore under pressure to find interpreters, who are often rare, in a country and system they often do not know and on the other hand, they always have to seek help. This situation also led them to bypass the issue and seek out Russian-speaking doctors. Still, the costs for professional interpreters are generally not reimbursed in GP practices and have to be paid by the patient [ 29 ]. There is a need for interpreters, preferably paid and professional, both when making and taking advantage of appointments. This has already been demanded for general practice and practices in general [ 30 , 31 , 32 ]. Biddle et al. [ 21 ] also emphasize the expansion of high-quality interpreting services in Germany. It cannot be the task of the refugees to look for and pay for interpreters. This should be urgently organized by the state, for example through (municipal) contact points for interpreter seekers and (telephone or video) interpreter services for medical consultations.

Limitations

Around half of the interviews were conducted with the help of interpreters. The real-time translation by interpreters demands a high level of concentration. An exact reproduction of all interview content is hardly possible, so that a loss of information cannot be prevented [ 33 ]. The interpreters were known to the patients from previous medical appointments and had already established a relationship of trust with them. However, multipliers, researchers and interpreters involved made it clear that participation was voluntary and emphasised the aims of the research work. Furthermore, the interviews were solely conducted in NRW, Germany’s most populous federal state. The study could therefore be expanded throughout Germany and with more participants in order to gain further insights - including into regional differences. However, through the broad spread of age groups, gender, locations, diseases and the inclusion of several multipliers, we have attempted to get a broad picture.

This study provides important and new information about the healthcare experiences of Ukrainian refugees in Germany, differences in the healthcare systems and resulting information and support needs from the perspective of refugees.

Participants’ experiences of the German healthcare system were predominantly positive, especially because of the quality of treatments and health insurance. Nonetheless, health system differences in pathways, responsibilities, structure, insurance and costs, quality, medication and prevention as well as waiting times are noticeable for Ukrainian refugees in the German healthcare system, and influence their utilization of services. On top of this, the language barrier is a huge and still unsolved problem. Disseminating information about the new healthcare system shortly after the arrival of Ukrainian refugees in Germany, conducting educational efforts and tackling language barriers are essential for successful integration, but are lacking in Germany.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

general practitioner

North Rhine-Westphalia

statutory health insurance

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Acknowledgements

We would like to thank all interview partners for their openness and very informative conversations. We would also like to thank all the experts of our advisory board for the deep and insightful discussions during the meetings and the engagement beyond, especially the two interpreters. We also thank the University of Witten/Herdecke for the financial support of the study.

This research received funding from the internal grant program (project IFF 2023-68) of the Faculty of Health at Witten/Herdecke University, Germany.

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KR developed the interview guide with team support, recruited participants with the assistance of multipliers, conducted the majority of the interviews, wrote big parts of the manuscript. JT mainly devised the basic idea and research concept, conducted background research on the topic, contributed essentially to the development of the interview guide, analysed the interviews in collaboration with JW, wrote big parts of the manuscript and provided guidance as the project leader throughout all phases. JW conducted essential research on the topic, conducted part of the interviews, jointly analysed them with JT and wrote parts of the results section. KW devised the basic idea, provided practical medical expertise and made significant contribution to data interpretation. EM contributed to the discussion section and significantly contribution to data interpretation. All authors read and approved the final manuscript and are accountable for all aspects of the work.

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What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

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What is Qualitative in Research

Unsettling definitions of qualitative research, what is “qualitative” in qualitative research why the answer does not matter but the question is important.

Avoid common mistakes on your manuscript.

If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.

To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker ( 1963 ) asks ‘How does one become a marijuana user?’ In contrast to pre-dispositional and psychological-individualistic theories of deviant behavior, Becker’s inherently social explanation contends that becoming a user of this substance is the result of a three-phase sequential learning process. First, potential users need to learn how to smoke it properly to produce the “correct” effects. If not, they are likely to stop experimenting with it. Second, they need to discover the effects associated with it; in other words, to get “high,” individuals not only have to experience what the drug does, but also to become aware that those sensations are related to using it. Third, they require learning to savor the feelings related to its consumption – to develop an acquired taste. Becker, who played music himself, gets close to the phenomenon by observing, taking part, and by talking to people consuming the drug: “half of the fifty interviews were conducted with musicians, the other half covered a wide range of people, including laborers, machinists, and people in the professions” (Becker 1963 :56).

Another central aspect derived through the common-to-all-research interplay between induction and deduction (Becker 2017 ), is that during the course of his research Becker adds scientifically meaningful new distinctions in the form of three phases—distinctions, or findings if you will, that strongly affect the course of his research: its focus, the material that he collects, and which eventually impact his findings. Each phase typically unfolds through social interaction, and often with input from experienced users in “a sequence of social experiences during which the person acquires a conception of the meaning of the behavior, and perceptions and judgments of objects and situations, all of which make the activity possible and desirable” (Becker 1963 :235). In this study the increased understanding of smoking dope is a result of a combination of the meaning of the actors, and the conceptual distinctions that Becker introduces based on the views expressed by his respondents. Understanding is the result of research and is due to an iterative process in which data, concepts and evidence are connected with one another (Becker 2017 ).

Indeed, there are many definitions of qualitative research, but if we look for a definition that addresses its distinctive feature of being “qualitative,” the literature across the broad field of social science is meager. The main reason behind this article lies in the paradox, which, to put it bluntly, is that researchers act as if they know what it is, but they cannot formulate a coherent definition. Sociologists and others will of course continue to conduct good studies that show the relevance and value of qualitative research addressing scientific and practical problems in society. However, our paper is grounded in the idea that providing a clear definition will help us improve the work that we do. Among researchers who practice qualitative research there is clearly much knowledge. We suggest that a definition makes this knowledge more explicit. If the first rationale for writing this paper refers to the “internal” aim of improving qualitative research, the second refers to the increased “external” pressure that especially many qualitative researchers feel; pressure that comes both from society as well as from other scientific approaches. There is a strong core in qualitative research, and leading researchers tend to agree on what it is and how it is done. Our critique is not directed at the practice of qualitative research, but we do claim that the type of systematic work we do has not yet been done, and that it is useful to improve the field and its status in relation to quantitative research.

The literature on the “internal” aim of improving, or at least clarifying qualitative research is large, and we do not claim to be the first to notice the vagueness of the term “qualitative” (Strauss and Corbin 1998 ). Also, others have noted that there is no single definition of it (Long and Godfrey 2004 :182), that there are many different views on qualitative research (Denzin and Lincoln 2003 :11; Jovanović 2011 :3), and that more generally, we need to define its meaning (Best 2004 :54). Strauss and Corbin ( 1998 ), for example, as well as Nelson et al. (1992:2 cited in Denzin and Lincoln 2003 :11), and Flick ( 2007 :ix–x), have recognized that the term is problematic: “Actually, the term ‘qualitative research’ is confusing because it can mean different things to different people” (Strauss and Corbin 1998 :10–11). Hammersley has discussed the possibility of addressing the problem, but states that “the task of providing an account of the distinctive features of qualitative research is far from straightforward” ( 2013 :2). This confusion, as he has recently further argued (Hammersley 2018 ), is also salient in relation to ethnography where different philosophical and methodological approaches lead to a lack of agreement about what it means.

Others (e.g. Hammersley 2018 ; Fine and Hancock 2017 ) have also identified the treat to qualitative research that comes from external forces, seen from the point of view of “qualitative research.” This threat can be further divided into that which comes from inside academia, such as the critique voiced by “quantitative research” and outside of academia, including, for example, New Public Management. Hammersley ( 2018 ), zooming in on one type of qualitative research, ethnography, has argued that it is under treat. Similarly to Fine ( 2003 ), and before him Gans ( 1999 ), he writes that ethnography’ has acquired a range of meanings, and comes in many different versions, these often reflecting sharply divergent epistemological orientations. And already more than twenty years ago while reviewing Denzin and Lincoln’ s Handbook of Qualitative Methods Fine argued:

While this increasing centrality [of qualitative research] might lead one to believe that consensual standards have developed, this belief would be misleading. As the methodology becomes more widely accepted, querulous challengers have raised fundamental questions that collectively have undercut the traditional models of how qualitative research is to be fashioned and presented (1995:417).

According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” ( 2018 :1). He lists five external treats: (1) that social research must be accountable and able to show its impact on society; (2) the current emphasis on “big data” and the emphasis on quantitative data and evidence; (3) the labor market pressure in academia that leaves less time for fieldwork (see also Fine and Hancock 2017 ); (4) problems of access to fields; and (5) the increased ethical scrutiny of projects, to which ethnography is particularly exposed. Hammersley discusses some more or less insufficient existing definitions of ethnography.

The current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.

Towards a Definition of Qualitative Research

Seen in an historical light, what is today called qualitative, or sometimes ethnographic, interpretative research – or a number of other terms – has more or less always existed. At the time the founders of sociology – Simmel, Weber, Durkheim and, before them, Marx – were writing, and during the era of the Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods (cf. Swedberg 1990 ), we can at least speak of qualitative forerunners.

Perhaps the most extended discussion of what later became known as qualitative methods in a classic work is Bronisław Malinowski’s ( 1922 ) Argonauts in the Western Pacific , although even this study does not explicitly address the meaning of “qualitative.” In Weber’s ([1921–-22] 1978) work we find a tension between scientific explanations that are based on observation and quantification and interpretative research (see also Lazarsfeld and Barton 1982 ).

If we look through major sociology journals like the American Sociological Review , American Journal of Sociology , or Social Forces we will not find the term qualitative sociology before the 1970s. And certainly before then much of what we consider qualitative classics in sociology, like Becker’ study ( 1963 ), had already been produced. Indeed, the Chicago School often combined qualitative and quantitative data within the same study (Fine 1995 ). Our point being that before a disciplinary self-awareness the term quantitative preceded qualitative, and the articulation of the former was a political move to claim scientific status (Denzin and Lincoln 2005 ). In the US the World War II seem to have sparked a critique of sociological work, including “qualitative work,” that did not follow the scientific canon (Rawls 2018 ), which was underpinned by a scientifically oriented and value free philosophy of science. As a result the attempts and practice of integrating qualitative and quantitative sociology at Chicago lost ground to sociology that was more oriented to surveys and quantitative work at Columbia under Merton-Lazarsfeld. The quantitative tradition was also able to present textbooks (Lundberg 1951 ) that facilitated the use this approach and its “methods.” The practices of the qualitative tradition, by and large, remained tacit or was part of the mentoring transferred from the renowned masters to their students.

This glimpse into history leads us back to the lack of a coherent account condensed in a definition of qualitative research. Many of the attempts to define the term do not meet the requirements of a proper definition: A definition should be clear, avoid tautology, demarcate its domain in relation to the environment, and ideally only use words in its definiens that themselves are not in need of definition (Hempel 1966 ). A definition can enhance precision and thus clarity by identifying the core of the phenomenon. Preferably, a definition should be short. The typical definition we have found, however, is an ostensive definition, which indicates what qualitative research is about without informing us about what it actually is :

Qualitative research 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)

Flick claims that the label “qualitative research” is indeed used as an umbrella for a number of approaches ( 2007 :2–4; 2002 :6), and it is not difficult to identify research fitting this designation. Moreover, whatever it is, it has grown dramatically over the past five decades. In addition, courses have been developed, methods have flourished, arguments about its future have been advanced (for example, Denzin and Lincoln 1994) and criticized (for example, Snow and Morrill 1995 ), and dedicated journals and books have mushroomed. Most social scientists have a clear idea of research and how it differs from journalism, politics and other activities. But the question of what is qualitative in qualitative research is either eluded or eschewed.

We maintain that this lacuna hinders systematic knowledge production based on qualitative research. Paul Lazarsfeld noted the lack of “codification” as early as 1955 when he reviewed 100 qualitative studies in order to offer a codification of the practices (Lazarsfeld and Barton 1982 :239). Since then many texts on “qualitative research” and its methods have been published, including recent attempts (Goertz and Mahoney 2012 ) similar to Lazarsfeld’s. These studies have tried to extract what is qualitative by looking at the large number of empirical “qualitative” studies. Our novel strategy complements these endeavors by taking another approach and looking at the attempts to codify these practices in the form of a definition, as well as to a minor extent take Becker’s study as an exemplar of what qualitative researchers actually do, and what the characteristic of being ‘qualitative’ denotes and implies. We claim that qualitative researchers, if there is such a thing as “qualitative research,” should be able to codify their practices in a condensed, yet general way expressed in language.

Lingering problems of “generalizability” and “how many cases do I need” (Small 2009 ) are blocking advancement – in this line of work qualitative approaches are said to differ considerably from quantitative ones, while some of the former unsuccessfully mimic principles related to the latter (Small 2009 ). Additionally, quantitative researchers sometimes unfairly criticize the first based on their own quality criteria. Scholars like Goertz and Mahoney ( 2012 ) have successfully focused on the different norms and practices beyond what they argue are essentially two different cultures: those working with either qualitative or quantitative methods. Instead, similarly to Becker ( 2017 ) who has recently questioned the usefulness of the distinction between qualitative and quantitative research, we focus on similarities.

The current situation also impedes both students and researchers in focusing their studies and understanding each other’s work (Lazarsfeld and Barton 1982 :239). A third consequence is providing an opening for critiques by scholars operating within different traditions (Valsiner 2000 :101). A fourth issue is that the “implicit use of methods in qualitative research makes the field far less standardized than the quantitative paradigm” (Goertz and Mahoney 2012 :9). Relatedly, the National Science Foundation in the US organized two workshops in 2004 and 2005 to address the scientific foundations of qualitative research involving strategies to improve it and to develop standards of evaluation in qualitative research. However, a specific focus on its distinguishing feature of being “qualitative” while being implicitly acknowledged, was discussed only briefly (for example, Best 2004 ).

In 2014 a theme issue was published in this journal on “Methods, Materials, and Meanings: Designing Cultural Analysis,” discussing central issues in (cultural) qualitative research (Berezin 2014 ; Biernacki 2014 ; Glaeser 2014 ; Lamont and Swidler 2014 ; Spillman 2014). We agree with many of the arguments put forward, such as the risk of methodological tribalism, and that we should not waste energy on debating methods separated from research questions. Nonetheless, a clarification of the relation to what is called “quantitative research” is of outmost importance to avoid misunderstandings and misguided debates between “qualitative” and “quantitative” researchers. Our strategy means that researchers, “qualitative” or “quantitative” they may be, in their actual practice may combine qualitative work and quantitative work.

In this article we accomplish three tasks. First, we systematically survey the literature for meanings of qualitative research by looking at how researchers have defined it. Drawing upon existing knowledge we find that the different meanings and ideas of qualitative research are not yet coherently integrated into one satisfactory definition. Next, we advance our contribution by offering a definition of qualitative research and illustrate its meaning and use partially by expanding on the brief example introduced earlier related to Becker’s work ( 1963 ). We offer a systematic analysis of central themes of what researchers consider to be the core of “qualitative,” regardless of style of work. These themes – which we summarize in terms of four keywords: distinction, process, closeness, improved understanding – constitute part of our literature review, in which each one appears, sometimes with others, but never all in the same definition. They serve as the foundation of our contribution. Our categories are overlapping. Their use is primarily to organize the large amount of definitions we have identified and analyzed, and not necessarily to draw a clear distinction between them. Finally, we continue the elaboration discussed above on the advantages of a clear definition of qualitative research.

In a hermeneutic fashion we propose that there is something meaningful that deserves to be labelled “qualitative research” (Gadamer 1990 ). To approach the question “What is qualitative in qualitative research?” we have surveyed the literature. In conducting our survey we first traced the word’s etymology in dictionaries, encyclopedias, handbooks of the social sciences and of methods and textbooks, mainly in English, which is common to methodology courses. It should be noted that we have zoomed in on sociology and its literature. This discipline has been the site of the largest debate and development of methods that can be called “qualitative,” which suggests that this field should be examined in great detail.

In an ideal situation we should expect that one good definition, or at least some common ideas, would have emerged over the years. This common core of qualitative research should be so accepted that it would appear in at least some textbooks. Since this is not what we found, we decided to pursue an inductive approach to capture maximal variation in the field of qualitative research; we searched in a selection of handbooks, textbooks, book chapters, and books, to which we added the analysis of journal articles. Our sample comprises a total of 89 references.

In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: qualitative (which was always included), definition, empirical, research, methodology, studies, fieldwork, interview and observation .

As a second phase of our research we searched within nine major sociological journals ( American Journal of Sociology , Sociological Theory , American Sociological Review , Contemporary Sociology , Sociological Forum , Sociological Theory , Qualitative Research , Qualitative Sociology and Qualitative Sociology Review ) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.

Lastly we picked two additional journals, Qualitative Research and Qualitative Sociology , in which we could expect to find texts addressing the notion of “qualitative.” From Qualitative Research we chose Volume 14, Issue 6, December 2014, and from Qualitative Sociology we chose Volume 36, Issue 2, June 2017. Within each of these we selected the first article; then we picked the second article of three prior issues. Again we went back another three issues and investigated article number three. Finally we went back another three issues and perused article number four. This selection criteria was used to get a manageable sample for the analysis.

The coding process of the 89 references we gathered in our selected review began soon after the first round of material was gathered, and we reduced the complexity created by our maximum variation sampling (Snow and Anderson 1993 :22) to four different categories within which questions on the nature and properties of qualitative research were discussed. We call them: Qualitative and Quantitative Research, Qualitative Research, Fieldwork, and Grounded Theory. This – which may appear as an illogical grouping – merely reflects the “context” in which the matter of “qualitative” is discussed. If the selection process of the material – books and articles – was informed by pre-knowledge, we used an inductive strategy to code the material. When studying our material, we identified four central notions related to “qualitative” that appear in various combinations in the literature which indicate what is the core of qualitative research. We have labeled them: “distinctions”, “process,” “closeness,” and “improved understanding.” During the research process the categories and notions were improved, refined, changed, and reordered. The coding ended when a sense of saturation in the material arose. In the presentation below all quotations and references come from our empirical material of texts on qualitative research.

Analysis – What is Qualitative Research?

In this section we describe the four categories we identified in the coding, how they differently discuss qualitative research, as well as their overall content. Some salient quotations are selected to represent the type of text sorted under each of the four categories. What we present are examples from the literature.

Qualitative and Quantitative

This analytic category comprises quotations comparing qualitative and quantitative research, a distinction that is frequently used (Brown 2010 :231); in effect this is a conceptual pair that structures the discussion and that may be associated with opposing interests. While the general goal of quantitative and qualitative research is the same – to understand the world better – their methodologies and focus in certain respects differ substantially (Becker 1966 :55). Quantity refers to that property of something that can be determined by measurement. In a dictionary of Statistics and Methodology we find that “(a) When referring to *variables, ‘qualitative’ is another term for *categorical or *nominal. (b) When speaking of kinds of research, ‘qualitative’ refers to studies of subjects that are hard to quantify, such as art history. Qualitative research tends to be a residual category for almost any kind of non-quantitative research” (Stiles 1998:183). But it should be obvious that one could employ a quantitative approach when studying, for example, art history.

The same dictionary states that quantitative is “said of variables or research that can be handled numerically, usually (too sharply) contrasted with *qualitative variables and research” (Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read:

Qualitative Analysis. For methods of obtaining, analyzing, and describing data, see [the various entries:] CONTENT ANALYSIS; COUNTED DATA; EVALUATION RESEARCH, FIELD WORK; GRAPHIC PRESENTATION; HISTORIOGRAPHY, especially the article on THE RHETORIC OF HISTORY; INTERVIEWING; OBSERVATION; PERSONALITY MEASUREMENT; PROJECTIVE METHODS; PSYCHOANALYSIS, article on EXPERIMENTAL METHODS; SURVEY ANALYSIS, TABULAR PRESENTATION; TYPOLOGIES. (Vol. 13:225)

Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists” (Alford 1998 :12). Qualitative research uses a variety of methods, such as intensive interviews or in-depth analysis of historical materials, and it is concerned with a comprehensive account of some event or unit (King et al. 1994 :4). Like quantitative research it can be utilized to study a variety of issues, but it tends to focus on meanings and motivations that underlie cultural symbols, personal experiences, phenomena and detailed understanding of processes in the social world. In short, qualitative research centers on understanding processes, experiences, and the meanings people assign to things (Kalof et al. 2008 :79).

Others simply say that qualitative methods are inherently unscientific (Jovanović 2011 :19). Hood, for instance, argues that words are intrinsically less precise than numbers, and that they are therefore more prone to subjective analysis, leading to biased results (Hood 2006 :219). Qualitative methodologies have raised concerns over the limitations of quantitative templates (Brady et al. 2004 :4). Scholars such as King et al. ( 1994 ), for instance, argue that non-statistical research can produce more reliable results if researchers pay attention to the rules of scientific inference commonly stated in quantitative research. Also, researchers such as Becker ( 1966 :59; 1970 :42–43) have asserted that, if conducted properly, qualitative research and in particular ethnographic field methods, can lead to more accurate results than quantitative studies, in particular, survey research and laboratory experiments.

Some researchers, such as Kalof, Dan, and Dietz ( 2008 :79) claim that the boundaries between the two approaches are becoming blurred, and Small ( 2009 ) argues that currently much qualitative research (especially in North America) tries unsuccessfully and unnecessarily to emulate quantitative standards. For others, qualitative research tends to be more humanistic and discursive (King et al. 1994 :4). Ragin ( 1994 ), and similarly also Becker, ( 1996 :53), Marchel and Owens ( 2007 :303) think that the main distinction between the two styles is overstated and does not rest on the simple dichotomy of “numbers versus words” (Ragin 1994 :xii). Some claim that quantitative data can be utilized to discover associations, but in order to unveil cause and effect a complex research design involving the use of qualitative approaches needs to be devised (Gilbert 2009 :35). Consequently, qualitative data are useful for understanding the nuances lying beyond those processes as they unfold (Gilbert 2009 :35). Others contend that qualitative research is particularly well suited both to identify causality and to uncover fine descriptive distinctions (Fine and Hallett 2014 ; Lichterman and Isaac Reed 2014 ; Katz 2015 ).

There are other ways to separate these two traditions, including normative statements about what qualitative research should be (that is, better or worse than quantitative approaches, concerned with scientific approaches to societal change or vice versa; Snow and Morrill 1995 ; Denzin and Lincoln 2005 ), or whether it should develop falsifiable statements; Best 2004 ).

We propose that quantitative research is largely concerned with pre-determined variables (Small 2008 ); the analysis concerns the relations between variables. These categories are primarily not questioned in the study, only their frequency or degree, or the correlations between them (cf. Franzosi 2016 ). If a researcher studies wage differences between women and men, he or she works with given categories: x number of men are compared with y number of women, with a certain wage attributed to each person. The idea is not to move beyond the given categories of wage, men and women; they are the starting point as well as the end point, and undergo no “qualitative change.” Qualitative research, in contrast, investigates relations between categories that are themselves subject to change in the research process. Returning to Becker’s study ( 1963 ), we see that he questioned pre-dispositional theories of deviant behavior working with pre-determined variables such as an individual’s combination of personal qualities or emotional problems. His take, in contrast, was to understand marijuana consumption by developing “variables” as part of the investigation. Thereby he presented new variables, or as we would say today, theoretical concepts, but which are grounded in the empirical material.

Qualitative Research

This category contains quotations that refer to descriptions of qualitative research without making comparisons with quantitative research. Researchers such as Denzin and Lincoln, who have written a series of influential handbooks on qualitative methods (1994; Denzin and Lincoln 2003 ; 2005 ), citing Nelson et al. (1992:4), argue that because qualitative research is “interdisciplinary, transdisciplinary, and sometimes counterdisciplinary” it is difficult to derive one single definition of it (Jovanović 2011 :3). According to them, in fact, “the field” is “many things at the same time,” involving contradictions, tensions over its focus, methods, and how to derive interpretations and findings ( 2003 : 11). Similarly, others, such as Flick ( 2007 :ix–x) contend that agreeing on an accepted definition has increasingly become problematic, and that qualitative research has possibly matured different identities. However, Best holds that “the proliferation of many sorts of activities under the label of qualitative sociology threatens to confuse our discussions” ( 2004 :54). Atkinson’s position is more definite: “the current state of qualitative research and research methods is confused” ( 2005 :3–4).

Qualitative research is about interpretation (Blumer 1969 ; Strauss and Corbin 1998 ; Denzin and Lincoln 2003 ), or Verstehen [understanding] (Frankfort-Nachmias and Nachmias 1996 ). It is “multi-method,” involving the collection and use of a variety of empirical materials (Denzin and Lincoln 1998; Silverman 2013 ) and approaches (Silverman 2005 ; Flick 2007 ). It focuses not only on the objective nature of behavior but also on its subjective meanings: individuals’ own accounts of their attitudes, motivations, behavior (McIntyre 2005 :127; Creswell 2009 ), events and situations (Bryman 1989) – what people say and do in specific places and institutions (Goodwin and Horowitz 2002 :35–36) in social and temporal contexts (Morrill and Fine 1997). For this reason, following Weber ([1921-22] 1978), it can be described as an interpretative science (McIntyre 2005 :127). But could quantitative research also be concerned with these questions? Also, as pointed out below, does all qualitative research focus on subjective meaning, as some scholars suggest?

Others also distinguish qualitative research by claiming that it collects data using a naturalistic approach (Denzin and Lincoln 2005 :2; Creswell 2009 ), focusing on the meaning actors ascribe to their actions. But again, does all qualitative research need to be collected in situ? And does qualitative research have to be inherently concerned with meaning? Flick ( 2007 ), referring to Denzin and Lincoln ( 2005 ), mentions conversation analysis as an example of qualitative research that is not concerned with the meanings people bring to a situation, but rather with the formal organization of talk. Still others, such as Ragin ( 1994 :85), note that qualitative research is often (especially early on in the project, we would add) less structured than other kinds of social research – a characteristic connected to its flexibility and that can lead both to potentially better, but also worse results. But is this not a feature of this type of research, rather than a defining description of its essence? Wouldn’t this comment also apply, albeit to varying degrees, to quantitative research?

In addition, Strauss ( 2003 ), along with others, such as Alvesson and Kärreman ( 2011 :10–76), argue that qualitative researchers struggle to capture and represent complex phenomena partially because they tend to collect a large amount of data. While his analysis is correct at some points – “It is necessary to do detailed, intensive, microscopic examination of the data in order to bring out the amazing complexity of what lies in, behind, and beyond those data” (Strauss 2003 :10) – much of his analysis concerns the supposed focus of qualitative research and its challenges, rather than exactly what it is about. But even in this instance we would make a weak case arguing that these are strictly the defining features of qualitative research. Some researchers seem to focus on the approach or the methods used, or even on the way material is analyzed. Several researchers stress the naturalistic assumption of investigating the world, suggesting that meaning and interpretation appear to be a core matter of qualitative research.

We can also see that in this category there is no consensus about specific qualitative methods nor about qualitative data. Many emphasize interpretation, but quantitative research, too, involves interpretation; the results of a regression analysis, for example, certainly have to be interpreted, and the form of meta-analysis that factor analysis provides indeed requires interpretation However, there is no interpretation of quantitative raw data, i.e., numbers in tables. One common thread is that qualitative researchers have to get to grips with their data in order to understand what is being studied in great detail, irrespective of the type of empirical material that is being analyzed. This observation is connected to the fact that qualitative researchers routinely make several adjustments of focus and research design as their studies progress, in many cases until the very end of the project (Kalof et al. 2008 ). If you, like Becker, do not start out with a detailed theory, adjustments such as the emergence and refinement of research questions will occur during the research process. We have thus found a number of useful reflections about qualitative research scattered across different sources, but none of them effectively describe the defining characteristics of this approach.

Although qualitative research does not appear to be defined in terms of a specific method, it is certainly common that fieldwork, i.e., research that entails that the researcher spends considerable time in the field that is studied and use the knowledge gained as data, is seen as emblematic of or even identical to qualitative research. But because we understand that fieldwork tends to focus primarily on the collection and analysis of qualitative data, we expected to find within it discussions on the meaning of “qualitative.” But, again, this was not the case.

Instead, we found material on the history of this approach (for example, Frankfort-Nachmias and Nachmias 1996 ; Atkinson et al. 2001), including how it has changed; for example, by adopting a more self-reflexive practice (Heyl 2001), as well as the different nomenclature that has been adopted, such as fieldwork, ethnography, qualitative research, naturalistic research, participant observation and so on (for example, Lofland et al. 2006 ; Gans 1999 ).

We retrieved definitions of ethnography, such as “the study of people acting in the natural courses of their daily lives,” involving a “resocialization of the researcher” (Emerson 1988 :1) through intense immersion in others’ social worlds (see also examples in Hammersley 2018 ). This may be accomplished by direct observation and also participation (Neuman 2007 :276), although others, such as Denzin ( 1970 :185), have long recognized other types of observation, including non-participant (“fly on the wall”). In this category we have also isolated claims and opposing views, arguing that this type of research is distinguished primarily by where it is conducted (natural settings) (Hughes 1971:496), and how it is carried out (a variety of methods are applied) or, for some most importantly, by involving an active, empathetic immersion in those being studied (Emerson 1988 :2). We also retrieved descriptions of the goals it attends in relation to how it is taught (understanding subjective meanings of the people studied, primarily develop theory, or contribute to social change) (see for example, Corte and Irwin 2017 ; Frankfort-Nachmias and Nachmias 1996 :281; Trier-Bieniek 2012 :639) by collecting the richest possible data (Lofland et al. 2006 ) to derive “thick descriptions” (Geertz 1973 ), and/or to aim at theoretical statements of general scope and applicability (for example, Emerson 1988 ; Fine 2003 ). We have identified guidelines on how to evaluate it (for example Becker 1996 ; Lamont 2004 ) and have retrieved instructions on how it should be conducted (for example, Lofland et al. 2006 ). For instance, analysis should take place while the data gathering unfolds (Emerson 1988 ; Hammersley and Atkinson 2007 ; Lofland et al. 2006 ), observations should be of long duration (Becker 1970 :54; Goffman 1989 ), and data should be of high quantity (Becker 1970 :52–53), as well as other questionable distinctions between fieldwork and other methods:

Field studies differ from other methods of research in that the researcher performs the task of selecting topics, decides what questions to ask, and forges interest in the course of the research itself . This is in sharp contrast to many ‘theory-driven’ and ‘hypothesis-testing’ methods. (Lofland and Lofland 1995 :5)

But could not, for example, a strictly interview-based study be carried out with the same amount of flexibility, such as sequential interviewing (for example, Small 2009 )? Once again, are quantitative approaches really as inflexible as some qualitative researchers think? Moreover, this category stresses the role of the actors’ meaning, which requires knowledge and close interaction with people, their practices and their lifeworld.

It is clear that field studies – which are seen by some as the “gold standard” of qualitative research – are nonetheless only one way of doing qualitative research. There are other methods, but it is not clear why some are more qualitative than others, or why they are better or worse. Fieldwork is characterized by interaction with the field (the material) and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.

Grounded Theory

Another major category we identified in our sample is Grounded Theory. We found descriptions of it most clearly in Glaser and Strauss’ ([1967] 2010 ) original articulation, Strauss and Corbin ( 1998 ) and Charmaz ( 2006 ), as well as many other accounts of what it is for: generating and testing theory (Strauss 2003 :xi). We identified explanations of how this task can be accomplished – such as through two main procedures: constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” (for example, Strauss and Corbin 1998 :1). We also read descriptions of its main traits, what it entails and fosters – for instance, an exceptional flexibility, an inductive approach (Strauss and Corbin 1998 :31–33; 1990; Esterberg 2002 :7), an ability to step back and critically analyze situations, recognize tendencies towards bias, think abstractly and be open to criticism, enhance sensitivity towards the words and actions of respondents, and develop a sense of absorption and devotion to the research process (Strauss and Corbin 1998 :5–6). Accordingly, we identified discussions of the value of triangulating different methods (both using and not using grounded theory), including quantitative ones, and theories to achieve theoretical development (most comprehensively in Denzin 1970 ; Strauss and Corbin 1998 ; Timmermans and Tavory 2012 ). We have also located arguments about how its practice helps to systematize data collection, analysis and presentation of results (Glaser and Strauss [1967] 2010 :16).

Grounded theory offers a systematic approach which requires researchers to get close to the field; closeness is a requirement of identifying questions and developing new concepts or making further distinctions with regard to old concepts. In contrast to other qualitative approaches, grounded theory emphasizes the detailed coding process, and the numerous fine-tuned distinctions that the researcher makes during the process. Within this category, too, we could not find a satisfying discussion of the meaning of qualitative research.

Defining Qualitative Research

In sum, our analysis shows that some notions reappear in the discussion of qualitative research, such as understanding, interpretation, “getting close” and making distinctions. These notions capture aspects of what we think is “qualitative.” However, a comprehensive definition that is useful and that can further develop the field is lacking, and not even a clear picture of its essential elements appears. In other words no definition emerges from our data, and in our research process we have moved back and forth between our empirical data and the attempt to present a definition. Our concrete strategy, as stated above, is to relate qualitative and quantitative research, or more specifically, qualitative and quantitative work. We use an ideal-typical notion of quantitative research which relies on taken for granted and numbered variables. This means that the data consists of variables on different scales, such as ordinal, but frequently ratio and absolute scales, and the representation of the numbers to the variables, i.e. the justification of the assignment of numbers to object or phenomenon, are not questioned, though the validity may be questioned. In this section we return to the notion of quality and try to clarify it while presenting our contribution.

Broadly, research refers to the activity performed by people trained to obtain knowledge through systematic procedures. Notions such as “objectivity” and “reflexivity,” “systematic,” “theory,” “evidence” and “openness” are here taken for granted in any type of research. Next, building on our empirical analysis we explain the four notions that we have identified as central to qualitative work: distinctions, process, closeness, and improved understanding. In discussing them, ultimately in relation to one another, we make their meaning even more precise. Our idea, in short, is that only when these ideas that we present separately for analytic purposes are brought together can we speak of qualitative research.

Distinctions

We believe that the possibility of making new distinctions is one the defining characteristics of qualitative research. It clearly sets it apart from quantitative analysis which works with taken-for-granted variables, albeit as mentioned, meta-analyses, for example, factor analysis may result in new variables. “Quality” refers essentially to distinctions, as already pointed out by Aristotle. He discusses the term “qualitative” commenting: “By a quality I mean that in virtue of which things are said to be qualified somehow” (Aristotle 1984:14). Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required (cf. Habermas [1981] 1987 ; Davidsson [ 1988 ] 2001) to identify what is new and relevant scientific knowledge. Relatedly, Ragin alludes to the idea of new and useful knowledge at a more concrete level: “Qualitative methods are appropriate for in-depth examination of cases because they aid the identification of key features of cases. Most qualitative methods enhance data” (1994:79). When Becker ( 1963 ) studied deviant behavior and investigated how people became marihuana smokers, he made distinctions between the ways in which people learned how to smoke. This is a classic example of how the strategy of “getting close” to the material, for example the text, people or pictures that are subject to analysis, may enable researchers to obtain deeper insight and new knowledge by making distinctions – in this instance on the initial notion of learning how to smoke. Others have stressed the making of distinctions in relation to coding or theorizing. Emerson et al. ( 1995 ), for example, hold that “qualitative coding is a way of opening up avenues of inquiry,” meaning that the researcher identifies and develops concepts and analytic insights through close examination of and reflection on data (Emerson et al. 1995 :151). Goodwin and Horowitz highlight making distinctions in relation to theory-building writing: “Close engagement with their cases typically requires qualitative researchers to adapt existing theories or to make new conceptual distinctions or theoretical arguments to accommodate new data” ( 2002 : 37). In the ideal-typical quantitative research only existing and so to speak, given, variables would be used. If this is the case no new distinction are made. But, would not also many “quantitative” researchers make new distinctions?

Process does not merely suggest that research takes time. It mainly implies that qualitative new knowledge results from a process that involves several phases, and above all iteration. Qualitative research is about oscillation between theory and evidence, analysis and generating material, between first- and second -order constructs (Schütz 1962 :59), between getting in contact with something, finding sources, becoming deeply familiar with a topic, and then distilling and communicating some of its essential features. The main point is that the categories that the researcher uses, and perhaps takes for granted at the beginning of the research process, usually undergo qualitative changes resulting from what is found. Becker describes how he tested hypotheses and let the jargon of the users develop into theoretical concepts. This happens over time while the study is being conducted, exemplifying what we mean by process.

In the research process, a pilot-study may be used to get a first glance of, for example, the field, how to approach it, and what methods can be used, after which the method and theory are chosen or refined before the main study begins. Thus, the empirical material is often central from the start of the project and frequently leads to adjustments by the researcher. Likewise, during the main study categories are not fixed; the empirical material is seen in light of the theory used, but it is also given the opportunity to kick back, thereby resisting attempts to apply theoretical straightjackets (Becker 1970 :43). In this process, coding and analysis are interwoven, and thus are often important steps for getting closer to the phenomenon and deciding what to focus on next. Becker began his research by interviewing musicians close to him, then asking them to refer him to other musicians, and later on doubling his original sample of about 25 to include individuals in other professions (Becker 1973:46). Additionally, he made use of some participant observation, documents, and interviews with opiate users made available to him by colleagues. As his inductive theory of deviance evolved, Becker expanded his sample in order to fine tune it, and test the accuracy and generality of his hypotheses. In addition, he introduced a negative case and discussed the null hypothesis ( 1963 :44). His phasic career model is thus based on a research design that embraces processual work. Typically, process means to move between “theory” and “material” but also to deal with negative cases, and Becker ( 1998 ) describes how discovering these negative cases impacted his research design and ultimately its findings.

Obviously, all research is process-oriented to some degree. The point is that the ideal-typical quantitative process does not imply change of the data, and iteration between data, evidence, hypotheses, empirical work, and theory. The data, quantified variables, are, in most cases fixed. Merging of data, which of course can be done in a quantitative research process, does not mean new data. New hypotheses are frequently tested, but the “raw data is often the “the same.” Obviously, over time new datasets are made available and put into use.

Another characteristic that is emphasized in our sample is that qualitative researchers – and in particular ethnographers – can, or as Goffman put it, ought to ( 1989 ), get closer to the phenomenon being studied and their data than quantitative researchers (for example, Silverman 2009 :85). Put differently, essentially because of their methods qualitative researchers get into direct close contact with those being investigated and/or the material, such as texts, being analyzed. Becker started out his interview study, as we noted, by talking to those he knew in the field of music to get closer to the phenomenon he was studying. By conducting interviews he got even closer. Had he done more observations, he would undoubtedly have got even closer to the field.

Additionally, ethnographers’ design enables researchers to follow the field over time, and the research they do is almost by definition longitudinal, though the time in the field is studied obviously differs between studies. The general characteristic of closeness over time maximizes the chances of unexpected events, new data (related, for example, to archival research as additional sources, and for ethnography for situations not necessarily previously thought of as instrumental – what Mannay and Morgan ( 2015 ) term the “waiting field”), serendipity (Merton and Barber 2004 ; Åkerström 2013 ), and possibly reactivity, as well as the opportunity to observe disrupted patterns that translate into exemplars of negative cases. Two classic examples of this are Becker’s finding of what medical students call “crocks” (Becker et al. 1961 :317), and Geertz’s ( 1973 ) study of “deep play” in Balinese society.

By getting and staying so close to their data – be it pictures, text or humans interacting (Becker was himself a musician) – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often (but certainly not always), and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly (Fine 2003 ; Becker 1970 ). This testing nonetheless often leads to new directions for the research. Becker, for example, says that he was initially reading psychological theories, but when facing the data he develops a theory that looks at, you may say, everything but psychological dispositions to explain the use of marihuana. Especially researchers involved with ethnographic methods have a fairly unique opportunity to dig up and then test (in a circular, continuous and temporal way) new research questions and findings as the research progresses, and thereby to derive previously unimagined and uncharted distinctions by getting closer to the phenomenon under study.

Let us stress that getting close is by no means restricted to ethnography. The notion of hermeneutic circle and hermeneutics as a general way of understanding implies that we must get close to the details in order to get the big picture. This also means that qualitative researchers can literally also make use of details of pictures as evidence (cf. Harper 2002). Thus, researchers may get closer both when generating the material or when analyzing it.

Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables (Franzosi 2016 :138). The data may originally have been “qualitative,” but once reduced to numbers there can only be a type of “hermeneutics” about what the number may stand for. The numbers themselves, however, are non-ambiguous. Thus, in quantitative research, interpretation, if done, is not about the data itself—the numbers—but what the numbers stand for. It follows that the interpretation is essentially done in a more “speculative” mode without direct empirical evidence (cf. Becker 2017 ).

Improved Understanding

While distinction, process and getting closer refer to the qualitative work of the researcher, improved understanding refers to its conditions and outcome of this work. Understanding cuts deeper than explanation, which to some may mean a causally verified correlation between variables. The notion of explanation presupposes the notion of understanding since explanation does not include an idea of how knowledge is gained (Manicas 2006 : 15). Understanding, we argue, is the core concept of what we call the outcome of the process when research has made use of all the other elements that were integrated in the research. Understanding, then, has a special status in qualitative research since it refers both to the conditions of knowledge and the outcome of the process. Understanding can to some extent be seen as the condition of explanation and occurs in a process of interpretation, which naturally refers to meaning (Gadamer 1990 ). It is fundamentally connected to knowing, and to the knowing of how to do things (Heidegger [1927] 2001 ). Conceptually the term hermeneutics is used to account for this process. Heidegger ties hermeneutics to human being and not possible to separate from the understanding of being ( 1988 ). Here we use it in a broader sense, and more connected to method in general (cf. Seiffert 1992 ). The abovementioned aspects – for example, “objectivity” and “reflexivity” – of the approach are conditions of scientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something (Heidegger [1927] 2001 ; Gadamer 1990 :368–384). We propose that this iterative process in which the process of understanding occurs is characteristic of qualitative research.

Improved understanding means that we obtain scientific knowledge of something that we as a scholarly community did not know before, or that we get to know something better. It means that we understand more about how parts are related to one another, and to other things we already understand (see also Fine and Hallett 2014 ). Understanding is an important condition for qualitative research. It is not enough to identify correlations, make distinctions, and work in a process in which one gets close to the field or phenomena. Understanding is accomplished when the elements are integrated in an iterative process.

It is, moreover, possible to understand many things, and researchers, just like children, may come to understand new things every day as they engage with the world. This subjective condition of understanding – namely, that a person gains a better understanding of something –is easily met. To be qualified as “scientific,” the understanding must be general and useful to many; it must be public. But even this generally accessible understanding is not enough in order to speak of “scientific understanding.” Though we as a collective can increase understanding of everything in virtually all potential directions as a result also of qualitative work, we refrain from this “objective” way of understanding, which has no means of discriminating between what we gain in understanding. Scientific understanding means that it is deemed relevant from the scientific horizon (compare Schütz 1962 : 35–38, 46, 63), and that it rests on the pre-understanding that the scientists have and must have in order to understand. In other words, the understanding gained must be deemed useful by other researchers, so that they can build on it. We thus see understanding from a pragmatic, rather than a subjective or objective perspective. Improved understanding is related to the question(s) at hand. Understanding, in order to represent an improvement, must be an improvement in relation to the existing body of knowledge of the scientific community (James [ 1907 ] 1955). Scientific understanding is, by definition, collective, as expressed in Weber’s famous note on objectivity, namely that scientific work aims at truths “which … can claim, even for a Chinese, the validity appropriate to an empirical analysis” ([1904] 1949 :59). By qualifying “improved understanding” we argue that it is a general defining characteristic of qualitative research. Becker‘s ( 1966 ) study and other research of deviant behavior increased our understanding of the social learning processes of how individuals start a behavior. And it also added new knowledge about the labeling of deviant behavior as a social process. Few studies, of course, make the same large contribution as Becker’s, but are nonetheless qualitative research.

Understanding in the phenomenological sense, which is a hallmark of qualitative research, we argue, requires meaning and this meaning is derived from the context, and above all the data being analyzed. The ideal-typical quantitative research operates with given variables with different numbers. This type of material is not enough to establish meaning at the level that truly justifies understanding. In other words, many social science explanations offer ideas about correlations or even causal relations, but this does not mean that the meaning at the level of the data analyzed, is understood. This leads us to say that there are indeed many explanations that meet the criteria of understanding, for example the explanation of how one becomes a marihuana smoker presented by Becker. However, we may also understand a phenomenon without explaining it, and we may have potential explanations, or better correlations, that are not really understood.

We may speak more generally of quantitative research and its data to clarify what we see as an important distinction. The “raw data” that quantitative research—as an idealtypical activity, refers to is not available for further analysis; the numbers, once created, are not to be questioned (Franzosi 2016 : 138). If the researcher is to do “more” or “change” something, this will be done by conjectures based on theoretical knowledge or based on the researcher’s lifeworld. Both qualitative and quantitative research is based on the lifeworld, and all researchers use prejudices and pre-understanding in the research process. This idea is present in the works of Heidegger ( 2001 ) and Heisenberg (cited in Franzosi 2010 :619). Qualitative research, as we argued, involves the interaction and questioning of concepts (theory), data, and evidence.

Ragin ( 2004 :22) points out that “a good definition of qualitative research should be inclusive and should emphasize its key strengths and features, not what it lacks (for example, the use of sophisticated quantitative techniques).” We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. Qualitative research, as defined here, is consequently a combination of two criteria: (i) how to do things –namely, generating and analyzing empirical material, in an iterative process in which one gets closer by making distinctions, and (ii) the outcome –improved understanding novel to the scholarly community. Is our definition applicable to our own study? In this study we have closely read the empirical material that we generated, and the novel distinction of the notion “qualitative research” is the outcome of an iterative process in which both deduction and induction were involved, in which we identified the categories that we analyzed. We thus claim to meet the first criteria, “how to do things.” The second criteria cannot be judged but in a partial way by us, namely that the “outcome” —in concrete form the definition-improves our understanding to others in the scientific community.

We have defined qualitative research, or qualitative scientific work, in relation to quantitative scientific work. Given this definition, qualitative research is about questioning the pre-given (taken for granted) variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.

We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables (Small 2008 ). Variables are epistemically fixed, but can vary in terms of dimensions, such as frequency or number. Age is an example; as a variable it can take on different numbers. In relation to quantitative research, qualitative research does not reduce its material to number and variables. If this is done the process of comes to a halt, the researcher gets more distanced from her data, and it makes it no longer possible to make new distinctions that increase our understanding. We have above discussed the components of our definition in relation to quantitative research. Our conclusion is that in the research that is called quantitative there are frequent and necessary qualitative elements.

Further, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands (see Goertz and Mahoney 2012 ). Our point is nonetheless that prejudices and preconceptions about researchers are unproductive, and that as other researchers have argued, differences may be exaggerated (e.g., Becker 1996 : 53, 2017 ; Marchel and Owens 2007 :303; Ragin 1994 ), and that a qualitative dimension is present in both kinds of work.

Several things follow from our findings. The most important result is the relation to quantitative research. In our analysis we have separated qualitative research from quantitative research. The point is not to label individual researchers, methods, projects, or works as either “quantitative” or “qualitative.” By analyzing, i.e., taking apart, the notions of quantitative and qualitative, we hope to have shown the elements of qualitative research. Our definition captures the elements, and how they, when combined in practice, generate understanding. As many of the quotations we have used suggest, one conclusion of our study holds that qualitative approaches are not inherently connected with a specific method. Put differently, none of the methods that are frequently labelled “qualitative,” such as interviews or participant observation, are inherently “qualitative.” What matters, given our definition, is whether one works qualitatively or quantitatively in the research process, until the results are produced. Consequently, our analysis also suggests that those researchers working with what in the literature and in jargon is often called “quantitative research” are almost bound to make use of what we have identified as qualitative elements in any research project. Our findings also suggest that many” quantitative” researchers, at least to some extent, are engaged with qualitative work, such as when research questions are developed, variables are constructed and combined, and hypotheses are formulated. Furthermore, a research project may hover between “qualitative” and “quantitative” or start out as “qualitative” and later move into a “quantitative” (a distinct strategy that is not similar to “mixed methods” or just simply combining induction and deduction). More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg 2017 ). Our results open up for an interaction not characterized by differences, but by different emphasis, and similarities.

Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi ( 2010 ) has discussed the relations between quantitative and qualitative approaches, and more specifically the relation between words and numbers. He analyzes texts and argues that scientific meaning cannot be reduced to numbers. Put differently, the meaning of the numbers is to be understood by what is taken for granted, and what is part of the lifeworld (Schütz 1962 ). Franzosi shows how one can go about using qualitative and quantitative methods and data to address scientific questions analyzing violence in Italy at the time when fascism was rising (1919–1922). Aspers ( 2006 ) studied the meaning of fashion photographers. He uses an empirical phenomenological approach, and establishes meaning at the level of actors. In a second step this meaning, and the different ideal-typical photographers constructed as a result of participant observation and interviews, are tested using quantitative data from a database; in the first phase to verify the different ideal-types, in the second phase to use these types to establish new knowledge about the types. In both of these cases—and more examples can be found—authors move from qualitative data and try to keep the meaning established when using the quantitative data.

A second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley 2007 ), to see whether new distinctions are made and whether this improves our understanding of what is researched, in addition to the evaluation of how the research was conducted. By making what is qualitative research explicit it becomes easier to communicate findings, and it is thereby much harder to fly under the radar with substandard research since there are standards of evaluation which make it easier to separate “good” from “not so good” qualitative research.

To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.

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Acknowledgements

Financial Support for this research is given by the European Research Council, CEV (263699). The authors are grateful to Susann Krieglsteiner for assistance in collecting the data. The paper has benefitted from the many useful comments by the three reviewers and the editor, comments by members of the Uppsala Laboratory of Economic Sociology, as well as Jukka Gronow, Sebastian Kohl, Marcin Serafin, Richard Swedberg, Anders Vassenden and Turid Rødne.

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

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

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

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

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

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

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

Conclusions

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

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Introduction

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

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

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

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

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

Research team

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

Study setting

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

Participants

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

Learning about the IFOMPT Cervical Framework

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

Think aloud case analyses data collection

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

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

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

Data analysis

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

Data analysis steps

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

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

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

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

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

Trustworthiness of findings

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

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

Diagnostic reasoning components

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

Cue acquisition

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

Hypothesis generation

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

Cue evaluation

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

Hypothesis evaluation

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

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

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

Use of the Framework to inform clinical reasoning processes

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

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

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

Deep knowledge of the Framework informs clinical reasoning processes

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

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

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

Synthesis of findings

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

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

Strengths and limitations

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

Implications

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

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

Data availability

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

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Acknowledgements

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

No funding was received to conduct this research study.

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School of Physical Therapy, Western University, London, Ontario, Canada

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

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

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Correspondence to Katie L. Kowalski .

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Western University Health Science Research Ethics Board granted ethical approval (Project ID: 119934). Participants provided written informed consent prior to participating in think aloud interviews.

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Competing interests

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

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The lead author of this study (AR) is the first author of the International IFOMPT Cervical Framework.

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

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Received : 11 February 2024

Accepted : 08 April 2024

Published : 02 May 2024

DOI : https://doi.org/10.1186/s12909-024-05399-x

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• International IFOMPT Cervical Framework
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