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The Oxford Handbook of Qualitative Research

Patricia Leavy Independent Scholar Kennebunk, ME, USA

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This handbook provides a broad introduction to qualitative research to those with little to no background in the subject while simultaneously providing substantive contributions to the field that will be of interest to even the most experienced researchers. The first two sections explore the history of qualitative research, ethical perspectives, and philosophical/theoretical approaches. The next three sections focus on the major methods of qualitative practice, as well as on newer approaches (such as arts-based research and internet research); area studies often excluded (such as museum studies and disaster studies); and mixed methods and participatory methods (such as community-based research). The next section covers key issues including data analysis, interpretation, writing, and assessment. The final section offers a commentary about politics and research and the move toward public scholarship. The Oxford Handbook of Qualitative Research is intended for students of all levels, faculty, and researchers across the social sciences.

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Criteria for Good Qualitative Research: A Comprehensive Review

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

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Drishti Yadav ORCID: orcid.org/0000-0002-2974-0323 1

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

What is Qualitative in Research

What is qualitative in qualitative research.

Avoid common mistakes on your manuscript.

Introduction

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

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

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

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

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

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

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

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

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

Criteria for Evaluating Qualitative Studies

Fundamental criteria: general research quality.

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

Qualitative Research: Interpretive Paradigms

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

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

Improving Quality: Strategies

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

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

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

Essential elements of a conceptual framework

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

How to Assess the Quality of the Research Findings?

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

Quality Checklists: Tools for Assessing the Quality

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

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

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

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

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

Conclusions, Future Directions, and Outlook

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

Prospects : A Road Ahead for Qualitative Research

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

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

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

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

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

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

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

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

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Yadav, D. Criteria for Good Qualitative Research: A Comprehensive Review. Asia-Pacific Edu Res 31 , 679–689 (2022). https://doi.org/10.1007/s40299-021-00619-0

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http://orcid.org/0000-0002-5048-2939 Ebiambu Agwara 1 ,
http://orcid.org/0000-0003-2920-9847 Kathy Martyn 1 ,
Elaine Macaninch 1 ,
Wanja Nyaga 1 ,
http://orcid.org/0000-0002-6589-4880 Luke Buckner 1 ,
http://orcid.org/0000-0003-0154-1960 Breanna Lepre 1 ,
http://orcid.org/0000-0003-4555-1407 Celia Laur 1 and
http://orcid.org/0000-0003-3295-168X Sumantra Ray 1 , 2 , 3
1 NNEdPro Global Institute for Food, Nutrition and Health , Cambridge , UK
2 School of Biomedical Sciences , Ulster University , Coleraine , UK
3 Fitzwilliam College , University of Cambridge , Cambridge , UK
Correspondence to Professor Sumantra Ray; s.ray{at}nnedpro.org.uk

Background Malnutrition continues to impact healthcare outcomes, quality of life and costs to healthcare systems. The implementation of nutrition care in healthcare practice may improve health outcomes for patients and the community. This paper describes the iterative development and implementation of nutrition medical education resources for doctors and healthcare professionals in England. These resources are part of the Nutrition Education Policy for Healthcare Practice initiative.

Method Action research methodology was employed to develop and implement nutrition education workshops for medical students and doctors. The workshop was developed iteratively by an interdisciplinary project team, and the content was initially based on the General Medical Council outcomes for graduates. It was evaluated using quantitative evaluation tools and informal qualitative feedback captured from attendees using tools provided by the host organisations and developed by the roadshow team.

Results A total of 6 nutrition education workshops were delivered to 169 participants. This simple educational package demonstrated potential for delivery in different healthcare settings; however, formal feedback was difficult to obtain. Evaluation results indicate that workshops were better received when delivered by doctors known to the participants and included local context and examples. Reported barriers to the workshops included difficulty for participants in finding the time to attend, beliefs that peers gave a low priority to nutrition and uncertainty about professional roles in the delivery of nutrition care.

Conclusion A key outcome of this project was the development of resources for nutrition training of doctors, adapted to local needs. However, relatively low attendance and multiple barriers faced in the delivery of these workshops highlight that there is no ideal ‘place’ for nutrition training in current healthcare teaching. Interprofessional education, through relevant clinical scenarios may increase awareness of the importance of nutrition in healthcare, support the alignment of health professional roles and improve subsequent knowledge and skills.

nutrition assessment

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https://doi.org/10.1136/bmjnph-2023-000692

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WHAT IS ALREADY KNOWN ON THIS TOPIC

There is a great need for more nutrition within medical education, as well as a need for greater clarity of a doctor’s role in nutritional care and when to refer for specialist advice.

WHAT THIS STUDY ADDS

The development and implementation of resources for nutrition training of doctors adapted to local needs.

This paper shows that there is no one ‘place’ for nutrition; hence, the Nutrition Implementation Coalition provides a ‘hub’ of material and expertise adapted to the needs of the providers and settings.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

The need for multiprofessional ‘hub’ of material and expertise that can support medical schools and healthcare professionals who may lack faculty to develop and implement nutrition education in practice.

Introduction

Malnutrition comprises the double burden of undernutrition and overnutrition including micronutrient deficiencies, which together continue to impact the healthcare outcomes and quality of life of individuals, as well as costs to the healthcare systems. 1 For example, in hospitals, rates of malnutrition remain high, averaging 35% internationally, and in 2015, it was estimated that malnutrition in England cost the National Health Service (NHS) almost £20 billion. 2

Implementing nutritional care in practice requires the application of nutrition knowledge and skills, and ideally this care is individualised to health priorities, patients’ goals, preferences and sociocultural context. 3 Dietitians are specifically trained to provide nutrition care; however, due to their limited numbers, they rely on nutritional problems being recognised by others with subsequent clinical referral. Furthermore, other health professionals, such as doctors and nurses, are well placed to initiate nutrition care and provide support of advice as they tend to have regular contact with patients and doctors are perceived by patients as a credible source of nutrition information. 4 This provides opportunities for discussions and nutrition screening. 5

However, although doctors, nurses and other health professionals perceive nutrition as important, they require the knowledge, skills and confidence to incorporate nutrition as part of patient care or to identify when an individual might benefit from a referral to a dietitian. Importantly, medical students and doctors' welcome further nutrition education, as professional bodies internationally now recommending doctors discuss diet with their patients. 6–8 Despite this perceived need, and continual focus on improving medical nutrition education, undergraduate or preregistration nutrition education for doctors is limited. 9 Moreover, there is limited information available on nutrition learning objectives or outcomes, or teaching methods. Internationally, only 45% of medical education accreditation and curriculum guidance was found to even mention nutrition, 10 and to this end, there is limited incentive for education providers to include nutrition in medical training.

In the UK, the responsibility for postgraduate medical education (PGME) is devolved to the respective professional bodies in England, Wales, Scotland and Northern Ireland. 11 The programmes are commonly referred to as foundation programmes, core training and specialty training. 12 During foundation training, junior doctors have protected learning time, and nutrition is identified as part of the syllabus followed in England, Wales, Scotland and Northern Ireland. 13 Separate curriculum exists for 32 specialty training programmes in the UK. 14 In specialty PGME, nutrition content varies depending on the perceived relevance of nutrition to the medical specialty with limited mandated content. Table 1 shows examples of where nutrition is mandated in UK postgraduate medical curriculum. In 2021, with the aim to standardise nutrition education in undergraduate medical training, a working party convened by the Association for Nutrition (AfN) published the nutrition curriculum for UK undergraduate medical students. 15 This builds on the UK General Medical Council (GMC) ‘outcomes for graduates’, 16 which stipulates the core competencies for medical graduates in the UK. However, ways to support systematic integration of nutrition into medical education are required, as there is currently no requirement to include nutrition in medical training. Even if nutrition education can be integrated into current medical training, there remains a need for nutrition education and ongoing support for medical doctors who are already qualified. 17

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Examples of where nutrition is mandated in UK postgraduate medical curriculum

With these challenges in mind, in March 2019, the NNEdPro Global Institute for Food, Nutrition and Health, which has a key focus on medical nutrition education, launched a nutrition education package as part of their ‘Nutrition Education Policy in Healthcare Practice (NEPHELP)’ project. The aims of NEPHELP were: (1) to develop, evaluate and implement nutrition education workshops and educational resources; (2) to understand the feasibility and acceptability of a nutrition education model via participant and facilitator feedback; and (3) to gain insights into where doctors and health professionals see the place for nutrition in their education. This paper primarily focuses on aim 1, and to a lesser extent, secondarily focuses on aims 2 and 3.

This paper describes the iterative development and delivery of a nutrition education workshop for junior doctors and health professionals piloted in Glasgow, then delivered at six sites across England. Feasibility and acceptability of the workshops are explored along with reflections on the place for nutrition in medical and healthcare profession education.

Methodological approach

Study design.

The development of NEPHELP used action research methodology, 18 which is considered a pragmatic approach to instigate change. The action research cycle includes problem identification (including reflection), planning, action (implementation of change and monitoring) and evaluation or reflection before starting a new situation analysis. Action research was considered rigorous in this context because it supported the aim of exploring both enablers and barriers to the implementation of nutrition education in medical practice with the research participants. 19

The project was conducted in two stages, including (1) an initial pilot workshop in Glasgow, followed by (2) the delivery of workshops across England as part of the ‘NEPHELP Nutrition Training Roadshow’ ( figure 1 ).

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Place for nutrition paper.

The NEPHELP team

The interdisciplinary teaching team consisted of medical doctors, a registered dietitian, associate and registered nutritionists, a registered nurse, academics and education professionals, all members of the NNEdPro Global Institute. The teaching team developed and delivered the workshops and the evaluation tool.

Stage 1: piloting the NEPHELP workshop

Workshop participants and recruitment.

This was conducted with a multiprofessional international audience attending the BMJ Quality and Safety in Healthcare conference at Glasgow in 2019. Participants voluntarily signed up for a 4-hour NEPHELP nutrition workshop.

Workshop content

The initial workshop content was based on GMC expected learning outcomes for medical graduates, 16 postgraduate curricula 13 20 and perceived nutrition priorities within clinical settings, based on the educational and professional experiences of the interdisciplinary team, and included an overview of nutrition science related to clinical care Case-based discussions were used to assist with the translation of nutrition knowledge into practice.

The workshop aimed for participants to: (1) understand key principles of human nutrition, (2) understand the importance of balanced diet for health, and in illness, recognise factors that impact on equitable access to healthy food, (3) explore how individuals can include nutritional screening, care and dietetic referral into their practice and (4) provide feedback on the acceptability of the workshop as a strategy for delivering nutrition education.

The NEPHELP evaluation tool included quantitative and open-ended questions, which were designed to explore the knowledge, attitude and practices in nutritional care, and perceptions of requirements for nutrition in medical education. Feedback on the workshop content and ideas on how the programme could be improved were also gathered to inform further development of the workshop.

Stage 2: delivering the NEPHELP ‘Nutrition Training Roadshow’ across England

In this second stage, termed the ‘roadshow’, the NEPHELP workshop was delivered, evaluated and adapted to six healthcare settings across England. The NEPHELP roadshow was delivered in three formats: (1) as a part of mandatory training within health settings (hospitals, primary care etc), (2) a standalone workshop or (3) as an invited workshop delivered as part of a general GP training day and organised by an external group.

Participants and recruitment

Workshop participants were invited by the PGME and NHS contacts who also circulated workshop information. The delivery of stage 2 workshops varied depending on NEPHELP facilitator availability, with some being codelivered between the NEPHELP team and local dietitians or doctors.

Following each iteration of the workshop, evaluation forms and informal reflections were captured to inform the refinement of workshop content. The NEPHELP evaluation tool (described above) was adapted to the audience in each workshop. Additional feedback was provided by PGME faculty through their own evaluation forms. This ‘in-house’ feedback differed for each centre, was designed and collected independently but shared with the NEPHELP team. NEPHELP observers took notes during workshop discussions, and after each workshop, the facilitators listened to the observations and critically reflected on the session.

The iterative nature of the action research methodology allowed for the continuous review of data as it was collected. Quantitative data collected through NEPHELP evaluation tool and PGME forms were analysed descriptively. Qualitative data collected from open questions in the evaluation tool, PGME forms, notes taken during the workshop by observers and postworkshop critical reflection sessions were subject to content analysis, 21 an approach widely used in qualitative research. Analysis was completed by two members of the NEPHELP team, who did not have prior relationships with any of the participants. EM and KM independently grouped the material into topics using a word processing package, and the main topics were then discussed with the wider NEPHELP team.

The initial 4-hour workshop was piloted in Glasgow in March 2019, with 40 interdisciplinary participants at the BMJ Quality and Safety in Healthcare conference. Following the pilot, the workshop was modified based on participant evaluations (n=4), oral feedback from participants and the NEPHELP team reflections. The roadshow was conducted between March 2019 and February 2020, with workshops conducted at 6 locations across England with 169 participants and a total of 13.5 hours ( table 2 ).

Overview of completed NEPHELP workshops (March 2019 to February 2020)

At the end of the workshop, five (12.5%) NEPHELP evaluation questionnaires were returned from two doctors working in internal medicine, one GP, one nurse and one service manager ( table 2 ). While all respondents agreed that the workshop was useful for themselves and their colleagues, there were suggestions that the workshop included greater involvement of community care and increased focus on elements of nutrition care across the care continuum. Following this feedback, the focus for NEPHELP to also consider general practitioners and other healthcare professionals was widened.

The total response rate for the NEPHELP evaluation tool was 12.5% for the pilot and 10% for subsequent workshops. In addition, 15% completed PGME evaluation tools, and 26% of participants contributed some feedback but the heterogenic nature meant there was limited consistency in evaluation methods between each session. The combined PGME and NEPHELP evaluation data are reported individually in table 3 .

Combined PGME and NEPHELP evaluation data

The roadshow

Of the six workshops held during the Roadshow, three were mandated sessions and three were voluntary, as summarised in table 2 . Mandated sessions had much higher attendance; however, there was a low response rate overall to the evaluation questionnaires. Feedback from each session was used to inform future sessions ( table 4 ).

Summary of evaluation findings from each workshop

Multiple methods for delivery were tested, spanning rapid sessions in existing training, to full day workshops, with no format perceived as being ideal. The variation in format addressed the logistical constraints on time and location, and the need to fit the workshops within existing programmes of study. For example, a full day session requested by a GP trainer (Essex) was held on a weekend, and although advertised and free, only one person attended. In contrast, the rapid session (East of England) attended by 60 participants aimed to see if the training could be added into an existing event, and if all learning objectives could be covered in the shorter time. Formal feedback from this session was limited.

NEPHELP evaluation responses

The mandated teaching in London at a teaching hospital for foundation year 2 had the highest response rate to the NEPHELP evaluation tool at 52% (n=17). Nine participants (53%) reported receiving no previous nutrition education, while eight (47%) recalled some nutrition training in their medical education. Of participants who reported receiving nutrition training, five reported receiving this education during medical school, one from a self-selected module, one during a biomedical sciences degree and one elsewhere in their foundation training. All participants felt that the clinical nutritional needs of patients were not prioritised, and as a result were poorly addressed in the hospital setting. As noted by one participant, nutrition is ‘ certainly, something that could be improved ’, but felt that it was ‘ unlikely to be top priority in a consultation ’.

When asked to give an example of where nutritional needs for a patient were met, 41% (n=7) recalled examples of acute nutrition, namely, either nasogastric or parenteral nutrition, 29% (n=5) reported seeing clinical benefit from malnutrition treatments and three specifically mentioned the benefits of dietitian involvement in secondary care. One participant noted examples “In upper GI (gastrointestinal) surgery a lot of patients were on TPN (total parenteral nutrition) or NG/NJ (naso gastric/naso jejunal) feeds.” Another mentioned “Gastro ward with dietitian input (eg, TPN patient).”

When these participants were asked about the barriers to effective nutritional care, 15 (88%) identified time as a barrier, 11 (61%) identified a lack of knowledge, 8 (47%) identified a lack of clarity on roles and responsibilities and 7 (41%) perceived a lack of interest from colleagues as a barrier to such care in practice. One participant said, “I'm aware as a junior in A&E [Accident and Emergency] it is quite slow spending time taking a good diet history and giving advice would make consultations even longer.” When questioned about including nutritional screening or history taking as part of their practice respondents reported the following reasons a lack of nutrition training (n=6, 35%), time pressures for doctors (n=5, 29%) and some participants perceived nutrition care as a dietitian’s role (n=4, 24%). Comments included, “Poor training and perception that nutrition is the preserve of dietitians. Time not allocated”. Another focused on the lack of education: “Little education in med school. Not much time. Unclear whose role it is.” The lack of interest and importance was also mentioned: “Both knowledge on importance but also lack of interest in implementing what little people do know about nutrition.”

Most respondents (88%) felt doctors had a role in nutrition care with half (n=9) identifying the role of a doctor in initial assessment to identify nutrition risks and a third (n=5) indicating the importance of onward referral to the dietitian as part of their role. As one participant mentioned, there are “Very few specialists so it needs to be taken responsibility for by all staff.” They saw their role as the “Assessing, advising, signposting and referring.” Another participant focused on actions to take, particularly regarding handover. “Reorganising when and where referrals are required. Risk assessment. Improving inter-team handover.” While one questioned the role of a doctor in nutrition care, highlighting bigger societal issues. “Some roles, but the most significant barriers lie in public health policy, food poverty and education.”

Most participants in this group (16/17) felt that nutrition education should be an essential element of medical training and found the content of the workshop relevant. When asked about the most appropriate timing of this nutrition education, 12 participants (71%) felt this should be linear, with nutrition education increasing from medical school to junior doctor, while 3 participants (18%) felt nutrition education was most relevant to junior doctors. Two participants (12%) felt nutrition training was most relevant to medical students and would be best placed in undergraduate medical education. Seven of the participants (41%) valued skill-based nutrition education and case-based learning. However, opinions varied on what was relevant nutrition content, but included, ‘practical examples and how to put into practice’ , ‘ important from Global public health perspective’, ‘common things in hospital for example, refeeding’, ‘eating disorders, intuitive eating, diet culture and how best to educate without promoting diet culture’. In contrast, one participant did not perceive nutrition as relevant in medical training as “Patient education and school age education plus socioeconomic factors far outweigh medical input” and others felt that “didactic teaching [was] less useful.”

Mandated versus voluntary attendance

Mandated sessions were better attended and evaluated. In the UK, all junior doctors have protected learning time to attend mandated teaching. 11 13 20 22 NEPHELP workshops were delivered in mandated teaching during two FY2 training sessions and one GP trainee protected teaching session. In contrast, attendance at non-mandated training was particularly poor. Participants commented on the difficulties experienced in attending non-mandated sessions due to professional and personal pressures. “If I don’t have to go it’s not something I would attend, at the end of a week I have other priorities”.

Training was generally better received when local doctors were present and less well received when other healthcare professionals individually delivered the same content. The perception was that training would have been better received if a medical role model acted as a peer educator, for example, where teaching was codelivered with another GP trainee as opposed to being delivered by non-medical members of the NEPHELP team who are unknown to the participants. Limited opportunity for interprofessional education (IPE) and poor collaboration in nutrition care across health systems was also identified as a barrier to effective nutrition care practice.

Low prioritisation of nutrition in clinical care

Many participants identified a low priority given to nutrition in clinical care. Foundation year trainees recognised that nutrition is not addressed adequately in clinical practice but did not have recommendations for how it could be improved, citing logistical challenges such as a lack of priority, time and senior recognition of nutrition in patient management, care planning and treatment. They also felt that there was limited time available for education and variation in opinion on the most important aspects of nutrition. Some topics rated as important were based on prior clinical experiences such as working in a ‘gastro’ environment, or seeing TPN/NG feeding, while others perceived a topic to be importance based on personal interests, such as the ‘low carbohydrate diet ’ . Many participants indicated that their personal nutrition knowledge, level of interest and social media informed their practice.

Lack of clarity on roles and responsibilities in nutrition care

While participants recognised the importance of nutrition, they remained unclear on their role and scope of practice (as doctors) in nutrition care. Participants attending the primary care training day did not feel that a session on nutrition was appropriate for them as GPs and perceived nutrition as relating solely to healthy eating. Many Foundation doctors found it challenging to address nutritional issues in practice and indicated that their focus was the immediate medical concern. Some participants believed that public health professionals should hold more responsibility than doctors in the delivery of nutrition care. Addressing misconceptions about the role of diet in the prevention and management of non-communicable diseases, its role in medical treatment across all settings, and how different members of the multi professional healthcare team can work synergistically to achieve favourable patient outcomes, may raise the profile of nutrition in medical practice.

It is recognised that collaboration across professions such as registered nurses, doctors and allied health professionals fosters a positive and rewarding practice environment and improves patient outcomes. 23 This collaboration has previously been identified by medical students and junior doctors with an interest in nutrition as a key factor to support the integration of nutrition into medical practice. 24

Interprofessional education (IPE) is recognised by the WHO as an ‘innovative strategy that will play an important role in mitigating the global health workforce crisis’ and address professional silo working. 25 The cross-cutting nature of nutrition, and its involvement in the promotion of health and prevention and management of disease, reiterates that nutrition should be a core element of all healthcare professional’s education. Ideally, it should be ideally through an IPE lens to foster a multidisciplinary approach in practice.

Challenges for multiprofessional learning, working and collaboration

During NEPHELP, there was a reluctance from PGME providers to include non-medical professionals within junior doctor-protected sessions, limiting the opportunity and scope for IPE. Moreover, there was a perception that the NEPHELP workshop was not as well received when a medical doctor was not part of the teaching team. For trainees, the historic paucity of nutrition education within medical training limits the number of role models who can model and advocate for nutrition care. 8 26 However, research has identified the importance of professional role models to support learning in medical education and how this authenticates the place for content and its relevance to clinical practice. 27

Using action research methodology, the NEPHELP team set out to develop an educational package based on GMC outcomes for graduates, which could be delivered in different healthcare settings. In addition, they sought to understand where doctors and health professionals see nutrition as fitting into their educational journey and considered the feasibility of this workshop approach.

Lessons learnt from NEPHELP

From this work, we recognise that there is no one ‘place’ for nutrition, but there is a need for clear curriculum content at all stages of a doctor’s education.

Undergraduate and postgraduate nutrition curriculum development

The recently published undergraduate nutrition curriculum for medical doctors represents a consensus among multiple stakeholders, nutrition professionals and medical royal colleges on the required nutrition competencies for medical graduate. 28 This benchmarks what should be taught in medical education as an accompaniment to GMC learning outcomes for graduates. In addition, the 2021 Foundation curriculum 13 supports engagement with third-sector organisations, which are at the forefront in providing services to support health prevention including services to support education or access to healthy foods or services directly addressing food poverty.

Clearer postgraduate mandated nutrition competencies within existing PGME curriculum may help to better elucidate key nutrition knowledge and skills for practicing doctors, which could be a useful accompaniment to the foundation doctor’s curriculum, helping to increase validity and visibility of nutrition while also clarifying the role of medical doctors and the wider MDT. However, F2 participants completing the NEPHELP evaluation tool indicated a preference for more linear nutrition education, suggesting a desire to advance nutrition along with other medical skills but with a clear preference for more clinically focused, case-based teaching.

To demonstrate interprofessional roles and responsibilities of care, there is a need for clinically relevant scenarios more closely aligned to existing roles and workplace expectations to ‘nudge’ professionals to raise the profile of nutrition in their practice, as part of an MDT approach. Educating doctors in the absence of the MDT may not address the issue.

Organisations such as NNEdPro, the AfN and GMC can work with educators, including medical schools and foundation programmes to create a framework for trainees to work towards achieving the role and competencies they outline.

Furthermore, recent findings from Lepre et al , 29 reflecting the expressed needs of end users within the medical/healthcare workforce, indicate the need for knowledge and skills to consider the findings from nutrition screening and assessment and coordinate nutrition care, thereby highlighting the importance of the findings from this work in implementation.

Summary of recommendations

Nutrition educators.

Nutrition content needs to reflect the context of the workplace, with most participants indicating their preference to more clinically focused practical teaching directly relevant to their roles and signposting to resources the participants can use.

Participants preferred practical-based/short-based/skills-based education, which can be easily linked back to practice and can be easily integrated into short windows of opportunity for education.

Universal nutrition education, such as NEPHELP, may offer a short, focused baseline form on which other nutrition education can be recommended to support core as well as more specialist and potentially a more expert specialist nutrition education pathway.

Clinicians in primary and secondary care

The needs of those in primary care and secondary care were noted to be significantly different, as well as a major need to reframe the communication and transfer of nutrition care between the two settings.

There is a need for IPE or discussion across professional boundaries to support nutrition pathways. Without this, it may be difficult to address some of the identified barriers. This may pose a challenge in finding a common language so that nutrition messaging is clear and breaks through professional silos within a more multiprofessional model of care.

Postgraduate medical educators

Although nutrition is mentioned in published curriculum frameworks, examples of how nutrition might be included in education for UK Junior doctors are limited 30 and should be developed to support capacity building.

Trainee GPs wanted more in-depth nutrition education suggesting we need a variety of options and opportunities; from the minimum standards to assure patient safety, to potential career pathways for further specialisation.

To support sustainability, a PGME nutrition curriculum may assist in reaching a consensus on expectations related to nutrition and professional working roles.

PGME providers can take advantage of existing multidisciplinary nutrition educators such as the UK Nutrition Implementation Coalition. Training workshops also need to be endorsed by a professional body with relevant continued professional education credits.

Strengths and limitations

Data from multiple sources of feedback were pooled to provide deeper insights into some of the potential barriers and enablers to implementing nutrition education.

Heterogenic feedback forms and processes in each setting limited analysis. Attempts to standardise data collection on participant opinions on the utility of the nutrition workshops, as well as perceptions on nutrition roles and responsibilities in practice, were made. The NEPHELP evaluation tool was not a validated tool, which limited the usefulness of the feedback captured. To minimise facilitator pre conceptions, postworkshop discussions, alongside evaluations from participants, were used.

Another limitation was the recruitment of participants to participate in the non-mandated sessions. This was particularly evident during the Essex Roadshow event, where despite the workshop being organised at the request of the primary care providers and the enthusiasm to run this workshop outside of normal working hours at the weekend, only one participant attended. Generally, due to the nature of nutrition education and its broad application across multiple areas of practice, most health practitioners would be interested in focused nutrition content that relates to their clinical setting, specialty and region. Hence, we would imagine that if the nutrition content is clinically and regionally specific, this might stimulate greater interest and enthusiasm in nutrition education and its application in their healthcare setting.

Demographics of participants completing feedback were mainly junior doctors and general practitioners. The low response rate limits the generalisability and transferability of our findings and does not consider the views of other healthcare professionals regarding enablers and barriers to nutrition education, as well as the provision of nutrition focused care on clinical practice.

The NEPHELP project successfully delivered and adapted a bespoke nutrition education programme for doctors. However, there was no clear a ‘place’ for this training and there are significant, ongoing, barriers to delivering nutrition training in the medical postgraduate setting.

For this reason, in the UK, NNEdPro, ERimNN (Education And Research In Medical Nutrition Network), Culinary Medicine UK and Nutritank have come together to form the Nutrition Implementation Coalition (2022–23). 31 A coalition encompassing multiprofessionals who can provide a central hub of material and expertise that will support medical schools and health professionals who may lack the current faculty to develop and implement nutrition education. Also, the multiprofessional nature of the coalition can act as a role model for interprofessional working to focus on developing the seamless delivery of nutritional care. Such coalitions may be one way of developing and sustaining interest in developing nutrition expertise, by work alongside mandatory training across the range of healthcare professionals in both primary and secondary care. Finding opportunities for the delivery of clinically relevant nutrition education in ‘bitesize’ sessions may tap into the need for solution-focused education. Nutrition is central to health and disease in both prevention and treatment, this has been recently highlighted through COVID-19 and its sequelae. The interest that developed during the pandemic could provide an opportunity to translate research back into fundamental nutrition training.

Recognising there is no one ‘place’ for nutrition, the Nutrition Implementation Coalition provides a strategy to provide a ‘hub’ of material and expertise that allows the content to be available yet adapted to the needs of the providers and settings. Beyond this paper, this research has continued with the development of the online NEPHELP course via a virtual learning environment and its evaluation in primary care.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants. Participants were given information sheets about the project and how their responses may be used for research, and to inform the educational evaluation and curriculum development. UK NHS National Research Ethics Service guidance indicates that ethics review was not required. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

NEPHELP Team & NNEdPro Organisational Support.

Stratton R ,
DiMaria-Ghalili RA ,
Mirtallo JM ,
Tobin BW , et al
Desbrow B ,
Hughes RM ,
Leveritt MD
Leveritt MD ,
Desbrow B , et al
Douglas PL ,
McCarthy H ,
McCotter LE , et al
Macaninch E ,
Buckner L ,
Amin P , et al
Crowley J ,
Mansfield KJ ,
Ray S , et al
General Medical Council
British Medical Association
Health Education England
Association for Nutrition
Macdonald MB ,
Ferguson LM , et al
Abramovich N ,
Burridge J , et al
Stevens FCJ ,
Aryee PA , et al
Maudsley RF
Douglas P , et al

EA and KM are joint first authors.

X @DrBreannaLepre, @Celia_Laur

EA and KM contributed equally.

Contributors The authors confirm contribution to the paper as follows: study conception and design: EM, KM, LB, CL, BL and SR. Data collection: WN, LB, EA, LB and EM. Analysis and interpretation of results: EA, SR and KM. Draft manuscript preparation: EA, KM and SR. All authors reviewed the results and approved the final version of the manuscript. SR is the guarantor of this work.

Funding NEPHELP was developed as a nutrition education programme for healthcare professionals following a grant from the Medical Nutrition International award for 2017-2019, with initial periods of time spent surveying needs of future participants. 8 The project continued through further AIM foundation funding through 2021.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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What is Qualitative in Research

Introduction

Criteria for Evaluating Qualitative Studies

Qualitative Research: Interpretive Paradigms

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How to Assess the Quality of the Research Findings?

Quality Checklists: Tools for Assessing the Quality

Conclusions, Future Directions, and Outlook

Prospects : A Road Ahead for Qualitative Research

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WHAT IS ALREADY KNOWN ON THIS TOPIC

WHAT THIS STUDY ADDS

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Introduction

Methodological approach

The NEPHELP team

Stage 1: piloting the NEPHELP workshop

Workshop content

Stage 2: delivering the NEPHELP ‘Nutrition Training Roadshow’ across England

Participants and recruitment

The roadshow

NEPHELP evaluation responses

Mandated versus voluntary attendance

Low prioritisation of nutrition in clinical care

Lack of clarity on roles and responsibilities in nutrition care

Challenges for multiprofessional learning, working and collaboration

Lessons learnt from NEPHELP

Undergraduate and postgraduate nutrition curriculum development

Summary of recommendations

Clinicians in primary and secondary care

Postgraduate medical educators

Strengths and limitations

Ethics statements

Ethics approval

Acknowledgments

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