scholarly articles on trustworthiness in qualitative research

Trustworthiness in Qualitative Research

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Validity, reliability, and generalizability in qualitative research

Lawrence leung.

1 Department of Family Medicine, Queen's University, Kingston, Ontario, Canada

2 Centre of Studies in Primary Care, Queen's University, Kingston, Ontario, Canada

In general practice, qualitative research contributes as significantly as quantitative research, in particular regarding psycho-social aspects of patient-care, health services provision, policy setting, and health administrations. In contrast to quantitative research, qualitative research as a whole has been constantly critiqued, if not disparaged, by the lack of consensus for assessing its quality and robustness. This article illustrates with five published studies how qualitative research can impact and reshape the discipline of primary care, spiraling out from clinic-based health screening to community-based disease monitoring, evaluation of out-of-hours triage services to provincial psychiatric care pathways model and finally, national legislation of core measures for children's healthcare insurance. Fundamental concepts of validity, reliability, and generalizability as applicable to qualitative research are then addressed with an update on the current views and controversies.

Nature of Qualitative Research versus Quantitative Research

The essence of qualitative research is to make sense of and recognize patterns among words in order to build up a meaningful picture without compromising its richness and dimensionality. Like quantitative research, the qualitative research aims to seek answers for questions of “how, where, when who and why” with a perspective to build a theory or refute an existing theory. Unlike quantitative research which deals primarily with numerical data and their statistical interpretations under a reductionist, logical and strictly objective paradigm, qualitative research handles nonnumerical information and their phenomenological interpretation, which inextricably tie in with human senses and subjectivity. While human emotions and perspectives from both subjects and researchers are considered undesirable biases confounding results in quantitative research, the same elements are considered essential and inevitable, if not treasurable, in qualitative research as they invariable add extra dimensions and colors to enrich the corpus of findings. However, the issue of subjectivity and contextual ramifications has fueled incessant controversies regarding yardsticks for quality and trustworthiness of qualitative research results for healthcare.

Impact of Qualitative Research upon Primary Care

In many ways, qualitative research contributes significantly, if not more so than quantitative research, to the field of primary care at various levels. Five qualitative studies are chosen to illustrate how various methodologies of qualitative research helped in advancing primary healthcare, from novel monitoring of chronic obstructive pulmonary disease (COPD) via mobile-health technology,[ 1 ] informed decision for colorectal cancer screening,[ 2 ] triaging out-of-hours GP services,[ 3 ] evaluating care pathways for community psychiatry[ 4 ] and finally prioritization of healthcare initiatives for legislation purposes at national levels.[ 5 ] With the recent advances of information technology and mobile connecting device, self-monitoring and management of chronic diseases via tele-health technology may seem beneficial to both the patient and healthcare provider. Recruiting COPD patients who were given tele-health devices that monitored lung functions, Williams et al. [ 1 ] conducted phone interviews and analyzed their transcripts via a grounded theory approach, identified themes which enabled them to conclude that such mobile-health setup and application helped to engage patients with better adherence to treatment and overall improvement in mood. Such positive findings were in contrast to previous studies, which opined that elderly patients were often challenged by operating computer tablets,[ 6 ] or, conversing with the tele-health software.[ 7 ] To explore the content of recommendations for colorectal cancer screening given out by family physicians, Wackerbarth, et al. [ 2 ] conducted semi-structure interviews with subsequent content analysis and found that most physicians delivered information to enrich patient knowledge with little regard to patients’ true understanding, ideas, and preferences in the matter. These findings suggested room for improvement for family physicians to better engage their patients in recommending preventative care. Faced with various models of out-of-hours triage services for GP consultations, Egbunike et al. [ 3 ] conducted thematic analysis on semi-structured telephone interviews with patients and doctors in various urban, rural and mixed settings. They found that the efficiency of triage services remained a prime concern from both users and providers, among issues of access to doctors and unfulfilled/mismatched expectations from users, which could arouse dissatisfaction and legal implications. In UK, a care pathways model for community psychiatry had been introduced but its benefits were unclear. Khandaker et al. [ 4 ] hence conducted a qualitative study using semi-structure interviews with medical staff and other stakeholders; adopting a grounded-theory approach, major themes emerged which included improved equality of access, more focused logistics, increased work throughput and better accountability for community psychiatry provided under the care pathway model. Finally, at the US national level, Mangione-Smith et al. [ 5 ] employed a modified Delphi method to gather consensus from a panel of nominators which were recognized experts and stakeholders in their disciplines, and identified a core set of quality measures for children's healthcare under the Medicaid and Children's Health Insurance Program. These core measures were made transparent for public opinion and later passed on for full legislation, hence illustrating the impact of qualitative research upon social welfare and policy improvement.

Overall Criteria for Quality in Qualitative Research

Given the diverse genera and forms of qualitative research, there is no consensus for assessing any piece of qualitative research work. Various approaches have been suggested, the two leading schools of thoughts being the school of Dixon-Woods et al. [ 8 ] which emphasizes on methodology, and that of Lincoln et al. [ 9 ] which stresses the rigor of interpretation of results. By identifying commonalities of qualitative research, Dixon-Woods produced a checklist of questions for assessing clarity and appropriateness of the research question; the description and appropriateness for sampling, data collection and data analysis; levels of support and evidence for claims; coherence between data, interpretation and conclusions, and finally level of contribution of the paper. These criteria foster the 10 questions for the Critical Appraisal Skills Program checklist for qualitative studies.[ 10 ] However, these methodology-weighted criteria may not do justice to qualitative studies that differ in epistemological and philosophical paradigms,[ 11 , 12 ] one classic example will be positivistic versus interpretivistic.[ 13 ] Equally, without a robust methodological layout, rigorous interpretation of results advocated by Lincoln et al. [ 9 ] will not be good either. Meyrick[ 14 ] argued from a different angle and proposed fulfillment of the dual core criteria of “transparency” and “systematicity” for good quality qualitative research. In brief, every step of the research logistics (from theory formation, design of study, sampling, data acquisition and analysis to results and conclusions) has to be validated if it is transparent or systematic enough. In this manner, both the research process and results can be assured of high rigor and robustness.[ 14 ] Finally, Kitto et al. [ 15 ] epitomized six criteria for assessing overall quality of qualitative research: (i) Clarification and justification, (ii) procedural rigor, (iii) sample representativeness, (iv) interpretative rigor, (v) reflexive and evaluative rigor and (vi) transferability/generalizability, which also double as evaluative landmarks for manuscript review to the Medical Journal of Australia. Same for quantitative research, quality for qualitative research can be assessed in terms of validity, reliability, and generalizability.

Validity in qualitative research means “appropriateness” of the tools, processes, and data. Whether the research question is valid for the desired outcome, the choice of methodology is appropriate for answering the research question, the design is valid for the methodology, the sampling and data analysis is appropriate, and finally the results and conclusions are valid for the sample and context. In assessing validity of qualitative research, the challenge can start from the ontology and epistemology of the issue being studied, e.g. the concept of “individual” is seen differently between humanistic and positive psychologists due to differing philosophical perspectives:[ 16 ] Where humanistic psychologists believe “individual” is a product of existential awareness and social interaction, positive psychologists think the “individual” exists side-by-side with formation of any human being. Set off in different pathways, qualitative research regarding the individual's wellbeing will be concluded with varying validity. Choice of methodology must enable detection of findings/phenomena in the appropriate context for it to be valid, with due regard to culturally and contextually variable. For sampling, procedures and methods must be appropriate for the research paradigm and be distinctive between systematic,[ 17 ] purposeful[ 18 ] or theoretical (adaptive) sampling[ 19 , 20 ] where the systematic sampling has no a priori theory, purposeful sampling often has a certain aim or framework and theoretical sampling is molded by the ongoing process of data collection and theory in evolution. For data extraction and analysis, several methods were adopted to enhance validity, including 1 st tier triangulation (of researchers) and 2 nd tier triangulation (of resources and theories),[ 17 , 21 ] well-documented audit trail of materials and processes,[ 22 , 23 , 24 ] multidimensional analysis as concept- or case-orientated[ 25 , 26 ] and respondent verification.[ 21 , 27 ]

Reliability

In quantitative research, reliability refers to exact replicability of the processes and the results. In qualitative research with diverse paradigms, such definition of reliability is challenging and epistemologically counter-intuitive. Hence, the essence of reliability for qualitative research lies with consistency.[ 24 , 28 ] A margin of variability for results is tolerated in qualitative research provided the methodology and epistemological logistics consistently yield data that are ontologically similar but may differ in richness and ambience within similar dimensions. Silverman[ 29 ] proposed five approaches in enhancing the reliability of process and results: Refutational analysis, constant data comparison, comprehensive data use, inclusive of the deviant case and use of tables. As data were extracted from the original sources, researchers must verify their accuracy in terms of form and context with constant comparison,[ 27 ] either alone or with peers (a form of triangulation).[ 30 ] The scope and analysis of data included should be as comprehensive and inclusive with reference to quantitative aspects if possible.[ 30 ] Adopting the Popperian dictum of falsifiability as essence of truth and science, attempted to refute the qualitative data and analytes should be performed to assess reliability.[ 31 ]

Generalizability

Most qualitative research studies, if not all, are meant to study a specific issue or phenomenon in a certain population or ethnic group, of a focused locality in a particular context, hence generalizability of qualitative research findings is usually not an expected attribute. However, with rising trend of knowledge synthesis from qualitative research via meta-synthesis, meta-narrative or meta-ethnography, evaluation of generalizability becomes pertinent. A pragmatic approach to assessing generalizability for qualitative studies is to adopt same criteria for validity: That is, use of systematic sampling, triangulation and constant comparison, proper audit and documentation, and multi-dimensional theory.[ 17 ] However, some researchers espouse the approach of analytical generalization[ 32 ] where one judges the extent to which the findings in one study can be generalized to another under similar theoretical, and the proximal similarity model, where generalizability of one study to another is judged by similarities between the time, place, people and other social contexts.[ 33 ] Thus said, Zimmer[ 34 ] questioned the suitability of meta-synthesis in view of the basic tenets of grounded theory,[ 35 ] phenomenology[ 36 ] and ethnography.[ 37 ] He concluded that any valid meta-synthesis must retain the other two goals of theory development and higher-level abstraction while in search of generalizability, and must be executed as a third level interpretation using Gadamer's concepts of the hermeneutic circle,[ 38 , 39 ] dialogic process[ 38 ] and fusion of horizons.[ 39 ] Finally, Toye et al. [ 40 ] reported the practicality of using “conceptual clarity” and “interpretative rigor” as intuitive criteria for assessing quality in meta-ethnography, which somehow echoed Rolfe's controversial aesthetic theory of research reports.[ 41 ]

Food for Thought

Despite various measures to enhance or ensure quality of qualitative studies, some researchers opined from a purist ontological and epistemological angle that qualitative research is not a unified, but ipso facto diverse field,[ 8 ] hence any attempt to synthesize or appraise different studies under one system is impossible and conceptually wrong. Barbour argued from a philosophical angle that these special measures or “technical fixes” (like purposive sampling, multiple-coding, triangulation, and respondent validation) can never confer the rigor as conceived.[ 11 ] In extremis, Rolfe et al. opined from the field of nursing research, that any set of formal criteria used to judge the quality of qualitative research are futile and without validity, and suggested that any qualitative report should be judged by the form it is written (aesthetic) and not by the contents (epistemic).[ 41 ] Rolfe's novel view is rebutted by Porter,[ 42 ] who argued via logical premises that two of Rolfe's fundamental statements were flawed: (i) “The content of research report is determined by their forms” may not be a fact, and (ii) that research appraisal being “subject to individual judgment based on insight and experience” will mean those without sufficient experience of performing research will be unable to judge adequately – hence an elitist's principle. From a realism standpoint, Porter then proposes multiple and open approaches for validity in qualitative research that incorporate parallel perspectives[ 43 , 44 ] and diversification of meanings.[ 44 ] Any work of qualitative research, when read by the readers, is always a two-way interactive process, such that validity and quality has to be judged by the receiving end too and not by the researcher end alone.

In summary, the three gold criteria of validity, reliability and generalizability apply in principle to assess quality for both quantitative and qualitative research, what differs will be the nature and type of processes that ontologically and epistemologically distinguish between the two.

Source of Support: Nil.

Conflict of Interest: None declared.

Peer pressure: assessing the trustworthiness of a peer-reviewed journal article

• Published: 02 June 2024

Cite this article

• David P. Cann 1  

Avoid common mistakes on your manuscript.

The first peer-reviewed journal article appeared almost 300 years ago in the Royal Society of Edinburgh [ 1 ]. The introduction to that first volume included a dedication from the Royal Society addressed to their patron, the king. They had hoped that their “undertakings to extend the knowledge of nature…” had “contributed, so eminently, to the progress of Science and of Taste in Europe.” From these humble beginnings to today, peer-reviewed articles have been held up as the gold standard of publishing—serving as a de facto vehicle for disseminating invaluable, indisputable, verifiable scientific findings.

Today, from my perspective as a scientific editor and researcher, journal articles have taken on an even higher profile. In the midst of emerging crises (e.g., disease, climate, artificial intelligence, weapons of mass destruction, natural disasters), government policy makers, journalists, business owners, and almost everyone else are looking to journal articles to help illuminate all sides of an issue. The public has fundamental questions about the crisis, including understanding its cause, the impact of the crisis on their daily life, predictions about the future course of events, and many, many more questions. While scientific information disseminated through peer-reviewed journal articles can certainly contribute to a greater understanding of these issues, their usefulness is sometimes grossly overstated, and their purpose is often misconstrued. My purpose in this commentary is to clarify what a peer-reviewed journal article is and what it is not, and what it can tell us and what it cannot. Furthermore, I would like to detail a process to ascertain whether or not a particular paper might be trustworthy or not. I believe this is fundamentally important these days as we try to gain a better understanding of the reality of the world around us. I will note that my background is in the physical sciences, which strongly influences my frame of reference. The reader should recognize that there are significant differences in the scientific culture and publishing activities between the physical sciences and engineering, life sciences, biomedical/health sciences, and social sciences.

First and foremost, a peer-reviewed journal article is a piece of the behind-the-scenes machinery that is the sausage making of science. Virtually all complex and interesting ideas in science require the integration of concepts, findings, analyses, and thoughts of many people. The most obvious expression of that is born out of the observation that very few journal articles are written by a single author. Even a single paper by itself represents the integrated ideas, expertise, and labor of the co-authors (and also any contributors listed in the Acknowledgments section). From this perspective, a single paper represents an incremental contribution to the body of knowledge, or a contribution to the “progress of science” as the members of the Royal Society saw it. A published paper is not like a screen play that is set in stone once the filming of a movie is completed. It really represents just one draft of an ongoing incremental process within a continuum that stretches from the early stages of the understanding of a scientific concept or phenomenon and will ceaselessly flow into the future as that concept is continually refined, clarified, and dutifully revised. While a published draft may give some sense of finality and resolution to the authors, it is really a snapshot-in-time of the authors data and analyses presented with the authors current understanding of the context of their work within the broader knowledge base. That one paper, soon after being published, will be overtaken by more and better data and a more refined understanding of that context.

With this perspective, a single paper cannot and should not be interpreted as a representation of an unchallengeable scientific fact. Rather, it is part of the continuum—one cog in the machinery of science that asymptotically and blindly approaches fundamental truths about the physical world. Facts in science come not from data in an individual paper but from the alignment of continuously evolving datasets contained in multiple papers from multiple authors with different vantage points that confirm, contextualize, and continually refine the fundamental conclusions.

The problem is that policy makers do not always have the luxury of waiting for an overwhelming weight of evidence to make decisions. Hence, these days, individual papers sometimes carry a great deal of weight in guiding such decisions. While there is necessarily certainty in the implementation of a policy, it is worthwhile appreciating that the data and understanding that underpins those decisions inherently have uncertainty . With more and better data and refined analyses, the uncertainty is usually lessened. However, it is possible that with more data, the conclusions change—necessitating a change in policy. While this may seem like a failure of science, it is merely the result of having to make decisions with insufficient data.

One of the motivations for writing this commentary is to provide a background on what a “trustworthy” paper looks like. Here, I would define a “trustworthy” paper as one with reliable, reproducible data and with analyses and conclusions that accurately present that data in the appropriate context. If we must make judgments on a paper in real time, even for informal purposes to broaden our own understanding of the current events, I believe there are ways to assess the likelihood that it represents reliable, reproducible science.

First, what exactly is a peer-review paper? The answer to that question is not as simple as it used to be. In recent years, fraudulent journals with prestigious-sounding names have popped up that publish articles on every imaginable scientific discipline. While many of these journals claim to have rigorous standards, the articles do not appear to have gone through any meaningful peer review. Their existence only adds to the confusion, and this topic has been discussed at length [ 2 , 3 ].

So, how do we know a good paper when we see it? In a sense, this is analogous to programming an artificial intelligence (AI)-based algorithm to quantify the “trustworthiness” of a particular article. First and foremost, it really starts with the authors. The experience of the authors and their track record of publishing within that discipline all factor into the consideration of the quality of an article. An author’s track record is usually publicly accessible on a number of different platforms, such as Google Scholar, Web of Science, or ORCID. While a particular scientist’s publication record is best judged from a qualitative standpoint, there are quantitative means of doing so. The h-index is a simple metric that can provide some input on an author’s research productivity and impact. Quite simply, the h-index indicates that an author with an h-index of “x” has published “x” papers that have been cited at least “x” times. Thus, authors with a high h-index have published a large number of papers that have been cited a large number of times. While the magnitude of the h-index varies quite a bit in different branches of science, an author with an h-index above 50 would likely be considered to have a solid track record in both quantity of publications and impact. Like most quantitative metrics, the h-index is certainly not perfect. One issue is that it can be easily “gamed” by having authors cite their own papers which artificially inflates their h-index. Nonetheless, for the purposes of assessing the trustworthiness of a particular paper, the h-index can be useful as an assessment of the author’s research track record.

Another important metric in determining the trustworthiness of a particular paper is the number of citations (which can be tracked quite easily through Web of Science, for example). As mentioned previously, citation is often an indicator of the value of a given scientific paper. It certainly represents a recognition that the technical content of the paper motivated or assisted the authors of a related paper, thus contributing to the slow and steady progress of science. A paper that has been cited many times can be considered to be more impactful than one that has not been cited many times. However, there is a time lag with citations given that it takes months to sometimes more than a year for a paper to appear in print. Thus, for a new paper, it is not a very useful feature to determine its trustworthiness.

There are more immediate measures of an articles impact including the number of times it has been downloaded, the number of times it has been re-tweeted, or liked, etc. While these measures are more immediate, they do not convey any judgment on the technical soundness of an article. There is simply no comparison between an article that has “gone viral” in social media and an article that has been cited many times by countless authors around the globe that value its scientific contribution to their own work.

When assessing an article’s trustworthiness, we can also consider the scientific journal that it appears in. If we were training an AI program to quantify the trustworthiness of an article, the journal that publishes the article conveys a great deal of legitimacy. Ultimately, every reputable journal has a team of editors whose primary job is to assess the technical soundness and impact of articles. The reputation of the journal is important in order to attract the best articles (like a “brand value”), so it is in their best interest to only publish high-quality and “trustworthy” articles. Mistakes happen of course, but the vast majority of articles that appear in these journals have been peer-reviewed by experts in the field. After those reviews are completed, editors will use this information and their own judgment to determine which papers will be published. In contrast, fraudulent journals publish articles without any meaningful peer review. I suppose they meet an economic need whereby authors will pay to “publish” a paper so that it may appear on their resumé. A paper in a prestigious-sounding journal might look authentic, and in fact, it might even have a DOI (which is short for a Digital Object Identifier). However, a DOI is not that special, and even this very editorial will duly receive one!

For most journals, it is now customary for articles to include a statement with regards to any conflict of interest that the authors might have. It is important for the reader to understand the funding source for the research as well as any institutional conflicts of interest. This allows the reader to assess the trustworthiness of the paper in the proper context.

But how do we know if a journal is reputable? Many journals have associations with scientific or professional societies, many of which go back centuries. The Royal Society of Chemistry was founded in London in 1841, and the American Ceramic Society has been around since 1898. Both societies publish journals as part of their core mission, and generally, articles published in those journals have been through a rigorous peer review. Many other journals are of high quality, despite the fact that they are not associated with a society. They have a team of editors dedicated to the quality of the articles that appear in their journal. But how can one determine whether such a journal is reputable? Journals generally publish the names of their team of editors, and it is possible to evaluate their experience and publishing record. There are also quantitative metrics for journals, including the Impact Factor which is somewhat like a citation rate for the journal. Journals which publish articles that are cited a large number of times will have a high impact factor, which indicates their articles are likely to be of higher trustworthiness. Of course, some articles are not published in a journal at all. Instead, they are simply posted on an online depository such as arXiv.org or bioRxiv.org. These articles may be formatted to look like they were published in a journal, they may receive a DOI, and they may look perfectly legitimate. However, sometimes it is not clear if they have gone through any meaningful peer-review process, and thus the article’s trustworthiness can be suspect.

In the end, one can conclude that citations, downloads, DOIs, and journal impact factors are all imperfect measures of the trustworthiness of a given article. What is left? The absolute last line of defense is the authors name and reputation. No researcher I know would ever willingly attach their name as co-author to a paper they did not believe in. Thus, the best measure of the trustworthiness of a paper is the list of authors. While it is highly unlikely that a paper authored by inexperienced researchers will be flawed or fraudulent, the converse statement is true. A paper authored by highly experienced researchers, measured by the parameters described in this editorial, including a long track record of peer-reviewed articles, published in high-impact-factor journals, and that has been cited many times, is highly likely to be trustworthy. Even more so, the progress of science is tied to human relationships. When a new graduate student embarks on their research, using something like the approach described above, I guide them through the process of becoming familiar with the literature relevant to their research topic. But one of the most powerful factors in assessing the quality of a paper is knowing the authors personally. Some of our most valued papers are written by collaborators who we have had a long relationship with. We may have visited their laboratories, seen their experimental facilities up close, asked frank questions about their experimental procedures, shared ideas and swapped specimens, and have gained a great deal of trust through all those interactions. None of this will appear on Web of Science, but these qualitative features are more significant than any quantitative metric described in this document.

Today, the peer-review system is certainly under stress. The length of time required to conduct a thorough scientific review seems wholly inconsistent with the expected pace of scientific discovery. This is a great challenge to the public’s faith in science. Nonetheless, until a new form of scientific communication arises, researchers will continue to strive to use journal articles to disseminate their work. In this manner, the original mission of the Royal Society is fulfilled, “to extend the knowledge of nature…” one paper at a time.

Transactions of the Royal Society of Edinburgh. vol 1 (1788)

https://www.scientificamerican.com/blog/information-culture/the-birth-of-modern-peer-review/

Elmore SA, Weston EH (2020) Predatory journals: what they are and how to avoid them. Toxicol Pathol 48(4):607–610. https://doi.org/10.1177/0192623320920209

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Cann, D.P. Peer pressure: assessing the trustworthiness of a peer-reviewed journal article. J Mater Sci (2024). https://doi.org/10.1007/s10853-024-09816-w

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Article Contents

“we’re on the same team”: a qualitative study on communication and care coordination surrounding the requirement to quit smoking prior to elective orthopaedic surgery.

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Sara E Golden, Christina J Sun, Allison Young, David A Katz, Mark W Vander Weg, Marissa Song Mayeda, Kenneth R Gundle, Steffani R Bailey, “We’re On The Same Team”: A Qualitative Study On Communication And Care Coordination Surrounding The Requirement To Quit Smoking Prior To Elective Orthopaedic Surgery, Nicotine & Tobacco Research , 2024;, ntae140, https://doi.org/10.1093/ntr/ntae140

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Many surgeons require patients to quit smoking prior to elective surgeries to reduce the risk of postoperative complications. Our aim was to qualitatively evaluate the communication and care experiences of patients and clinicians involved in conversations about quitting smoking prior to elective orthopaedic surgery.

A qualitative interview study of rural-residing Veterans, primary care providers (PCPs), and Veterans Administration (VA) orthopaedic surgery staff and pharmacists, who care for rural Veterans. We performed a combination of deductive and inductive approaches to support conventional content analysis using a Patient-Centered Care framework.

Patients appreciated a shared approach with their PCP on the plan and reasons for cessation. Despite not knowing if the motivation for elective surgeries served as a teachable moment to facilitate long-term abstinence, almost all clinicians believed it typically helped in the short-term. There was a lack of standardized workflow between primary care and surgery, especially when patients used care delivered outside of VA.

While clinician-provided information about the reasons behind the requirement to quit smoking preoperatively was beneficial, patients appreciated the opportunity to collaborate with their care teams on developing a plan for cessation and abstinence. Other aspects of patient-centered care need to be leveraged, such as the therapeutic alliance or patient-as-person, to build trust and improve communication surrounding tobacco use treatment. System-level changes may need to be made to improve coordination and connection of clinicians within and across disciplines.

This study included perspectives from patients, primary care teams, and surgical teams and found that, in addition to providing information, clinicians need to address other aspects of patient-centered care such as the therapeutic alliance and patient-as-person domains to promote patient engagement in tobacco use treatment. This, in turn, could enhance the potential of surgery as a teachable moment and patient success in quitting smoking.

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• Published: 03 June 2024

Actions for mitigating the negative effects of patient participation in patient safety: a qualitative study

• Michael Van der Voorden 1 ,
• Arie Franx 1 &
• Kees Ahaus 2  

BMC Health Services Research volume  24 , Article number:  700 ( 2024 ) Cite this article

Metrics details

Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department.

This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals ( N  = 8) and patients ( N  = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach.

Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: ‘structure’, ‘culture’, ‘education’, ‘emotional’, and ‘physical and technology’. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients.

Conclusions

Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, ‘politics’. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations’ structure, culture and practices.

Peer Review reports

Every day, 830 women worldwide die as a result of complications during and following pregnancy and childbirth [ 1 ]. Most of these complications are considered preventable and often occur during hospitalization [ 1 , 2 , 3 , 4 ]. In Obstetrics, this mainly involves severe bleeding and infection after childbirth [ 1 ]. Preventable complications occur not only within Obstetrics but also within all specialties and therefore are a reason why patient safety has become an international priority [ 5 , 6 , 7 ]. In this regard, patient participation is increasingly used as a strategy to improve patient safety [ 8 , 9 , 10 ].

Recent research within the context of Obstetrics indeed shows the added value of patient participation in in-hospital patient safety [ 11 ] and more broadly [ 10 , 12 , 13 ]. A common example of patient participation, including Obstetrics patients, is shared decision-making, where the patient is expected to receive sufficient information from the professional and be supported in making medical choices [ 14 , 15 ]. This can help detect inconsistencies in care [ 16 ]. Another example is the use of a surgical safety checklist in cesarean deliveries [ 17 , 18 ], which can contribute to a reduction in errors and complications [ 17 , 19 ]. A third illustration is where patients are enabled to monitor their medication and thereby contribute to medication management [ 20 , 21 , 22 ], a reduction in medication errors, and improved outcomes [ 14 , 23 ].

Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged [ 24 ]. First, involving patients in safety initiatives can lead to anxiety in patients [ 25 ]. This includes situations where patients gain a better understanding of medication errors, which increases anxiety [ 24 ]. Second, the relationship between the patient and a professional can be negatively affected [ 26 ]. Sometimes this occurs because, when the patient and professional do negotiate, there are differences in opinions as to whether the patient’s wishes and needs are medically justified [ 24 ]. Third, more responsibility may be placed on the patient than the patient wants [ 24 , 27 ]. For example, patients may feel they have too much responsibility or that professionals have shifted too much responsibility onto them [ 24 ]. Fourth, patient participation in safety initiatives can take up more of the professional’s time [ 24 , 26 ] since a ‘participating’ patient may pose more questions to healthcare professionals.

To ultimately promote patient safety within an Obstetrics department, it is important to mitigate these negative effects of patient participation in patient safety. To this end, we firstly conducted a general review of the literature on actions that could be taken and classified these according to the model by Bate et al. [ 28 ]. This model has six categories of actions: ‘structure’, ‘political’, ‘cultural’, ‘educational’, ’emotional’, and ’physical and technology’ to promote healthcare improvements [ 28 ]. The reviewed literature looked at how to deal in general with common problems such as anxious patients [ 29 ] or an unsatisfactory patient-doctor relationship [ 30 ]. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department.

Study design

The aim of this study was to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department.

To achieve the goal of this research, qualitative research was employed. As a form of qualitative research, an exploratory interview study was conducted to uncover the actions of both patients and professionals within an Obstetrics department. The Standards for Reporting Qualitative Research checklist [ 31 ] was used to provide transparency (see Additional file 1 ).

Inclusion criteria and participants

This study was conducted within the Obstetrics Department of Erasmus Medical University Center in Rotterdam, the Netherlands. Interviews were held with both patients and birth care professionals to capture their thoughts on appropriate actions to mitigate the negative effects of patient participation on patient safety. Initially, 32 patients and 21 professionals were approached by email, phone, or face-to-face. The inclusion criteria for the patients were that the patient had been admitted to the Obstetrics department, were potentially willing to participate in an interview at least three weeks and no more than six weeks after childbirth, and had mastered the Dutch language sufficiently to fully participate. Inclusion criteria for the professionals were a position as a physician or clinical midwife, at least six months of employment in the Obstetrics department, and sufficient mastery of the Dutch language. A lack of time was the major reason given for nonparticipation by professionals. Patients mostly declined because of insufficient energy after childbirth. We continued to enroll participants until data saturation was achieved. This was achieved once eight patients and eight professionals had been interviewed (see Table  1 ). Data saturation is reached when the researcher begins to hear the same comments repeatedly within interviews [ 32 ]. Within this group of respondents, data saturation was reached because the same actions emerged in the last interviews. This occurred even after the clinical midwife was added alongside the gynecologists.

Data collection

Interviews were conducted between March 2020 and January 2021 by one researcher (MV). Due to COVID-19 concerns, safety measures were observed and the interviews took place on the basis of the patients’ and professionals’ preferences. Nine interviews were conducted face-to-face and seven were conducted by phone. The interviews lasted an average of 59 minutes (range: 43 to 101 minutes) with a focus on forms of individual patient participation. The four negative effects of patient participation on patient safety identified in an earlier study [ 24 ] were used as a starting point. The interview topic guide developed for this purpose [ 24 ] was also used for this study. In addition, in this study both patients and professionals were specifically asked about actions that could be taken to mitigate these negative effects. The in-depth interviews provided a sense of the local culture in this department. Following the interviews, a member check was carried out by asking the respondents to check for factual inaccuracies in the transcripts. Twelve of the sixteen participants took part in this check. None reported any factual inaccuracies, and no changes were made.

Data analysis

The texts of the interviews were transcribed, analyzed, and coded by one of the authors using ATLAS.ti V.8 for Windows. ATLAS.ti is a widely used tool to structure qualitative analysis [ 33 ] and we opted for deductive analysis because this was an appropriate approach to classify the proposed actions [ 28 ]) and generate an accessible overview of the actions identified. The model by Bate et al. [ 28 ] was used for this purpose, aiming to systematically identify the actions within the six different categories for healthcare improvement. Because the actions can influence each other and are interdependent, it is suitable to do this according to the classified themes that are interconnected. Firstly, it concerns structural, which involves organizing, planning, and coordinating quality efforts. Secondly, political addresses and deals with the politics of change surrounding any quality improvement effort. Thirdly, cultural entails giving quality a shared, collective meaning, value, and significance within the organization. Fourthly, educational is characterized by creating a learning process that supports improvement. Fifthly, emotional involves engaging and motivating people by linking quality improvement efforts to inner sentiments and deeper commitments and beliefs. Sixthly, it pertains to physical and technological, which involves designing physical infrastructure and technological systems that support and sustain quality efforts [ 28 ]. For the coding process, codes were initially assigned to the various actions mentioned by both patients and professionals, enabling us to provide an overview of the actions suggested. Furthermore, this approach provided insight into the level of consensus and the differences and similarities in the actions suggested by patients and by professionals. These actions were then classified according to the six categories proposed by Bate et al. [ 28 ]. All the actions suggested by our participants could be fitted within these categories.

The interviews yielded 18 actions, 13 of which were identified by both patients and professionals. These 18 actions could all be placed in one of five of the six categories proposed by Bate et al. Table  2 below provides a summary of the categories, suggested actions , and whether they were offered by patients, professionals, or both. For an overview of illustrative quotes that most effectively illustrate the story of the results, see Table  3 .

The first category ‘structure’ is about establishing working arrangements to prevent negative effects and to ensure patient participation in patient safety should negative effects arise.

Appoint a case manager

The respondents mentioned the importance of having a case manager in the primary process as a priority. As soon as patients experience a decrease in trust or the relationship between patient and professional is negatively affected, patients would like to know to whom they can go to discuss the situation. The case manager would then have the task of reassuring patients and ensuring transparency.

Make time for adequate attention

Both patients and professionals believed that when a patient’s confidence decreases or the relationship between patient and professional has been affected negatively, it is important that they can engage in a conversation about their anxiety. This requires the professionals to be able to free up time to accomplish this.

Provide information concerning responsibilities

To ensure that patients do not feel too much responsibility and that professionals hand over sufficient responsibility, professionals mentioned that it is important to adequately inform patients about the responsibilities of both patients and professionals. When patients know what they are responsible for, they feel more involved in their own care pathway. If errors or deviations in the care pathway are identified by patients, they generally become more anxious and trust may decrease. When this happens, it is important to keep the patient well-informed and provide clarity about the course of action.

Prepare well for childbirth

Patients considered this action important so that they can experience as little unnecessary anxiety as possible just before and during childbirth. In doing so, it should be made clear to patients exactly what to expect during childbirth. The interviews highlighted that good preparation for delivery can lead to a better patient experience.

Clarify role of partner or family

To maintain a sense of safety for patients in all situations, the professionals said that it is important that they establish protocols and standard information packages to ensure they discuss issues with the partner or contact person of the mother-to-be. Here, it is important that the professional takes responsibility for discussing this, so that the patient does not feel that the onus is on herself to pass on information.

The actions within ‘the culture’ category concern ensuring a patient-centered cultural shift, where it is important that professionals work together with the same values.

Patient-centered culture change

The suggested cultural changes related to patient-centeredness touch not only on actions within the culture theme, but also within other themes. From the interviews, it was clear that the respondents could conceive actions related to the mindset and motivation of the professionals. Further, what patients find important seems to be receiving minimal attention at present. In addition, patients were given minimal voice in the care process. To mitigate the negative effects, a cultural change is needed through which a patient’s values become the focus of their care.

Encourage patient participation

Professionals admitted that they do not always encourage patient participation because they frequently consider patients’ wants and needs as medically irresponsible and of little relevance to the outcome. As a result, professionals may shy away from patient participation. To mitigate the negative effects, it is important that patients are encouraged to participate in a desirable way. The professionals indicated that patients who want to proactively participate can be labeled as difficult.

Actively listen to the patient

Here, the professionals indicated that they are not used to actively listening to the patient. Both patients and professionals indicated that active listening is important to hear clearly why patients have anxieties.

Be transparent

Patients said that they are very dependent on the information they receive from professionals. Anxiety can be alleviated by openness and transparency. Moreover, patients indicated that it is important to provide full information when there are more questions. Provided this happens, patients indicate that there is less interference from them because they then know enough.

Work unambiguously

Unambiguous working was mentioned by both patients and professionals although both have different interpretations of this. From the patients’ point of view, it is mainly about unambiguous policies and not doing things that have not been agreed upon. For professionals, it is more about working with consistent values. That is, as soon as a negative effect arises, it is important that professionals have a consistent way of approaching patients.

Educational

Actions within the ‘educational’ category are about establishing an educational system that seeks to learn from negative effects in order to make improvements and avoid future negative effects.

Improve negotiation skills

The professionals reported that, at the point when patients and professionals start to create a birth plan and the patients and professionals negotiate the patient’s wants and needs and maybe fail to come to an agreement, they require conversational techniques that they do not always possess and therefore need to learn these skills.

Train on shared decision-making

Both patients and professionals indicated the need for training to enable them to take a more active role and participate more effectively in patient safety. This training should focus on shared decision-making, aiming to inform both patients and professionals on what responsibility they should take on and what is expected of them.

Ensure systematic feedback

Patients and professionals both indicated that healthcare organizations should use a standard questionnaire to continuously examine any negative outcomes and identify improvements that could be made to avoid these. Furthermore, this systematic feedback should be structurally fed back to the professionals in order that they can learn from it.

The ‘emotional’ theme is about sharing experiences and engaging patients by managing their expectations and showing leadership.

Share stories

The respondents mentioned that structurally listening to experiences and perceptions is an action that can prevent future negative effects. To establish this process, it is necessary to hold focus groups or open conversations with patients. This should lead to professionals being encouraged to work on making improvements.

Demonstrate leadership

Professionals reported that when the relationship between a patient and a professional has been negatively affected, it is important that the professional demonstrates leadership. This requires professionals to continuously explain why something is done, how it is done, and why it makes sense from the professional’s perspective to do it this way. Furthermore, professionals indicated that this requires listening to patients’ objections and that it is the role of professionals to actively address these objections.

Manage expectations

Respondents indicated that in situations where confidence decreases, it is important that patients know where they stand and that their confidence is restored. The professionals indicated that they often feel they have to live up to unrealistic expectations, such as in terms of facilities in the birthing room. As a result, patients and professionals may cease to get along. Patients reported here that it is important that boundaries and limitations are indicated in advance.

Physical and technology

The ‘physical and technology’ category is about ensuring that the negative effects of patient participation in patient safety are actually mitigated.

Create app for patients’ questions

Patient participation initiatives related to patient safety result in more questions arising from patients, requiring professionals to spend more time answering them. To make this more efficient, patients suggested developing an app so they could send questions to the professionals in advance. This was with the goal of reducing the time input by professionals. In addition, some professionals indicated that there should be an app that contains all the information that is important for the patient.

Clarify the patient journey

Both patients and professionals mentioned that it is important to reduce patients’ sense of bearing considerable responsibility, as this would contribute to managing their expectations during the patient journey. The professional will need to collaborate with an advisor to develop a patient journey that could provide an overview of when and where the patient should obtain appropriate information and therefore know what is expected.

In a previous study, we identified four different negative effects of patient participation in patient safety [ 24 ]. To ultimately promote patient safety in an Obstetrics department, this study aims to identify actions to mitigate the negative effects of patient participation in patient safety. These findings are relevant because the approach to addressing these negative effects of patient participation in patient safety within an Obstetrics department is currently lacking. Based on this, Obstetrics departments within hospitals can implement these actions in practice. Within this study, eighteen actions have been identified and four particularly relevant findings are discussed below.

Firstly, the results indicate that the common thread among the eighteen actions is a focus on ‘patient-centered culture change’. Currently, however, this department primarily view it from the perspective of the professionals, rather than adequately considering the viewpoint of the patients. Within this category ‘culture’, various actions emerged: patient-centered culture change, encourage patient participation, actively listen to the patient, be transparent, and work unambiguously. Within this paragraph, further exploration is conducted through comparisons to illustrate the importance of achieving a cultural shift towards the patient’s perspective within this context. An interesting angle here could come from the service dominant logic: that it is not only service providers that create value, but rather that service receivers do so for themselves in use or in collaboration with service providers [ 34 , 35 , 36 ]. This involves an evolution where service-dominant logic shifts the focus from goods to services [ 37 ]. This consideration, and what can be learned from service dominant logic, has resulted in an application called ‘value-in-use’. Hereby, value is created by the user during the usage of resources, processes (and/or their outcomes) [ 38 ]. Translating this to the Obstetrics department of this study, the conclusion could be that participation through patients in safety initiatives within birth care remains at a low level. The respondents indicated that the general line of thought and much of the reasoning is done from the perspective of professionals and does not adequately include the patients’ expertise, knowledge, and thinking. That the patient is not always perceived as a partner is not a surprising outcome, as this has been highlighted in several studies [ 39 , 40 ]. This is, for example, because patient-centered care in maternity care is perceived differently in practice [ 41 ]. Additionally, it is important to acknowledge that effecting such changes within organizations is challenging and requires significant engagement from patients [ 42 ] and professionals [ 43 ]. Continuing to invest in this area remains valuable, as the literature describes the positive contribution in terms of better outcomes, experiences, and reduced costs [ 44 , 45 ]. This reflection demonstrates that the underlying theme of this study, aiming for a cultural shift towards patient-centeredness, is valuable.

Secondly, recognizing the importance of achieving a cultural shift towards the patient’s perspective, this section delves deeper into how it is possible to accomplish this within an Obstetrics context.

This involves examining the link with the results of this study, falling under the categories of ‘educational’ and ‘emotional’. Several recent studies have examined how health care organizations can develop patient-centered care and how to implement this in practice [ 46 , 47 , 48 , 49 ]. A previous study [ 50 ] investigated the link between patient safety and patient-centered care within an Obstetrics department, concluding that professionals play an important role in achieving a culture of patient-centered care. In particular, professionals’ knowledge on doing so, demonstration of leadership, academic supervision, mentorship, and financial resources were cited as key components [ 50 ]. Looking at this study, demonstrate leadership was indicated by professionals and categorized under ‘emotional’. In practice, professionals often face various challenges in demonstrating leadership [ 51 , 52 ] Also within the organization where this study took place, efforts are being made to further formalize and strengthen the leadership role, where professionals perform both clinical and management tasks. Various studies indicate that doing so without proper training or preparation is difficult [ 53 , 54 ], and a structured approach is needed for it to succeed [ 52 ]. Additionally, share stories and manage expectations were mentioned in this study. The action of sharing stories could closely relate to systematically gathering feedback and actually taking action based on it in practice. Listening to the stories of obstetric patients aligns well with the idea of driving a culture change towards patient-centered care, by better understanding what they actually want rather than imposing guidelines [ 55 ]. At the same time, effectively listening to patients in general is complex and involves various challenges, such as professionals’ time constraints [ 56 ]. Moreover, it is noted that receiving feedback and actually acting upon it is also complex [ 57 ], thus intersecting with the educational category of actions. Thereby, managing patient expectations is crucial to prepare them for the choices that need to be made [ 58 ]. There often appears to be a difference between the expectations of an obstetric patient has for or during childbirth, particularly stemming from the established birth plan, and what actually occurs in practice. This while various professionals observe that unrealistic expectations are included in the birth plan [ 59 ]. In this regard, the expectations that patients have can influence patient satisfaction, underscoring the importance of professionals managing patient expectations [ 60 ]. This leads to the conclusion that actions in the ‘emotional’ category are complex and require more attention to implement in practice.

Having the right negotiation skills was categorized as an ‘educational’ action in this current study and again was only suggested by the professionals. The desired negotiation skills among professionals are essential for proper interaction with the patient, improving quality, as well as handling tensions or conflicts [ 61 ]. Since this is still insufficiently integrated into practice, there needs to be sufficient time and financial investment to make this possible through training(s) [ 62 ]. Other actions mentioned within the specific context of Obstetrics in other studies did not emerge as important actions in our study. In this study, two other ‘educational’ actions have been identified: training on shared decision-making and ensuring systematic feedback. Shared decision-making is already being experimented with and integrated within this Obstetrics department. However, both patients and professionals have indicated the need for training to better implement this in practice. The literature also suggests that Obstetric patients do not yet perceive shared decision making as adequately integrated [ 63 ]. One reason for this shortfall is the additional time commitment required from professionals on a daily basis [ 64 ]. Within this Obstetrics department, a significant amount of patient feedback is already being collected. However, there is currently no effective cycle in place to learn from and improve based on this feedback. Therefore, it can be argued that the feedback is not yet being adequately utilized.

Third, it is notable that within the categories ‘structure’ and ‘physical and technology’, actions emerge that intuitively seem embedded in practice. Under the category ‘structure’, the actions include appoint a case manager, make time for adequate attention, provide information concerning responsibilities, prepare well for childbirth, and clarify the role of partner or family. When it comes to appointing a case manager, this is something that is receiving increasing attention in the practice of the department and the hospital, particularly for patients who, in addition to being pregnant, also have (other) medical diseases. The case manager can be deployed as a point of contact at the individual level to align the care plan with the patient, as well as in collaboration with various other professionals [ 65 ]. It can be said that this is still perceived as relatively new within Dutch maternity care [ 66 ]. When it comes to making time for adequate attention, providing information concerning responsibilities, preparing well for childbirth, and clarifying the role of partner or family it may seem as if these actions are self-evident and therefore can be applied easily in the practice of an Obstetrics department. Given the often urgent nature of an Obstetrics department, time pressure in such situations can increase. A previous study [ 67 ] indicates that when time pressure is higher within an Obstetrics department, professionals feel a stronger need to make decisions themselves. This could explain why both patients and professionals have mentioned all three actions.

Under the category ‘physical and technology’, the actions include creating an app for patients’ questions and clarifying the patient journey. The suggestion of creating an app within this Obstetrics department is somewhat surprising, as such an app for patient questions may already be implemented within the hospital. However, it is possible that its usage is still minimal or that patients and professionals are not sufficiently familiar with it. In a study on the use of eHealth and mobile health within an Obstetric context, it is suggested that it is the role of professionals to involve pregnant women in order to lead to successful integration [ 68 ]. Additionally, the results suggest that for managing responsibilities and the expectations associated with them, it is essential to provide better insight into the patient journey. It could be valuable to make the patient journey transparent, with it being the responsibility of professionals to capture the perceptions, preferences, and expectations of the patient upfront [ 69 ].

Fourth, our study yielded 18 actions to mitigate the negative effects of patient participation in patient safety within an Obstetrics department in five of these six categories. That is, no one mentioned an action falling within the ‘politics’ category that Bate et al. define as: ‘dealing with conflicts and tensions between different interests and power relations’ . We offer two possible explanations for why politics was not mentioned in our study. First, many respondents within an Obstetrics department were unfamiliar with the topic being addressed in this study and, consequently, may not have been able to put it into a broader perspective and suggest actions in the political sphere. Second, the actions were primarily envisaged from the practical perspectives of the patients and professionals. As such, one could argue that politics as previously defined are largely absent. This can be seen as an interesting result because the literature often discusses tensions that can arise between patients and professionals when there are conflicting interests [ 70 , 71 , 72 ]. An example from the obstetric literature suggests that with patient participation in the form of promoting shared decision-making, tension can arise when the patient is challenged to make a choice. However, this may conflict with the clinician’s clinical experience or care standards [ 73 ]. Ultimately, this could affect patient safety if the patient prioritizes their own interests over the clinical ones. Another specific example from the obstetric literature shows that among Black American women, a study revealed a sense of powerlessness where doctors played a dominant role in the process [ 74 ]. Based on this, it could be argued that there is potentially a ‘politics’ element based on power relations and the interaction between patients and professionals. And it is plausible that in the future, consideration should be given to actions in the ‘politics’ domain, as such tensions may arise in practice.

Strengths and limitations

First, this study is an inventory off the actions to be taken from the input of both patients and professionals. Because the strength of this is that it allows the conclusion that most of the actions (13/18) were mentioned by both groups. Second, to our knowledge, this is the first study to examine, from the perspective of patient participation in patient safety, the mitigation of negative effects within an Obstetrics department. Thus, it contributes to closing a gap in the scientific literature. Despite these strengths, there are three limitations. Our sample size was limited both in terms of patients and professionals. Additionally, most of the patients were highly educated, and there was no equal distribution among professionals, thus potentially not reflecting the broader population. This might have introduced selection bias [ 75 ]. However, additional respondents were recruited until data saturation was achieved. Second, the generalizability of this research is limited, although this is not necessarily a goal in qualitative research [ 76 ]. That is, the actions identified come from a specific context and generate an overview of this. Third, by choosing to analyze the data deductively based on Bate et al.’s model [ 28 ], the results were shaped by the categories therein. Other models for deductive analysis might have revealed broader or different actions. Nevertheless, the model used does provide specific categories that can then be further elaborated by practitioners.

Eighteen different actions emerged within five categories from this study in a specific context of an Obstetrics department. No actions fit within the model’s sixth category of ‘politics’. The main finding from this study is that most of the actions highlight the need for a patient-centered culture change. Currently, this still relies heavily on the perspective of professionals and too little consideration is given to that of patients. Future studies could repeat our approach but in a different specific context to see whether other practical actions would be identified for further development. This could include looking at other respondents within the study population, such as other job groups of professionals or less educated patients.

Practical implications

A specialty or department must recognize that these negative effects occur in patient participation within the realm of patient safety. By doing so, space, money and time have to be created to elaborate on these actions by patients and professionals and integrate them into the organizations’ structure, culture and practices.

Data availability

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

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Acknowledgements

The authors would like to thank the Obstetrics Department of Erasmus University Medical Center and the individual patients and professionals involved for participating in this study and thereby providing relevant data.

The authors have not received a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

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M.V.: Conceptualization, methodology, formal analysis, investigation, data curation, writing, original draft, review & editing A.F.: conceptualization, resources, review & editing, supervision K.A.: conceptualization, resources, review & editing, supervision.

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Correspondence to Michael Van der Voorden .

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Van der Voorden, M., Franx, A. & Ahaus, K. Actions for mitigating the negative effects of patient participation in patient safety: a qualitative study. BMC Health Serv Res 24 , 700 (2024). https://doi.org/10.1186/s12913-024-11154-1

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Received : 22 November 2023

Accepted : 29 May 2024

Published : 03 June 2024

DOI : https://doi.org/10.1186/s12913-024-11154-1

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