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Understanding Descriptive Research Designs and Methods

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• 1 Author Affiliation: Senior Nurse Scientist and Clinical Nurse Specialist, Office of Nursing Research & Innovation, Nursing Institute, Cleveland Clinic, Ohio.
• PMID: 31789957
• DOI: 10.1097/NUR.0000000000000493
• Nurse Clinicians / psychology*
• Nursing Research / methods*
• Research Design*

The potential of working hypotheses for deductive exploratory research

• Open access
• Published: 08 December 2020
• Volume 55 , pages 1703–1725, ( 2021 )

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• Mattia Casula   ORCID: orcid.org/0000-0002-7081-8153 1 ,
• Nandhini Rangarajan 2 &
• Patricia Shields   ORCID: orcid.org/0000-0002-0960-4869 2  

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While hypotheses frame explanatory studies and provide guidance for measurement and statistical tests, deductive, exploratory research does not have a framing device like the hypothesis. To this purpose, this article examines the landscape of deductive, exploratory research and offers the working hypothesis as a flexible, useful framework that can guide and bring coherence across the steps in the research process. The working hypothesis conceptual framework is introduced, placed in a philosophical context, defined, and applied to public administration and comparative public policy. Doing so, this article explains: the philosophical underpinning of exploratory, deductive research; how the working hypothesis informs the methodologies and evidence collection of deductive, explorative research; the nature of micro-conceptual frameworks for deductive exploratory research; and, how the working hypothesis informs data analysis when exploratory research is deductive.

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1 Introduction

Exploratory research is generally considered to be inductive and qualitative (Stebbins 2001 ). Exploratory qualitative studies adopting an inductive approach do not lend themselves to a priori theorizing and building upon prior bodies of knowledge (Reiter 2013 ; Bryman 2004 as cited in Pearse 2019 ). Juxtaposed against quantitative studies that employ deductive confirmatory approaches, exploratory qualitative research is often criticized for lack of methodological rigor and tentativeness in results (Thomas and Magilvy 2011 ). This paper focuses on the neglected topic of deductive, exploratory research and proposes working hypotheses as a useful framework for these studies.

To emphasize that certain types of applied research lend themselves more easily to deductive approaches, to address the downsides of exploratory qualitative research, and to ensure qualitative rigor in exploratory research, a significant body of work on deductive qualitative approaches has emerged (see for example, Gilgun 2005 , 2015 ; Hyde 2000 ; Pearse 2019 ). According to Gilgun ( 2015 , p. 3) the use of conceptual frameworks derived from comprehensive reviews of literature and a priori theorizing were common practices in qualitative research prior to the publication of Glaser and Strauss’s ( 1967 ) The Discovery of Grounded Theory . Gilgun ( 2015 ) coined the terms Deductive Qualitative Analysis (DQA) to arrive at some sort of “middle-ground” such that the benefits of a priori theorizing (structure) and allowing room for new theory to emerge (flexibility) are reaped simultaneously. According to Gilgun ( 2015 , p. 14) “in DQA, the initial conceptual framework and hypotheses are preliminary. The purpose of DQA is to come up with a better theory than researchers had constructed at the outset (Gilgun 2005 , 2009 ). Indeed, the production of new, more useful hypotheses is the goal of DQA”.

DQA provides greater level of structure for both the experienced and novice qualitative researcher (see for example Pearse 2019 ; Gilgun 2005 ). According to Gilgun ( 2015 , p. 4) “conceptual frameworks are the sources of hypotheses and sensitizing concepts”. Sensitizing concepts frame the exploratory research process and guide the researcher’s data collection and reporting efforts. Pearse ( 2019 ) discusses the usefulness for deductive thematic analysis and pattern matching to help guide DQA in business research. Gilgun ( 2005 ) discusses the usefulness of DQA for family research.

Given these rationales for DQA in exploratory research, the overarching purpose of this paper is to contribute to that growing corpus of work on deductive qualitative research. This paper is specifically aimed at guiding novice researchers and student scholars to the working hypothesis as a useful a priori framing tool. The applicability of the working hypothesis as a tool that provides more structure during the design and implementation phases of exploratory research is discussed in detail. Examples of research projects in public administration that use the working hypothesis as a framing tool for deductive exploratory research are provided.

In the next section, we introduce the three types of research purposes. Second, we examine the nature of the exploratory research purpose. Third, we provide a definition of working hypothesis. Fourth, we explore the philosophical roots of methodology to see where exploratory research fits. Fifth, we connect the discussion to the dominant research approaches (quantitative, qualitative and mixed methods) to see where deductive exploratory research fits. Sixth, we examine the nature of theory and the role of the hypothesis in theory. We contrast formal hypotheses and working hypotheses. Seven, we provide examples of student and scholarly work that illustrates how working hypotheses are developed and operationalized. Lastly, this paper synthesizes previous discussion with concluding remarks.

2 Three types of research purposes

The literature identifies three basic types of research purposes—explanation, description and exploration (Babbie 2007 ; Adler and Clark 2008 ; Strydom 2013 ; Shields and Whetsell 2017 ). Research purposes are similar to research questions; however, they focus on project goals or aims instead of questions.

Explanatory research answers the “why” question (Babbie 2007 , pp. 89–90), by explaining “why things are the way they are”, and by looking “for causes and reasons” (Adler and Clark 2008 , p. 14). Explanatory research is closely tied to hypothesis testing. Theory is tested using deductive reasoning, which goes from the general to the specific (Hyde 2000 , p. 83). Hypotheses provide a frame for explanatory research connecting the research purpose to other parts of the research process (variable construction, choice of data, statistical tests). They help provide alignment or coherence across stages in the research process and provide ways to critique the strengths and weakness of the study. For example, were the hypotheses grounded in the appropriate arguments and evidence in the literature? Are the concepts imbedded in the hypotheses appropriately measured? Was the best statistical test used? When the analysis is complete (hypothesis is tested), the results generally answer the research question (the evidence supported or failed to support the hypothesis) (Shields and Rangarajan 2013 ).

Descriptive research addresses the “What” question and is not primarily concerned with causes (Strydom 2013 ; Shields and Tajalli 2006 ). It lies at the “midpoint of the knowledge continuum” (Grinnell 2001 , p. 248) between exploration and explanation. Descriptive research is used in both quantitative and qualitative research. A field researcher might want to “have a more highly developed idea of social phenomena” (Strydom 2013 , p. 154) and develop thick descriptions using inductive logic. In science, categorization and classification systems such as the periodic table of chemistry or the taxonomies of biology inform descriptive research. These baseline classification systems are a type of theorizing and allow researchers to answer questions like “what kind” of plants and animals inhabit a forest. The answer to this question would usually be displayed in graphs and frequency distributions. This is also the data presentation system used in the social sciences (Ritchie and Lewis 2003 ; Strydom 2013 ). For example, if a scholar asked, what are the needs of homeless people? A quantitative approach would include a survey that incorporated a “needs” classification system (preferably based on a literature review). The data would be displayed as frequency distributions or as charts. Description can also be guided by inductive reasoning, which draws “inferences from specific observable phenomena to general rules or knowledge expansion” (Worster 2013 , p. 448). Theory and hypotheses are generated using inductive reasoning, which begins with data and the intention of making sense of it by theorizing. Inductive descriptive approaches would use a qualitative, naturalistic design (open ended interview questions with the homeless population). The data could provide a thick description of the homeless context. For deductive descriptive research, categories, serve a purpose similar to hypotheses for explanatory research. If developed with thought and a connection to the literature, categories can serve as a framework that inform measurement, link to data collection mechanisms and to data analysis. Like hypotheses they can provide horizontal coherence across the steps in the research process.

Table  1 demonstrated these connections for deductive, descriptive and explanatory research. The arrow at the top emphasizes the horizontal or across the research process view we emphasize. This article makes the case that the working hypothesis can serve the same purpose as the hypothesis for deductive, explanatory research and categories for deductive descriptive research. The cells for exploratory research are filled in with question marks.

The remainder of this paper focuses on exploratory research and the answers to questions found in the table:

What is the philosophical underpinning of exploratory, deductive research?

What is the Micro-conceptual framework for deductive exploratory research? [ As is clear from the article title we introduce the working hypothesis as the answer .]

How does the working hypothesis inform the methodologies and evidence collection of deductive exploratory research?

How does the working hypothesis inform data analysis of deductive exploratory research?

3 The nature of exploratory research purpose

Explorers enter the unknown to discover something new. The process can be fraught with struggle and surprises. Effective explorers creatively resolve unexpected problems. While we typically think of explorers as pioneers or mountain climbers, exploration is very much linked to the experience and intention of the explorer. Babies explore as they take their first steps. The exploratory purpose resonates with these insights. Exploratory research, like reconnaissance, is a type of inquiry that is in the preliminary or early stages (Babbie 2007 ). It is associated with discovery, creativity and serendipity (Stebbins 2001 ). But the person doing the discovery, also defines the activity or claims the act of exploration. It “typically occurs when a researcher examines a new interest or when the subject of study itself is relatively new” (Babbie 2007 , p. 88). Hence, exploration has an open character that emphasizes “flexibility, pragmatism, and the particular, biographically specific interests of an investigator” (Maanen et al. 2001 , p. v). These three purposes form a type of hierarchy. An area of inquiry is initially explored . This early work lays the ground for, description which in turn becomes the basis for explanation . Quantitative, explanatory studies dominate contemporary high impact journals (Twining et al. 2017 ).

Stebbins ( 2001 ) makes the point that exploration is often seen as something like a poor stepsister to confirmatory or hypothesis testing research. He has a problem with this because we live in a changing world and what is settled today will very likely be unsettled in the near future and in need of exploration. Further, exploratory research “generates initial insights into the nature of an issue and develops questions to be investigated by more extensive studies” (Marlow 2005 , p. 334). Exploration is widely applicable because all research topics were once “new.” Further, all research topics have the possibility of “innovation” or ongoing “newness”. Exploratory research may be appropriate to establish whether a phenomenon exists (Strydom 2013 ). The point here, of course, is that the exploratory purpose is far from trivial.

Stebbins’ Exploratory Research in the Social Sciences ( 2001 ), is the only book devoted to the nature of exploratory research as a form of social science inquiry. He views it as a “broad-ranging, purposive, systematic prearranged undertaking designed to maximize the discovery of generalizations leading to description and understanding of an area of social or psychological life” (p. 3). It is science conducted in a way distinct from confirmation. According to Stebbins ( 2001 , p. 6) the goal is discovery of potential generalizations, which can become future hypotheses and eventually theories that emerge from the data. He focuses on inductive logic (which stimulates creativity) and qualitative methods. He does not want exploratory research limited to the restrictive formulas and models he finds in confirmatory research. He links exploratory research to Glaser and Strauss’s ( 1967 ) flexible, immersive, Grounded Theory. Strydom’s ( 2013 ) analysis of contemporary social work research methods books echoes Stebbins’ ( 2001 ) position. Stebbins’s book is an important contribution, but it limits the potential scope of this flexible and versatile research purpose. If we accepted his conclusion, we would delete the “Exploratory” row from Table  1 .

Note that explanatory research can yield new questions, which lead to exploration. Inquiry is a process where inductive and deductive activities can occur simultaneously or in a back and forth manner, particularly as the literature is reviewed and the research design emerges. Footnote 1 Strict typologies such as explanation, description and exploration or inductive/deductive can obscures these larger connections and processes. We draw insight from Dewey’s ( 1896 ) vision of inquiry as depicted in his seminal “Reflex Arc” article. He notes that “stimulus” and “response” like other dualities (inductive/deductive) exist within a larger unifying system. Yet the terms have value. “We need not abandon terms like stimulus and response, so long as we remember that they are attached to events based upon their function in a wider dynamic context, one that includes interests and aims” (Hildebrand 2008 , p. 16). So too, in methodology typologies such as deductive/inductive capture useful distinctions with practical value and are widely used in the methodology literature.

We argue that there is a role for exploratory, deductive, and confirmatory research. We maintain all types of research logics and methods should be in the toolbox of exploratory research. First, as stated above, it makes no sense on its face to identify an extremely flexible purpose that is idiosyncratic to the researcher and then basically restrict its use to qualitative, inductive, non-confirmatory methods. Second, Stebbins’s ( 2001 ) work focused on social science ignoring the policy sciences. Exploratory research can be ideal for immediate practical problems faced by policy makers, who could find a framework of some kind useful. Third, deductive, exploratory research is more intentionally connected to previous research. Some kind of initial framing device is located or designed using the literature. This may be very important for new scholars who are developing research skills and exploring their field and profession. Stebbins’s insights are most pertinent for experienced scholars. Fourth, frameworks and deductive logic are useful for comparative work because some degree of consistency across cases is built into the design.

As we have seen, the hypotheses of explanatory and categories of descriptive research are the dominate frames of social science and policy science. We certainly concur that neither of these frames makes a lot of sense for exploratory research. They would tend to tie it down. We see the problem as a missing framework or missing way to frame deductive, exploratory research in the methodology literature. Inductive exploratory research would not work for many case studies that are trying to use evidence to make an argument. What exploratory deductive case studies need is a framework that incorporates flexibility. This is even more true for comparative case studies. A framework of this sort could be usefully applied to policy research (Casula 2020a ), particularly evaluative policy research, and applied research generally. We propose the Working Hypothesis as a flexible conceptual framework and as a useful tool for doing exploratory studies. It can be used as an evaluative criterion particularly for process evaluation and is useful for student research because students can develop theorizing skills using the literature.

Table  1 included a column specifying the philosophical basis for each research purpose. Shifting gears to the philosophical underpinning of methodology provides useful additional context for examination of deductive, exploratory research.

4 What is a working hypothesis

The working hypothesis is first and foremost a hypothesis or a statement of expectation that is tested in action. The term “working” suggest that these hypotheses are subject to change, are provisional and the possibility of finding contradictory evidence is real. In addition, a “working” hypothesis is active, it is a tool in an ongoing process of inquiry. If one begins with a research question, the working hypothesis could be viewed as a statement or group of statements that answer the question. It “works” to move purposeful inquiry forward. “Working” also implies some sort of community, mostly we work together in relationship to achieve some goal.

Working Hypothesis is a term found in earlier literature. Indeed, both pioneering pragmatists, John Dewey and George Herbert Mead use the term working hypothesis in important nineteenth century works. For both Dewey and Mead, the notion of a working hypothesis has a self-evident quality and it is applied in a big picture context. Footnote 2

Most notably, Dewey ( 1896 ), in one of his most pivotal early works (“Reflex Arc”), used “working hypothesis” to describe a key concept in psychology. “The idea of the reflex arc has upon the whole come nearer to meeting this demand for a general working hypothesis than any other single concept (Italics added)” (p. 357). The notion of a working hypothesis was developed more fully 42 years later, in Logic the Theory of Inquiry , where Dewey developed the notion of a working hypothesis that operated on a smaller scale. He defines working hypotheses as a “provisional, working means of advancing investigation” (Dewey 1938 , pp. 142). Dewey’s definition suggests that working hypotheses would be useful toward the beginning of a research project (e.g., exploratory research).

Mead ( 1899 ) used working hypothesis in a title of an American Journal of Sociology article “The Working Hypothesis and Social Reform” (italics added). He notes that a scientist’s foresight goes beyond testing a hypothesis.

Given its success, he may restate his world from this standpoint and get the basis for further investigation that again always takes the form of a problem. The solution of this problem is found over again in the possibility of fitting his hypothetical proposition into the whole within which it arises. And he must recognize that this statement is only a working hypothesis at the best, i.e., he knows that further investigation will show that the former statement of his world is only provisionally true, and must be false from the standpoint of a larger knowledge, as every partial truth is necessarily false over against the fuller knowledge which he will gain later (Mead 1899 , p. 370).

Cronbach ( 1975 ) developed a notion of working hypothesis consistent with inductive reasoning, but for him, the working hypothesis is a product or result of naturalistic inquiry. He makes the case that naturalistic inquiry is highly context dependent and therefore results or seeming generalizations that may come from a study and should be viewed as “working hypotheses”, which “are tentative both for the situation in which they first uncovered and for other situations” (as cited in Gobo 2008 , p. 196).

A quick Google scholar search using the term “working hypothesis” show that it is widely used in twentieth and twenty-first century science, particularly in titles. In these articles, the working hypothesis is treated as a conceptual tool that furthers investigation in its early or transitioning phases. We could find no explicit links to exploratory research. The exploratory nature of the problem is expressed implicitly. Terms such as “speculative” (Habib 2000 , p. 2391) or “rapidly evolving field” (Prater et al. 2007 , p. 1141) capture the exploratory nature of the study. The authors might describe how a topic is “new” or reference “change”. “As a working hypothesis, the picture is only new, however, in its interpretation” (Milnes 1974 , p. 1731). In a study of soil genesis, Arnold ( 1965 , p. 718) notes “Sequential models, formulated as working hypotheses, are subject to further investigation and change”. Any 2020 article dealing with COVID-19 and respiratory distress would be preliminary almost by definition (Ciceri et al. 2020 ).

5 Philosophical roots of methodology

According to Kaplan ( 1964 , p. 23) “the aim of methodology is to help us understand, in the broadest sense not the products of scientific inquiry but the process itself”. Methods contain philosophical principles that distinguish them from other “human enterprises and interests” (Kaplan 1964 , p. 23). Contemporary research methodology is generally classified as quantitative, qualitative and mixed methods. Leading scholars of methodology have associated each with a philosophical underpinning—positivism (or post-positivism), interpretivism or constructivist and pragmatism, respectively (Guba 1987 ; Guba and Lincoln 1981 ; Schrag 1992 ; Stebbins 2001 ; Mackenzi and Knipe 2006 ; Atieno 2009 ; Levers 2013 ; Morgan 2007 ; O’Connor et al. 2008 ; Johnson and Onwuegbuzie 2004 ; Twining et al. 2017 ). This section summarizes how the literature often describes these philosophies and informs contemporary methodology and its literature.

Positivism and its more contemporary version, post-positivism, maintains an objectivist ontology or assumes an objective reality, which can be uncovered (Levers 2013 ; Twining et al. 2017 ). Footnote 3 Time and context free generalizations are possible and “real causes of social scientific outcomes can be determined reliably and validly (Johnson and Onwuegbunzie 2004 , p. 14). Further, “explanation of the social world is possible through a logical reduction of social phenomena to physical terms”. It uses an empiricist epistemology which “implies testability against observation, experimentation, or comparison” (Whetsell and Shields 2015 , pp. 420–421). Correspondence theory, a tenet of positivism, asserts that “to each concept there corresponds a set of operations involved in its scientific use” (Kaplan 1964 , p. 40).

The interpretivist, constructivists or post-modernist approach is a reaction to positivism. It uses a relativist ontology and a subjectivist epistemology (Levers 2013 ). In this world of multiple realities, context free generalities are impossible as is the separation of facts and values. Causality, explanation, prediction, experimentation depend on assumptions about the correspondence between concepts and reality, which in the absence of an objective reality is impossible. Empirical research can yield “contextualized emergent understanding rather than the creation of testable theoretical structures” (O’Connor et al. 2008 , p. 30). The distinctively different world views of positivist/post positivist and interpretivist philosophy is at the core of many controversies in methodology, social and policy science literature (Casula 2020b ).

With its focus on dissolving dualisms, pragmatism steps outside the objective/subjective debate. Instead, it asks, “what difference would it make to us if the statement were true” (Kaplan 1964 , p. 42). Its epistemology is connected to purposeful inquiry. Pragmatism has a “transformative, experimental notion of inquiry” anchored in pluralism and a focus on constructing conceptual and practical tools to resolve “problematic situations” (Shields 1998 ; Shields and Rangarajan 2013 ). Exploration and working hypotheses are most comfortably situated within the pragmatic philosophical perspective.

6 Research approaches

Empirical investigation relies on three types of methodology—quantitative, qualitative and mixed methods.

6.1 Quantitative methods

Quantitative methods uses deductive logic and formal hypotheses or models to explain, predict, and eventually establish causation (Hyde 2000 ; Kaplan 1964 ; Johnson and Onwuegbunzie 2004 ; Morgan 2007 ). Footnote 4 The correspondence between the conceptual and empirical world make measures possible. Measurement assigns numbers to objects, events or situations and allows for standardization and subtle discrimination. It also allows researchers to draw on the power of mathematics and statistics (Kaplan 1964 , pp. 172–174). Using the power of inferential statistics, quantitative research employs research designs, which eliminate competing hypotheses. It is high in external validity or the ability to generalize to the whole. The research results are relatively independent of the researcher (Johnson & Onwuegbunzie 2004 ).

Quantitative methods depend on the quality of measurement and a priori conceptualization, and adherence to the underlying assumptions of inferential statistics. Critics charge that hypotheses and frameworks needlessly constrain inquiry (Johnson and Onwuegbunzie 2004 , p. 19). Hypothesis testing quantitative methods support the explanatory purpose.

6.2 Qualitative methods

Qualitative researchers who embrace the post-modern, interpretivist view, Footnote 5 question everything about the nature of quantitative methods (Willis et al. 2007 ). Rejecting the possibility of objectivity, correspondence between ideas and measures, and the constraints of a priori theorizing they focus on “unique impressions and understandings of events rather than to generalize the findings” (Kolb 2012 , p. 85). Characteristics of traditional qualitative research include “induction, discovery, exploration, theory/hypothesis generation and the researcher as the primary ‘instrument’ of data collection” (Johnson and Onwuegbunzie 2004 , p. 18). It also concerns itself with forming “unique impressions and understandings of events rather than to generalize findings” (Kolb 2012 , p. 85). The data of qualitative methods are generated via interviews, direct observation, focus groups and analysis of written records or artifacts.

Qualitative methods provide for understanding and “description of people’s personal experiences of phenomena”. They enable descriptions of detailed “phenomena as they are situated and embedded in local contexts.” Researchers use naturalistic settings to “study dynamic processes” and explore how participants interpret experiences. Qualitative methods have an inherent flexibility, allowing researchers to respond to changes in the research setting. They are particularly good at narrowing to the particular and on the flipside have limited external validity (Johnson and Onwuegbunzie 2004 , p. 20). Instead of specifying a suitable sample size to draw conclusions, qualitative research uses the notion of saturation (Morse 1995 ).

Saturation is used in grounded theory—a widely used and respected form of qualitative research, and a well-known interpretivist qualitative research method. Introduced by Glaser and Strauss ( 1967 ), this “grounded on observation” (Patten and Newhart 2000 , p. 27) methodology, focuses on “the creation of emergent understanding” (O’Connor et al. 2008 , p. 30). It uses the Constant Comparative method, whereby researchers develop theory from data as they code and analyze at the same time. Data collection, coding and analysis along with theoretical sampling are systematically combined to generate theory (Kolb 2012 , p. 83). The qualitative methods discussed here support exploratory research.

A close look at the two philosophies and assumptions of quantitative and qualitative research suggests two contradictory world views. The literature has labeled these contradictory views the Incompatibility Theory, which sets up a quantitative versus qualitative tension similar to the seeming separation of art and science or fact and values (Smith 1983a , b ; Guba 1987 ; Smith and Heshusius 1986 ; Howe 1988 ). The incompatibility theory does not make sense in practice. Yin ( 1981 , 1992 , 2011 , 2017 ), a prominent case study scholar, showcases a deductive research methodology that crosses boundaries using both quantaitive and qualitative evidence when appropriate.

6.3 Mixed methods

Turning the “Incompatibility Theory” on its head, Mixed Methods research “combines elements of qualitative and quantitative research approaches … for the broad purposes of breadth and depth of understanding and corroboration” (Johnson et al. 2007 , p. 123). It does this by partnering with philosophical pragmatism. Footnote 6 Pragmatism is productive because “it offers an immediate and useful middle position philosophically and methodologically; it offers a practical and outcome-oriented method of inquiry that is based on action and leads, iteratively, to further action and the elimination of doubt; it offers a method for selecting methodological mixes that can help researchers better answer many of their research questions” (Johnson and Onwuegbunzie 2004 , p. 17). What is theory for the pragmatist “any theoretical model is for the pragmatist, nothing more than a framework through which problems are perceived and subsequently organized ” (Hothersall 2019 , p. 5).

Brendel ( 2009 ) constructed a simple framework to capture the core elements of pragmatism. Brendel’s four “p”’s—practical, pluralism, participatory and provisional help to show the relevance of pragmatism to mixed methods. Pragmatism is purposeful and concerned with the practical consequences. The pluralism of pragmatism overcomes quantitative/qualitative dualism. Instead, it allows for multiple perspectives (including positivism and interpretivism) and, thus, gets around the incompatibility problem. Inquiry should be participatory or inclusive of the many views of participants, hence, it is consistent with multiple realities and is also tied to the common concern of a problematic situation. Finally, all inquiry is provisional . This is compatible with experimental methods, hypothesis testing and consistent with the back and forth of inductive and deductive reasoning. Mixed methods support exploratory research.

Advocates of mixed methods research note that it overcomes the weaknesses and employs the strengths of quantitative and qualitative methods. Quantitative methods provide precision. The pictures and narrative of qualitative techniques add meaning to the numbers. Quantitative analysis can provide a big picture, establish relationships and its results have great generalizability. On the other hand, the “why” behind the explanation is often missing and can be filled in through in-depth interviews. A deeper and more satisfying explanation is possible. Mixed-methods brings the benefits of triangulation or multiple sources of evidence that converge to support a conclusion. It can entertain a “broader and more complete range of research questions” (Johnson and Onwuegbunzie 2004 , p. 21) and can move between inductive and deductive methods. Case studies use multiple forms of evidence and are a natural context for mixed methods.

One thing that seems to be missing from mixed method literature and explicit design is a place for conceptual frameworks. For example, Heyvaert et al. ( 2013 ) examined nine mixed methods studies and found an explicit framework in only two studies (transformative and pragmatic) (p. 663).

7 Theory and hypotheses: where is and what is theory?

Theory is key to deductive research. In essence, empirical deductive methods test theory. Hence, we shift our attention to theory and the role and functions of the hypotheses in theory. Oppenheim and Putnam ( 1958 ) note that “by a ‘theory’ (in the widest sense) we mean any hypothesis, generalization or law (whether deterministic or statistical) or any conjunction of these” (p. 25). Van Evera ( 1997 ) uses a similar and more complex definition “theories are general statements that describe and explain the causes of effects of classes of phenomena. They are composed of causal laws or hypotheses, explanations, and antecedent conditions” (p. 8). Sutton and Staw ( 1995 , p. 376) in a highly cited article “What Theory is Not” assert the that hypotheses should contain logical arguments for “why” the hypothesis is expected. Hypotheses need an underlying causal argument before they can be considered theory. The point of this discussion is not to define theory but to establish the importance of hypotheses in theory.

Explanatory research is implicitly relational (A explains B). The hypotheses of explanatory research lay bare these relationships. Popular definitions of hypotheses capture this relational component. For example, the Cambridge Dictionary defines a hypothesis a “an idea or explanation for something that is based on known facts but has not yet been proven”. Vocabulary.Com’s definition emphasizes explanation, a hypothesis is “an idea or explanation that you then test through study and experimentation”. According to Wikipedia a hypothesis is “a proposed explanation for a phenomenon”. Other definitions remove the relational or explanatory reference. The Oxford English Dictionary defines a hypothesis as a “supposition or conjecture put forth to account for known facts.” Science Buddies defines a hypothesis as a “tentative, testable answer to a scientific question”. According to the Longman Dictionary the hypothesis is “an idea that can be tested to see if it is true or not”. The Urban Dictionary states a hypothesis is “a prediction or educated-guess based on current evidence that is yet be tested”. We argue that the hypotheses of exploratory research— working hypothesis — are not bound by relational expectations. It is this flexibility that distinguishes the working hypothesis.

Sutton and Staw (1995) maintain that hypotheses “serve as crucial bridges between theory and data, making explicit how the variables and relationships that follow from a logical argument will be operationalized” (p. 376, italics added). The highly rated journal, Computers and Education , Twining et al. ( 2017 ) created guidelines for qualitative research as a way to improve soundness and rigor. They identified the lack of alignment between theoretical stance and methodology as a common problem in qualitative research. In addition, they identified a lack of alignment between methodology, design, instruments of data collection and analysis. The authors created a guidance summary, which emphasized the need to enhance coherence throughout elements of research design (Twining et al. 2017 p. 12). Perhaps the bridging function of the hypothesis mentioned by Sutton and Staw (1995) is obscured and often missing in qualitative methods. Working hypotheses can be a tool to overcome this problem.

For reasons, similar to those used by mixed methods scholars, we look to classical pragmatism and the ideas of John Dewey to inform our discussion of theory and working hypotheses. Dewey ( 1938 ) treats theory as a tool of empirical inquiry and uses a map metaphor (p. 136). Theory is like a map that helps a traveler navigate the terrain—and should be judged by its usefulness. “There is no expectation that a map is a true representation of reality. Rather, it is a representation that allows a traveler to reach a destination (achieve a purpose). Hence, theories should be judged by how well they help resolve the problem or achieve a purpose ” (Shields and Rangarajan 2013 , p. 23). Note that we explicitly link theory to the research purpose. Theory is never treated as an unimpeachable Truth, rather it is a helpful tool that organizes inquiry connecting data and problem. Dewey’s approach also expands the definition of theory to include abstractions (categories) outside of causation and explanation. The micro-conceptual frameworks Footnote 7 introduced in Table  1 are a type of theory. We define conceptual frameworks as the “way the ideas are organized to achieve the project’s purpose” (Shields and Rangarajan 2013 p. 24). Micro-conceptual frameworks do this at the very close to the data level of analysis. Micro-conceptual frameworks can direct operationalization and ways to assess measurement or evidence at the individual research study level. Again, the research purpose plays a pivotal role in the functioning of theory (Shields and Tajalli 2006 ).

8 Working hypothesis: methods and data analysis

We move on to answer the remaining questions in the Table  1 . We have established that exploratory research is extremely flexible and idiosyncratic. Given this, we will proceed with a few examples and draw out lessons for developing an exploratory purpose, building a framework and from there identifying data collection techniques and the logics of hypotheses testing and analysis. Early on we noted the value of the Working Hypothesis framework for student empirical research and applied research. The next section uses a masters level student’s work to illustrate the usefulness of working hypotheses as a way to incorporate the literature and structure inquiry. This graduate student was also a mature professional with a research question that emerged from his job and is thus an example of applied research.

Master of Public Administration student, Swift ( 2010 ) worked for a public agency and was responsible for that agency’s sexual harassment training. The agency needed to evaluate its training but had never done so before. He also had never attempted a significant empirical research project. Both of these conditions suggest exploration as a possible approach. He was interested in evaluating the training program and hence the project had a normative sense. Given his job, he already knew a lot about the problem of sexual harassment and sexual harassment training. What he did not know much about was doing empirical research, reviewing the literature or building a framework to evaluate the training (working hypotheses). He wanted a framework that was flexible and comprehensive. In his research, he discovered Lundvall’s ( 2006 ) knowledge taxonomy summarized with four simple ways of knowing ( Know - what, Know - how, Know - why, Know - who ). He asked whether his agency’s training provided the participants with these kinds of knowledge? Lundvall’s categories of knowing became the basis of his working hypotheses. Lundvall’s knowledge taxonomy is well suited for working hypotheses because it is so simple and is easy to understand intuitively. It can also be tailored to the unique problematic situation of the researcher. Swift ( 2010 , pp. 38–39) developed four basic working hypotheses:

WH1: Capital Metro provides adequate know - what knowledge in its sexual harassment training

WH2: Capital Metro provides adequate know - how knowledge in its sexual harassment training

WH3: Capital Metro provides adequate know - why knowledge in its sexual harassment training

WH4: Capital Metro provides adequate know - who knowledge in its sexual harassment training

From here he needed to determine what would determine the different kinds of knowledge. For example, what constitutes “know what” knowledge for sexual harassment training. This is where his knowledge and experience working in the field as well as the literature come into play. According to Lundvall et al. ( 1988 , p. 12) “know what” knowledge is about facts and raw information. Swift ( 2010 ) learned through the literature that laws and rules were the basis for the mandated sexual harassment training. He read about specific anti-discrimination laws and the subsequent rules and regulations derived from the laws. These laws and rules used specific definitions and were enacted within a historical context. Laws, rules, definitions and history became the “facts” of Know-What knowledge for his working hypothesis. To make this clear, he created sub-hypotheses that explicitly took these into account. See how Swift ( 2010 , p. 38) constructed the sub-hypotheses below. Each sub-hypothesis was defended using material from the literature (Swift 2010 , pp. 22–26). The sub-hypotheses can also be easily tied to evidence. For example, he could document that the training covered anti-discrimination laws.

WH1: Capital Metro provides adequate know - what knowledge in its sexual Harassment training

WH1a: The sexual harassment training includes information on anti-discrimination laws (Title VII).

WH1b: The sexual harassment training includes information on key definitions.

WH1c: The sexual harassment training includes information on Capital Metro’s Equal Employment Opportunity and Harassment policy.

WH1d: Capital Metro provides training on sexual harassment history.

Know-How knowledge refers to the ability to do something and involves skills (Lundvall and Johnson 1994 , p. 12). It is a kind of expertise in action. The literature and his experience allowed James Smith to identify skills such as how to file a claim or how to document incidents of sexual harassment as important “know-how” knowledge that should be included in sexual harassment training. Again, these were depicted as sub-hypotheses.

WH2: Capital Metro provides adequate know - how knowledge in its sexual Harassment training

WH2a: Training is provided on how to file and report a claim of harassment

WH2b: Training is provided on how to document sexual harassment situations.

WH2c: Training is provided on how to investigate sexual harassment complaints.

WH2d: Training is provided on how to follow additional harassment policy procedures protocol

Note that the working hypotheses do not specify a relationship but rather are simple declarative sentences. If “know-how” knowledge was found in the sexual harassment training, he would be able to find evidence that participants learned about how to file a claim (WH2a). The working hypothesis provides the bridge between theory and data that Sutton and Staw (1995) found missing in exploratory work. The sub-hypotheses are designed to be refined enough that the researchers would know what to look for and tailor their hunt for evidence. Figure  1 captures the generic sub-hypothesis design.

A Common structure used in the development of working hypotheses

When expected evidence is linked to the sub-hypotheses, data, framework and research purpose are aligned. This can be laid out in a planning document that operationalizes the data collection in something akin to an architect’s blueprint. This is where the scholar explicitly develops the alignment between purpose, framework and method (Shields and Rangarajan 2013 ; Shields et al. 2019b ).

Table  2 operationalizes Swift’s working hypotheses (and sub-hypotheses). The table provide clues as to what kind of evidence is needed to determine whether the hypotheses are supported. In this case, Smith used interviews with participants and trainers as well as a review of program documents. Column one repeats the sub-hypothesis, column two specifies the data collection method (here interviews with participants/managers and review of program documents) and column three specifies the unique questions that focus the investigation. For example, the interview questions are provided. In the less precise world of qualitative data, evidence supporting a hypothesis could have varying degrees of strength. This too can be specified.

For Swift’s example, neither the statistics of explanatory research nor the open-ended questions of interpretivist, inductive exploratory research is used. The deductive logic of inquiry here is somewhat intuitive and similar to a detective (Ulriksen and Dadalauri 2016 ). It is also a logic used in international law (Worster 2013 ). It should be noted that the working hypothesis and the corresponding data collection protocol does not stop inquiry and fieldwork outside the framework. The interviews could reveal an unexpected problem with Smith’s training program. The framework provides a very loose and perhaps useful ways to identify and make sense of the data that does not fit the expectations. Researchers using working hypotheses should be sensitive to interesting findings that fall outside their framework. These could be used in future studies, to refine theory or even in this case provide suggestions to improve sexual harassment training. The sensitizing concepts mentioned by Gilgun ( 2015 ) are free to emerge and should be encouraged.

Something akin to working hypotheses are hidden in plain sight in the professional literature. Take for example Kerry Crawford’s ( 2017 ) book Wartime Sexual Violence. Here she explores how basic changes in the way “advocates and decision makers think about and discuss conflict-related sexual violence” (p. 2). She focused on a subsequent shift from silence to action. The shift occurred as wartime sexual violence was reframed as a “weapon of war”. The new frame captured the attention of powerful members of the security community who demanded, initiated, and paid for institutional and policy change. Crawford ( 2017 ) examines the legacy of this key reframing. She develops a six-stage model of potential international responses to incidents of wartime violence. This model is fairly easily converted to working hypotheses and sub-hypotheses. Table  3 shows her model as a set of (non-relational) working hypotheses. She applied this model as a way to gather evidence among cases (e.g., the US response to sexual violence in the Democratic Republic of the Congo) to show the official level of response to sexual violence. Each case study chapter examined evidence to establish whether the case fit the pattern formalized in the working hypotheses. The framework was very useful in her comparative context. The framework allowed for consistent comparative analysis across cases. Her analysis of the three cases went well beyond the material covered in the framework. She freely incorporated useful inductively informed data in her analysis and discussion. The framework, however, allowed for alignment within and across cases.

9 Conclusion

In this article we argued that the exploratory research is also well suited for deductive approaches. By examining the landscape of deductive, exploratory research, we proposed the working hypothesis as a flexible conceptual framework and a useful tool for doing exploratory studies. It has the potential to guide and bring coherence across the steps in the research process. After presenting the nature of exploratory research purpose and how it differs from two types of research purposes identified in the literature—explanation, and description. We focused on answering four different questions in order to show the link between micro-conceptual frameworks and research purposes in a deductive setting. The answers to the four questions are summarized in Table  4 .

Firstly, we argued that working hypothesis and exploration are situated within the pragmatic philosophical perspective. Pragmatism allows for pluralism in theory and data collection techniques, which is compatible with the flexible exploratory purpose. Secondly, after introducing and discussing the four core elements of pragmatism (practical, pluralism, participatory, and provisional), we explained how the working hypothesis informs the methodologies and evidence collection of deductive exploratory research through a presentation of the benefits of triangulation provided by mixed methods research. Thirdly, as is clear from the article title, we introduced the working hypothesis as the micro-conceptual framework for deductive explorative research. We argued that the hypotheses of explorative research, which we call working hypotheses are distinguished from those of the explanatory research, since they do not require a relational component and are not bound by relational expectations. A working hypothesis is extremely flexible and idiosyncratic, and it could be viewed as a statement or group of statements of expectations tested in action depending on the research question. Using examples, we concluded by explaining how working hypotheses inform data collection and analysis for deductive exploratory research.

Crawford’s ( 2017 ) example showed how the structure of working hypotheses provide a framework for comparative case studies. Her criteria for analysis were specified ahead of time and used to frame each case. Thus, her comparisons were systemized across cases. Further, the framework ensured a connection between the data analysis and the literature review. Yet the flexible, working nature of the hypotheses allowed for unexpected findings to be discovered.

The evidence required to test working hypotheses is directed by the research purpose and potentially includes both quantitative and qualitative sources. Thus, all types of evidence, including quantitative methods should be part of the toolbox of deductive, explorative research. We show how the working hypotheses, as a flexible exploratory framework, resolves many seeming dualisms pervasive in the research methods literature.

To conclude, this article has provided an in-depth examination of working hypotheses taking into account philosophical questions and the larger formal research methods literature. By discussing working hypotheses as applied, theoretical tools, we demonstrated that working hypotheses fill a unique niche in the methods literature, since they provide a way to enhance alignment in deductive, explorative studies.

In practice, quantitative scholars often run multivariate analysis on data bases to find out if there are correlations. Hypotheses are tested because the statistical software does the math, not because the scholar has an a priori, relational expectation (hypothesis) well-grounded in the literature and supported by cogent arguments. Hunches are just fine. This is clearly an inductive approach to research and part of the large process of inquiry.

In 1958 , Philosophers of Science, Oppenheim and Putnam use the notion of Working Hypothesis in their title “Unity of Science as Working Hypothesis.” They too, use it as a big picture concept, “unity of science in this sense, can be fully realized constitutes an over-arching meta-scientific hypothesis, which enables one to see a unity in scientific activities that might otherwise appear disconnected or unrelated” (p. 4).

It should be noted that the positivism described in the research methods literature does not resemble philosophical positivism as developed by philosophers like Comte (Whetsell and Shields 2015 ). In the research methods literature “positivism means different things to different people….The term has long been emptied of any precise denotation …and is sometimes affixed to positions actually opposed to those espoused by the philosophers from whom the name derives” (Schrag 1992 , p. 5). For purposes of this paper, we are capturing a few essential ways positivism is presented in the research methods literature. This helps us to position the “working hypothesis” and “exploratory” research within the larger context in contemporary research methods. We are not arguing that the positivism presented here is anything more. The incompatibility theory discussed later, is an outgrowth of this research methods literature…

It should be noted that quantitative researchers often use inductive reasoning. They do this with existing data sets when they run correlations or regression analysis as a way to find relationships. They ask, what does the data tell us?

Qualitative researchers are also associated with phenomenology, hermeneutics, naturalistic inquiry and constructivism.

See Feilzer ( 2010 ), Howe ( 1988 ), Johnson and Onwuegbunzie ( 2004 ), Morgan ( 2007 ), Onwuegbuzie and Leech ( 2005 ), Biddle and Schafft ( 2015 ).

The term conceptual framework is applicable in a broad context (see Ravitch and Riggan 2012 ). The micro-conceptual framework narrows to the specific study and informs data collection (Shields and Rangarajan 2013 ; Shields et al. 2019a ) .

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Casula, M., Rangarajan, N. & Shields, P. The potential of working hypotheses for deductive exploratory research. Qual Quant 55 , 1703–1725 (2021). https://doi.org/10.1007/s11135-020-01072-9

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Preparedness for a first clinical placement in nursing: a descriptive qualitative study

• Philippa H. M. Marriott 1 ,
• Jennifer M. Weller-Newton 2   nAff3 &
• Katharine J. Reid 4  

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A first clinical placement for nursing students is a challenging period involving translation of theoretical knowledge and development of an identity within the healthcare setting; it is often a time of emotional vulnerability. It can be a pivotal moment for ambivalent nursing students to decide whether to continue their professional training. To date, student expectations prior to their first clinical placement have been explored in advance of the experience or gathered following the placement experience. However, there is a significant gap in understanding how nursing students’ perspectives about their first clinical placement might change or remain consistent following their placement experiences. Thus, the study aimed to explore first-year nursing students’ emotional responses towards and perceptions of their preparedness for their first clinical placement and to examine whether initial perceptions remain consistent or change during the placement experience.

The research utilised a pre-post qualitative descriptive design. Six focus groups were undertaken before the first clinical placement (with up to four participants in each group) and follow-up individual interviews ( n  = 10) were undertaken towards the end of the first clinical placement with first-year entry-to-practice postgraduate nursing students. Data were analysed thematically.

Three main themes emerged: (1) adjusting and managing a raft of feelings, encapsulating participants’ feelings about learning in a new environment and progressing from academia to clinical practice; (2) sinking or swimming, comprising students’ expectations before their first clinical placement and how these perceptions are altered through their clinical placement experience; and (3) navigating placement, describing relationships between healthcare staff, patients, and peers.

Conclusions

This unique study of first-year postgraduate entry-to-practice nursing students’ perspectives of their first clinical placement adds to the extant knowledge. By examining student experience prior to and during their first clinical placement experience, it is possible to explore the consistency and change in students’ narratives over the course of an impactful experience. Researching the narratives of nursing students embarking on their first clinical placement provides tertiary education institutions with insights into preparing students for this critical experience.

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First clinical placements enable nursing students to develop their professional identity through initial socialisation, and where successful, first clinical placement experiences can motivate nursing students to persist with their studies [ 1 , 2 , 3 , 4 ]. Where the transition from the tertiary environment to learning in the healthcare workplace is turbulent, it may impact nursing students’ learning, their confidence and potentially increase attrition rates from educational programs [ 2 , 5 , 6 ]. Attrition from preregistration nursing courses is a global concern, with the COVID-19 pandemic further straining the nursing workforce; thus, the supply of nursing professionals is unlikely to meet demand [ 7 ]. The COVID-19 pandemic has also impacted nursing education, with student nurses augmenting the diminishing nursing workforce [ 7 , 8 ].

The first clinical placement often triggers immense anxiety and fear for nursing students [ 9 , 10 ]. Research suggests that among nursing students, anxiety arises from perceived knowledge deficiencies, role ambiguity, the working environment, caring for ‘real’ people, potentially causing harm, exposure to nudity and death, and ‘not fitting in’ [ 2 , 3 , 11 ]. These stressors are reported internationally and often relate to inadequate preparation for entering the clinical environment [ 2 , 10 , 12 ]. Previous research suggests that high anxiety before the first clinical placement can be related to factors likely to affect patient outcomes, such as self-confidence and efficacy [ 13 ]. High anxiety during clinical placement may impair students’ capacity to learn, thus compromising the value of the clinical environment for learning [ 10 ].

The first clinical placement often occurs soon after commencing nursing training and can challenge students’ beliefs, philosophies, and preconceived ideas about nursing. An experience of cultural or ‘reality’ shock often arises when entering the healthcare setting, creating dissonance between reality and expectations [ 6 , 14 ]. These experiences may be exacerbated by tertiary education providers teaching of ‘ideal’ clinical practice [ 2 , 6 ]. The perceived distance between theoretical knowledge and what is expected in a healthcare placement, as opposed to what occurs on clinical placement, has been well documented as the theory-practice gap or an experience of cognitive dissonance [ 2 , 3 ].

Given the pivotal role of the first clinical placement in nursing students’ trajectories to nursing practice, it is important to understand students’ experiences and to explore how the placement experience shapes initial perceptions. Existing research focusses almost entirely either on describing nursing students’ projected emotions and perceptions prior to undertaking a first clinical placement [ 3 ] or examines student perceptions of reflecting on a completed first placement [ 15 ]. We wished to examine consistency and change in student perception of their first clinical placement by tracking their experiences longitudinally. We focused on a first clinical placement undertaken in a Master of Nursing Science. This two-year postgraduate qualification provides entry-to-practice nursing training for students who have completed any undergraduate qualification. The first clinical placement component of the course aimed to orient students to the clinical environment, support students to acquire skills and develop their clinical reasoning through experiential learning with experienced nursing mentors.

This paper makes a significant contribution to understanding how nursing students’ perceptions might develop over time because of their clinical placement experiences. Our research addresses a further gap in the existing literature, by focusing on students completing an accelerated postgraduate two-year entry-to-practice degree open to students with any prior undergraduate degree. Thus, the current research aimed to understand nursing students’ emotional responses and expectations and their perceptions of preparedness before attending their first clinical placement and to contrast these initial perceptions with their end-of-placement perspectives.

Study design

A descriptive qualitative study was undertaken, utilising a pre- and post-design for data collection. Focus groups with first-year postgraduate entry-to-practice nursing students were conducted before the first clinical placement, with individual semi-structured interviews undertaken during the first clinical placement.

Setting and participants

All first-year students enrolled in the two-year Master of Nursing Science program ( n  = 190) at a tertiary institution in Melbourne, Australia, were eligible to participate. There were no exclusion criteria. At the time of this study, students were enrolled in a semester-long subject focused on nursing assessment and care. They studied the theoretical underpinnings of nursing and science, theoretical and practical nursing clinical skills and Indigenous health over the first six weeks of the course. Students completed a preclinical assessment as a hurdle before commencing a three-week clinical placement in a hospital setting, a subacute or acute environment. Overall, the clinical placement aimed to provide opportunities for experiential learning, skill acquisition, development of clinical reasoning skills and professional socialisation [ 16 , 17 ].

In total, sixteen students participated voluntarily in a focus group of between 60 and 90 min duration; ten of these students also participated in individual interviews of between 30 and 60 min duration, a number sufficient to reach data saturation. Table  1 shows the questions used in the focus groups conducted before clinical placement commenced and the questions for the semi-structured interview questions conducted during clinical placement. Study participants’ undergraduate qualifications included bachelor’s degrees in science, arts and business. A small number of participants had previous healthcare experience (e.g. as healthcare assistants). The participants attended clinical placement in the Melbourne metropolitan, Victorian regional and rural hospital locations.

Data collection

The study comprised two phases. The first phase comprised six focus groups prior to the first clinical placement, and the second phase comprised ten individual semi-structured interviews towards the end of the first clinical placement. Focus groups (with a maximum of four participants) and individual interviews were conducted by the lead author online via Zoom and were audio-recorded. Capping group size to a relatively small number considered diversity of perceptions and opportunities for participants to share their insights and to confirm or contradict their peers, particularly in the online environment [ 18 , 19 ].

Focus groups and interview questions were developed with reference to relevant literature, piloted with volunteer final-year nursing students, and then verified with the coauthors. All focus groups and interviewees received the same structured questions (Table  1 ) to ensure consistency and to facilitate comparison across the placement experience in the development of themes. Selective probing of interviewees’ responses for clarification to gain in-depth responses was undertaken. Nonverbal cues, impressions, or observations were noted.

The lead author was a registered nurse who had a clinical teaching role within the nursing department and was responsible for coordinating clinical placement experiences. To ensure rigour during the data collection process, the lead author maintained a reflective account, exploring her experiences of the discussions, reflecting on her interactions with participants as a researcher and as a clinical educator, and identifying areas for improvement (for instance allowing participants to tell their stories with fewer prompts). These reflections in conjunction with regular discussion with the other authors throughout the data collection period, aided in identifying any researcher biases, feelings and thoughts that possibly influenced the research [ 20 ].

To maintain rigour during the data analysis phase, we adhered to a systematic process involving input from all authors to code the data and to identify, refine and describe the themes and subthemes reported in this work. This comprehensive analytic process, reported in detail in the following section, was designed to ensure that the findings arising from this research were derived from a rigorous approach to analysing the data.

Data analysis

Focus groups and interviews were transcribed using the online transcription service Otter ( https://otter.ai/ ) and then checked and anonymised by the first author. Preliminary data analysis was carried out simultaneously by the first author using thematic content analysis proposed by Braun and Clarke [ 21 ] using NVivo 12 software [ 22 ]. All three authors undertook a detailed reading of the first three transcripts from both the focus groups and interviews and independently identified major themes. This preliminary coding was used as the basis of a discussion session to identify common themes between authors, to clarify sources of disagreement and to establish guidelines for further coding. Subsequent coding of the complete data set by the lead author identified a total of 533 descriptive codes; no descriptive code was duplicated across the themes. Initially, the descriptive codes were grouped into major themes identified from the literature, but with further analysis, themes emerged that were unique to the current study.

The research team met frequently during data analysis to discuss the initial descriptive codes, to confirm the major themes and subthemes, to revise themes on which there was disagreement and to identify any additional themes. Samples of quotes were reviewed by the second and third authors to decide whether these quotes were representative of the identified themes. The process occurred iteratively to refine the thematic categories, to discuss the definitions of each theme and to identify exemplar quotes.

Ethical considerations

The lead author was a clinical teacher and the clinical placement coordinator in the nursing department at the time of the study. Potential risks of perceived coercion and power imbalances were identified because of the lead author’s dual roles as an academic and as a researcher. To manage these potential risks, an academic staff member who was not part of the research study informed students about the study during a face-to-face lecture and ensured that all participants received a plain language statement identifying the lead author’s role and how perceived conflicts of interest would be managed. These included the lead author not undertaking any teaching or assessment role for the duration of the study and ensuring that placement allocations were completed prior to undertaking recruitment for the study. All students who participated in the study provided informed written consent. No financial or other incentives were offered. Approval to conduct the study was granted by the University of Melbourne Human Research Ethics Committee (Ethics ID 1955997.1).

Three main themes emerged describing students’ feelings and perceptions of their first clinical placement. In presenting the findings, before or during has been assigned to participants’ quotes to clarify the timing of students’ perspectives related to the clinical placement.

Major theme 1: Adjusting and managing a raft of feelings

The first theme encompassed the many positive and negative feelings about work-integrated learning expressed by participants before and during their clinical placement. Positive feelings before clinical placement were expressed by participants who were comfortable with the unknown and cautiously optimistic.

I am ready to just go with the flow, roll with the punches (Participant [P]1 before).

Overwhelmingly, however, the majority of feelings and thoughts anticipating the first clinical placement were negatively oriented. Students who expressed feelings of fear, anxiety, lack of knowledge, lack of preparedness, uncertainty about nursing as a career, or strong concerns about being a burden were all classified as conveying negative feelings. These negative feelings were categorised into four subthemes.

Subtheme 1.1 I don’t have enough knowledge

All participants expressed some concerns and anxiety before their first clinical placement. These encompassed concerns about knowledge inadequacy and were linked to a perception of under preparedness. Participants’ fears related to harming patients, responsibility for managing ‘real’ people, medication administration, and incomplete understanding of the language and communication skills within a healthcare setting. Anxiety for many participants merged with the logistics and management of their life during the clinical placement.

I’m scared that they will assume that I have more knowledge than I do (P3 before). I feel quite similar with P10, especially when she said fear of unknown and fear that she might do something wrong (P9 before).

Subtheme 1.2 Worry about judgment, being seen through that lens

Participants voiced concerns that they would be judged negatively by patients or healthcare staff because they perceived that the student nurse belonged to specific social groups related to their cultural background, ethnicity or gender. Affiliation with these groups contributed to students’ sense of self or identity, with students often describing such groups as a community. Before the clinical placement, participants worried that such judgements would impact the support they received on placement and their ability to deliver patient care.

Some older patients might prefer to have nurses from their own background, their own ethnicity, how they would react to me, or if racism is involved (P10 before). I just don’t want to reinforce like, whatever negative perceptions people might have of that community (P16 before).

Participants’ concerns prior to the first clinical placement about judgement or poor treatment because of patients’ preconceived ideas about specific ethnic groups did not eventuate.

I mean, it didn’t really feel like very much of a thing once I was actually there. It is one of those things you stress about, and it does not really amount to anything (P16 during).

Some students’ placement experiences revealed the positive benefits of their cultural background to enhancing patient care. One student affirmed that the placement experience reinforced their commitment to nursing and that this was related to their ability to communicate with patients whose first language was not English.

Yeah, definitely. Like, I can speak a few dialects. You know, I can actually see a difference with a lot of the non-English speaking background people. As soon as you, as soon as they’re aware that you’re trying and you’re trying to speak your language, they, they just open up. Yeah, yes. And it improves the care (P10 during).

However, a perceived lack of judgement was sometimes attributed to wearing the full personal protective equipment required during the COVID-19 pandemic, which meant that their personal features were largely obscured. For this reason, it was more difficult for patients to make assumptions or attributions about students’ ethnic or gender identity based on their appearance.

People tend to assume and call us all girls, which was irritating. It was mostly just because all of us were so covered up, no one could see anyone’s faces (P16 during).

Subtheme 1.3 Is nursing really for me?

Prior to their first clinical placement experience, many participants expressed ambivalence about a nursing career and anticipated that undertaking clinical placement could determine their suitability for the profession. Once exposed to clinical placement, the majority of students were completely committed to their chosen profession, with a minority remaining ambivalent or, in rare cases, choosing to leave the course. Not yet achieving full commitment to a nursing career was related to not wishing to work in the ward they had for their clinical placement, while remaining open to trying different specialities.

I didn’t have an actual idea of what I wanted to do after arts, this wasn’t something that I was aiming towards specifically (P14 before). I think I’m still not 100%, but enough to go on, that I’m happy to continue the course as best as I can (P11 during).

Subtheme 1.4 Being a burden

Before clinical placement, participants had concerns about being burdensome and how this would affect their clinical placement experiences.

If we end up being a burden to them, an extra responsibility for them on top of their day, then we might not be treated as well (P10 before).

A sense of burden remained a theme during the clinical placement for participants for the first five to seven days, after which most participants acknowledged that their role became more active. As students contributed more productively to their placement, their feelings of being a burden reduced.

Major theme 2: Sinking or swimming

The second major theme, sinking or swimming, described participants’ expectations about a successful placement experience and identified themes related to students’ successes (‘swimming’) or difficulties (‘sinking’) during their placement experience. Prior to clinical placement, without a realistic preview of what the experience might entail, participants were uncertain of their role, hoped for ‘nice’ supervising nurses and anticipated an observational role that would keep them afloat.

I will focus on what I want to learn and see if that coincides with what is expected, I guess (P15 before).

During the clinical placement, the reality was very different, with a sense of sinking. Participants discovered, some with shock, that they were expected to participate actively in the healthcare team.

I got the sense that they were not going to muck around, and, you know, they’re ‘gonna’ use the free labour that came with me (P1 during).

Adding to the confusion about the expected placement experience, participants believed that healthcare staff were unclear about students’ scope of practice for a postgraduate entry-to-practice degree, creating misalignment between students’ and supervising nurses’ expectations.

It seems to me like the educators don’t really seem to have a clear picture of what the scope is, and what is actually required or expected of us (P10 during).

In exploring perceived expectations of the clinical placement and the modifying effect of placement on initial expectations, three subthemes were identified: translation to practice is overwhelming, trying to find the rhythm or jigsaw pieces, and individual agency.

Subtheme 2.1 Translation to practice is overwhelming

Before clinical placement, participants described concerns about insufficient knowledge to enable them to engage effectively with the placement experience.

If I am doing an assessment understanding what are those indications and why I would be doing it or not doing it at a certain time (P1 before).

Integrating and applying theoretical content while navigating an unfamiliar clinical environment created a significant gap between theory and practice during clinical placement. As the clinical placement experience proceeded and initial fears dissipated, students became more aware of applying their theoretical knowledge in the clinical context.

We’re learning all this theory and clinical stuff, but then we don’t really have a realistic idea of what it’s like until we’re kind of thrown into it for three weeks (P10 during).

Subtheme 2.2 Trying to find the rhythm or the jigsaw pieces

Before clinical placement, participants described learning theory and clinical skills with contextual unfamiliarity. They had the jigsaw pieces but did not know how to assemble it; they had the music but did not know the final song. When discussing their expectations about clinical placement, the small number of participants with a healthcare background (e.g. as healthcare assistants) proposed realistic answers, whereas others struggled to answer or cited stories from friends or television. With a lack of context, feelings of unpreparedness were exacerbated. Once in the clinical environment, participants further emphasised that they could not identify what they needed to know to successfully prepare for clinical placement.

It was never really pieced together. We’ve learned bits and pieces, and then we’re putting it together ourselves (P8 during). On this course I feel it was this is how you do it, but I did not know how it was supposed to be played, I did not know the rhythm (P4 during).

Subtheme 2.3 Individual agency

Participants’ individual agency, their attitude, self-efficacy, and self-motivation affected their clinical placement experiences. Participant perceptions in advance of the clinical placement experience remained consistent with their perspectives following clinical placement. Before clinical placement, participants who were highly motivated to learn exhibited a growth mindset [ 23 ] and planned to be proactive in delivering patient care. During their clinical placement, initially positive students remained positive and optimistic about their future. Participants who believed that their first clinical placement role would be largely observational and were less proactive about applying their knowledge and skills identified boredom and a lack of learning opportunities on clinical placement.

A shadowing position, we don’t have enough skills and authority to do any work, not do any worthwhile skills (P3 before). I thought it would be a lot busier, because we’re limited with our scope, so there’s not much we can do, it’s just a bit slower than I thought (P12 during).

Individual agency appears to influence a successful first clinical placement; other factors may also be implicated but were not the focus of this study. Further research exploring the relationships between students’ age, life experience, resilience, individual agency, and the use of coping strategies during a first clinical placement would be useful.

Major theme 3: The reality of navigating placement relationships

The third main theme emphasised the reality of navigating clinical placement relationships and explored students’ relationships with healthcare staff, patients, and peers. Before clinical placement, many participants, especially those with healthcare backgrounds, expressed fears about relationships with supervising nurses. They perceived that the dynamics of the team and the healthcare workplace might influence the support they received. Several participants were nervous about attending placement on their own without peers for support, especially if the experience was challenging. Participants identified expectations of being mistreated, believing that it was unavoidable, and prepared themselves to not take it personally.

For me it’s where we’re going to land, are we going to be in a supportive, kind of nurturing environment, or is it just kind of sink or swim? (P5 before). If you don’t really trust them, you’re nervous the entire time and you’ll be like what if I get it wrong (P16 before).

Despite these concerns, students strongly emphasised the value of relationships during their first clinical placement, with these perceptions unchanged by their clinical placement experience. Where relationships were positive, participants felt empowered to be autonomous, and their self-confidence increased.

You get that that instant reaction from the patients. And that makes you feel more confident. So that really got me through the first week (P14 during). I felt like I was intruding, then as I started to build a bit of rapport with the people, and they saw that I was around, I don’t feel that as much now (P1 during).

Such development hinged on the receptiveness and support of supervising nurses, the team on the ward, and patients and could be hindered by poor relationships.

He was the old-style buddy nurse in his fifties, every time I questioned him, he would go ssshh, just listen, no questions, it was very stressful (P10 during). It depends whether the buddy sees us as an extra pair of hands, or we’re learners (P11 during).

Where students experienced poor behaviour from supervising nurses, they described a range of emotional responses to these interactions and also coping strategies including avoiding unfriendly staff and actively seeking out those who were more inclusive.

If they weren’t very nice, it wouldn’t be very enjoyable and if they didn’t trust you, then it would be a bit frustrating, that like I can do this, but you won’t let me (P12 during). If another nurse was not nice to me, and I was their buddy, I would literally just not buddy with them and go and follow whoever was nice to me (P4 during).

Relationships with peers were equally important; students on clinical placement with peers valued the shared experience. In contrast, students who attended clinical placement alone at a regional or rural hospital felt disconnected from the opportunities that learning with peers afforded.

Our research explored the emotional responses and perceptions of preparedness of postgraduate entry-to-practice nursing students prior to and during their first clinical placement. In this study, we described how the perceptions of nursing students remained consistent or were modified by their clinical placement experiences. Our analysis of students’ experiences identified three major themes: adjusting and managing a raft of feelings; sinking or swimming; and the reality of navigating placement relationships. We captured similar themes identified in the literature; however, our study also identified novel aspects of nursing students’ experiences of their first clinical placement.

The key theme, adjusting and managing a raft of feelings, which encapsulates anxiety before clinical placement, is consistent with previous research. This theme included concerns in communicating with healthcare staff and managing registered nurses’ negative attitudes and expectations, in addition to an academic workload [ 11 , 24 ]. Concerns not previously identified in the literature included a fear of judgement or discrimination by healthcare staff or patients that might impact the reputation of marginalised communities. Fortunately, these initial fears largely dissipated during clinical placement. Some students discovered that a diverse cultural background was an asset during their clinical placement. Although these initial fears were ameliorated by clinical placement experiences, evidence of such fears before clinical placement is concerning. Further research to identify appropriate support for nursing students from culturally diverse or marginalised communities is warranted. For example, a Finnish study highlighted the importance of mentoring culturally diverse students, creating a pedagogical atmosphere during clinical placement and integrating cultural diversity into nursing education [ 25 ].

Preclinical expectations of being mistreated can be viewed as an unavoidable phenomenon for nursing students [ 26 ]. The existing literature highlights power imbalances and hierarchical differences within the healthcare system, where student nurses may be marginalised, disrespected, and ignored [ 9 , 27 , 28 ]. During their clinical placement, students in our study reported unintentional incivility by supervising nurses: feeling not wanted, ignored, or asked to remain quiet by supervising nurses who were unfriendly or highly critical. These findings were similar to those of Thomas et al.’s [ 29 ] UK study and were particularly heightened at the beginning of clinical placement. Several students acknowledged that nursing staff fatigue from a high turnover of students on their ward and the COVID-19 pandemic could be contributing factors. In response to such incivility, students reported decreased self-confidence and described becoming quiet and withdrawing from active participation with their patients. Students oriented their behaviour towards repetitive low-level tasks, aiming to please and help their supervising nurse, to the detriment of learning opportunities. Fortunately, these incidents did not appear to impact nursing students’ overall experience of clinical placement. Indeed, students found positive experiences with different supervising nurses and their own self-reflection assisted with coping. Other active strategies to combat incivility identified in the current study that were also identified by Thomas et al. [ 29 ] included avoiding nurses who were uncivil, asking to work with nurses who were ‘nice’ to them, and seeking out support from other staff as a coping strategy. The nursing students in our study were undertaking a postgraduate entry-to-practice qualification and already had an undergraduate degree. The likely greater levels of experience and maturity of this cohort may influence their resilience when working with unsupportive supervising nurses and identifying strategies to manage challenging situations.

The theory-practice gap emerged in the theme of sinking or swimming. A theory-practice gap describes the perceived dissonance between theoretical knowledge and expectations for the first clinical placement, as opposed to the reality of the experience, and has been reported in previous studies (see, for instance, 24 , 30 , 31 , 32 ). Existing research has shown that when the first clinical placement does not meet inexperienced student nurses’ expectations, a disconnect between theory and practice occurs, creating feelings of being lost and insecure within the new environment, potentially impacting students’ motivation and risk of attrition [ 19 , 33 ]. The current study identified further areas exacerbating the theory-practice gap. Before the clinical placement, students without a healthcare background lacked context for their learning. They lacked understanding of nurses’ shift work and were apprehensive about applying clinical skills learned in the classroom. Hence, some students were uncertain if they were prepared for their first clinical placement or even how to prepare, which increased their anxiety. Prior research has demonstrated that applying theoretical knowledge more seamlessly during clinical placement was supported when students knew what to expect [ 6 ]. For instance, a Canadian study exposed students as observers to the healthcare setting before starting clinical placement, enabling early theory to practice connections that minimised misconceptions and false assumptions during clinical placement [ 34 ].

In the current study, the theory-practice gap was further exacerbated during clinical placement, where healthcare staff were confused about students’ scope of practice and the course learning objectives and expectations in a postgraduate entry-to-practice nursing qualification. The central booking system for clinical placements classifies first-year nursing students who participated in this study as equivalent to second-year undergraduate nursing students. Such a classification could create a misalignment between clinical educators’ expectations and their delivery of education versus students’ actual learning needs and capacity [ 3 , 31 ]. Additional communication to healthcare partners is warranted to enhance understanding of the scope of practice and expectations of a first-year postgraduate entry-to-practice nursing student. Educating and empowering students to communicate their learning needs within their scope of practice is also required.

Our research identified a link between students’ personality traits or individual agency and their first clinical placement experience. The importance of a positive orientation towards learning and the nursing profession in preparedness for clinical placement has been highlighted in previous studies [ 31 ]. Students’ experience of their first clinical placement in our study appeared to be strongly influenced by their mindset [ 23 ]. Some students demonstrated motivation to learn, were happy to ‘roll with the punches’, yet remain active in their learning requirements, whereas others perceived their role as observational and expected supervising nurses to provide learning opportunities. Students who anticipated a passive learning approach prior to their first clinical placement reported boredom, limited activity, and lack of opportunities during their first clinical placement. These students could have a lowered sense of self-efficacy, which may lead to a greater risk of doubt, stress, and reduced commitment to the profession [ 35 ]. Self-efficacy theory explores self-perceived confidence and competence around people’s beliefs in their ability to influence events, which is associated with motivation and is key to nursing students progressing in their career path confidently [ 35 , 36 ]. In the current study, students who actively engaged in their learning process used strategies such as self-reflection and sought support from clinical educators, peers and family. Such active approaches to learning appeared to increase their resilience and motivation to learn as they progressed in their first clinical placement.

Important relationships with supervising nurses, peers, or patients were highlighted in the theme of the reality of navigating placement relationships. This theme links with previous research findings about belongingness. Belongingness is a fundamental human need and impacts students’ behaviour, emotions, cognitive processes, overall well-being, and socialisation into the profession [ 37 , 38 ]. Nursing students who experience belongingness feel part of a team and are more likely to report positive experiences. Several students in the current study described how feeling part of a team improved self-confidence and empowered work-integrated learning. Nonetheless, compared with previous literature (see for instance, 2), working as a team and belongingness were infrequent themes. Such infrequency could be related to the short duration of the clinical placement. In shorter clinical placements, nursing students learn a range of technical skills but have less time to develop teamwork skills and experience socialisation to the profession [ 29 , 39 ].

Positive relationships with supervising nurses appeared fundamental to students’ experiences. Previous research has shown that in wards with safe psycho-social climates, where the culture tolerates mistakes, regarding them as learning opportunities, a pedagogical atmosphere prevails [ 25 , 39 ]. Whereas, if nursing students experience insolent behaviours or incivility, this not only impacts learning it can also affect career progression [ 26 ]. Participants who felt safe asking questions were given responsibility, had autonomy to conduct skills within their scope of practice and thrived in their learning. This finding aligns with previous research affirming that a welcoming and supportive clinical placement environment, where staff are caring, approachable and helpful, enables student nurses to flourish [ 36 , 40 , 41 , 42 ]. Related research highlights that students’ perception of a good clinical placement is linked to participation within the community and instructor behaviour over the quality of the clinical environment and opportunities [ 27 , 28 ]. Over a decade ago, a large European study found that the single most important element for students’ clinical learning was the supervisory relationship [ 39 ]. In our study, students identified how supervising nurses impacted their emotions and this was critical to their experience of clinical placement, rather than how effective they were in their teaching, delivery of feedback, or their knowledge base.

Students’ relationships with patients were similarly important for a successful clinical placement. Before the clinical placement, students expressed anxiety and fears in communicating and interacting with patients, particularly if they were dying or acutely unwell, which is reflective of the literature [ 2 , 10 , 11 ]. However, during clinical placement, relationships with patients positively impacted nursing students’ experiences, especially at the beginning when they felt particularly vulnerable in a new environment. Towards the end of clinical placement, feelings of incompetence, nervousness and uncertainty had subsided. Students were more active in patient care, which increased self-confidence, empowerment, and independence, in turn further improving relationships with patients and creating a positive feedback loop [ 36 , 42 , 43 ].

Limitations

This study involved participants from one university and a single course, thus limiting the generalisability of the results. Thus, verification of the major themes identified in this research in future studies is needed. Nonetheless, the purpose of this study was to explore in detail the way in which the experiences of clinical placement for student nurses modified initial emotional responses towards undertaking placement and their perceptions of preparedness. Participants in this study undertook their clinical placement in a variety of different hospital wards in different specialties, which contributed to the rigour of the study in identifying similar themes in nursing students’ experiences across diverse placement contexts.

This study explored the narratives of first-year nursing students undertaking a postgraduate entry-to-practice qualification on their preparedness for clinical placement. Exploring students’ changing perspectives before and during the clinical placement adds to extant knowledge about nursing students’ emotional responses and perceptions of preparedness. Our research highlighted the role that preplacement emotions and expectations may have in shaping nursing students’ clinical placement experiences. Emerging themes from this study highlighted the importance students placed on relationships with peers, patients, and supervising nurses. Significant anxiety and other negative emotions experienced by nursing students prior to the first clinical placement suggests that further research is needed to explore the impact of contextual learning to scaffold students’ transition to the clinical environment. The findings of this research also have significant implications for educational practice. Additional educational support for nursing students prior to entering the clinical environment for the first time might include developing students’ understanding of the clinical environment, such as through increasing students’ understanding of the different roles of nurses in the clinical context through pre-recorded interviews with nurses. Modified approaches to simulated teaching prior to the first clinical placement would also be useful to increase the emphasis on students applying their learning in a team-based, student-led context, rather than emphasising discrete clinical skill competencies. Finally, increasing contact between students and university-based educators throughout the placement would provide further opportunities for students to debrief, to receive support and to manage some of the negative emotions identified in this study. Further supporting the transition to the first clinical placement could be fundamental to reducing the theory-practice gap and allaying anxiety. Such support is crucial during their first clinical placement to reduce attrition and boost the nursing workforce.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the conditions of our ethics approval but may be available from the corresponding author on reasonable request and subject to permission from the Human Research Ethics Committee.

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Acknowledgements

The authors wish to thank the first-year nursing students who participated in this study and generously shared their experiences of undertaking their first clinical placement.

No funding was received for this study.

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Jennifer M. Weller-Newton

Present address: School of Nursing and Midwifery, University of Canberra, Kirinari Drive, Bruce, Canberra, ACT, 2617, Australia

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Department of Nursing, The University of Melbourne, Grattan St, Parkville, VIC, 3010, Australia

Philippa H. M. Marriott

Department of Rural Health, The University of Melbourne, Grattan St, Shepparton, VIC, 3630, Australia

Present address: Department of Medical Education, Melbourne Medical School, The University of Melbourne, Grattan St, Parkville, VIC, 3010, Australia

Katharine J. Reid

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All authors made a substantial contribution to conducting the research and preparing the manuscript for publication. P.M., J.W-N. and K.R. conceptualised the research and designed the study. P.M. undertook the data collection, and all authors were involved in thematic analysis and interpretation. P.M. wrote the first draft of the manuscript, K.R. undertook a further revision and all authors contributed to subsequent versions. All authors approved the final version for submission. Each author is prepared to take public responsibility for the research.

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The research was undertaken in accordance with the National Health and Medical Research Council of Australia’s National Statement on Ethical Conduct in Human Research and the Australian Code for the Responsible Conduct of Research. Ethical approval to conduct the study was obtained from the University of Melbourne Human Research Ethics Committee (Ethics ID 1955997.1). All participants received a plain language statement that described the requirements of the study. All participants provided informed written consent to participate, which was affirmed verbally at the beginning of focus groups and interviews.

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Marriott, P.H.M., Weller-Newton, J.M. & Reid, K.J. Preparedness for a first clinical placement in nursing: a descriptive qualitative study. BMC Nurs 23 , 345 (2024). https://doi.org/10.1186/s12912-024-01916-x

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Parental experiences of caring for preterm infants in the neonatal intensive care unit, Limpopo Province: a descriptive qualitative study exploring the cultural determinants

• Madimetja J. Nyaloko 1 ,
• Welma Lubbe 1 ,
• Salaminah S. Moloko-Phiri 1 &
• Khumoetsile D. Shopo 1  

BMC Health Services Research volume  24 , Article number:  669 ( 2024 ) Cite this article

Metrics details

Parent-infant interaction is highly recommended during the preterm infant hospitalisation period in the Neonatal Intensive Care Unit (NICU). Integrating culturally sensitive healthcare during hospitalisation of preterm infants is critical for positive health outcomes. However, there is still a paucity of evidence on parental experience regarding cultural practices that can be integrated into preterm infant care in the NICU. The study explored and described the cultural determinants of parents that can be integrated into the care of preterm infants in the NICU.

A descriptive qualitative research design was followed where twenty ( n =20) parents of preterm infants were purposively selected. The study was conducted in the NICU in Limpopo using in-depth individual interviews. Taguette software and a thematic analysis framework were used to analyse the data. The COREQ guidelines and checklist were employed to ensure reporting standardisation.

Four themes emerged from the thematic analysis: 1) Lived experienced by parents of preterm infants, 2) Interactions with healthcare professionals, 3) Cultural practices concerning preterm infant care, and 4) Indigenous healthcare practices for preterm infants.

Conclusions

The study emphasised a need for healthcare professionals to understand the challenges parents of preterm infants face in NICU care. Furthermore, healthcare professionals should know indigenous healthcare practices to ensure relevant, culturally sensitive care.

Peer Review reports

Introduction and background

Parenting is an intricate process involving the upbringing and caring for a child from infancy to adulthood through promoting and supporting the child’s physical, emotional, social, and intellectual development [ 1 ]. This process becomes challenging, particularly when it involves preterm infants admitted to the hospital [ 2 ]. The birth of a preterm infant can be an epoch-making, evocative, and occasionally devastating parental experience [ 3 ]. A preterm infant is defined as a child born before the 37 th week of pregnancy is completed [ 4 ]. Annually, approximately 15 million preterm births are documented out of 160 million live births, accounting for an 11.5% global preterm birth rate [ 5 ]. Between 2010 and 2020, more than 60% of global preterm births occurred in South Asia and Sub-Saharan Africa [ 5 ]. One in every seven infants in South Africa was born before their due date and required NICU admission [ 5 ].

The NICU is typically a foreign and intimidating environment for parents, due to the need for continuous monitoring and medical intervention for infants who are fragile and sick. Parents can experience stress, guilt, anxiety, and sadness due to the infant's uncertain health prognosis [ 6 ]. The active involvement of parents in preterm infant care activities in the NICU is crucial for infant developmental outcomes [ 7 ]. Healthcare professionals should comprehend the parental experience of caring for a preterm infant in the NICU to address parental needs and enhance parent-infant interaction and attachment [ 8 ]. This interaction may in turn increase parental satisfaction, thus promoting more appropriate parent-infant interaction, including attachment and bonding [ 9 ].

Although parent-infant interaction is beneficial, cultural variables need to be acknowledged. Parenting is deeply rooted in a culture characterized by ideologies concerning how an individual should act, feel and think as an in-group member [ 10 ]. Therefore, the parental involvement and parent-infant interaction might be disrupted if the parental cultural practice is not considered. Cultural practices influence the parents' infant care approach [ 11 , 12 ]. The values and ideals of culture are conveyed to the next generation through child-rearing practices, which implies that cultures are contextually sensitive parenting guidelines [ 13 ].

Parents of preterm infants in Limpopo Province, South Africa, come from various cultural backgrounds, which may influence how they understand and react to the care provided to their preterm infant in the NICU. Various childrearing practices associated with culture influence the health of preterm infants [ 14 ]. These practices include massaging the baby, applying oil to the eyes and ears, burping the baby, applying black carbon to the eyes, and trimming the nails. Parental involvement in preterm infant care in the NICU may also be influenced by culture [ 15 ]. The cultural views and ideas of healthcare professionals can potentially affect the standard of care offered to preterm infants and their parents in the NICU. These cultural views and ideas are health beliefs that explain the cause of illness, its prevention or treatment methods, and the appropriate individuals who should participate in the healing process [ 16 ].

Healthcare professionals who have a comprehensive understanding of the parental cultural determinants can facilitate the nurturing and promoting of adequate parental-infant care and interaction, which is the foundation for developing preterm infants [ 17 ]. Lack of support from healthcare professionals regarding the cultural aspects of parent-infant interaction may negate parents' cultural practices, and increase negative perceptions and dissatisfaction with the healthcare service provided in the NICU [ 17 ]. Consequently, this may result in a lack of parental awareness or responsiveness to the infant, associated with delayed infant cognitive development and multiple behavioural problems [ 18 ].

Despite the recognition of the importance of parental involvement in NICU care and the documented emotional challenges experienced by parents, there is a gap in the literature regarding the specific experiences and cultural practices of parents caring for preterm infants which can be integrated in NICU in settings, such as Limpopo Province in South Africa. The province has seen a significant increase in the number of newborn babies weighing under 2,500 grams in recent years [ 19 ]. The study aimed to explore and describe the cultural determinants of parents that can be integrated into the care of preterm infants admitted to the NICU in Limpopo Province to ensure culturally sensitive care. This study is unique due to its focus on South Africa, specifically Limpopo Province, which is the centre of cultural practices due to its rurality. The main research question was: 'What are the cultural determinants which influence the parental experience that can be integrated into the care of preterm infants in the NICU in Limpopo Province?

The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed to ensure standardisation in reporting the study type, design, execution, analysis, and results [ 20 ].

The study applied a qualitative research design following a descriptive approach [ 21 ]. In-depth individual interviews were used to explore and describe the experiences of parents of preterm infants admitted to the NICU in Limpopo Province through a cultural determinant lens.

The current study was conducted in the NICU of a tertiary hospital in Limpopo Province, South Africa. Limpopo Province was selected based on two grounds: 1) Cultural practices are more evident in rural villages than in semi-urban or urban settings [ 22 ], 84.2% of the study population live in rural areas [ 23 ]; and 2) one in every seven infants is born before its due date in South Africa [ 5 ], the Limpopo Province accounts for high preterm birth rates [ 19 ].

Participants and sample

The population comprised mothers of a preterm infant admitted to the NICU. For this study, a parent was defined as the mother of a preterm infant in the NICU. Purposive sampling was used to select twenty ( n =20) participants from the NICU in a tertiary hospital [ 24 ]. The inclusion criteria required that 1) the participant be the parent of a preterm infant; 2) the parent had a preterm infant in the NICU for a minimum of two weeks (As set out by the researcher, the contextually relevant time for an immersive experience was two weeks); 3) the parent be able to speak either Sepedi, Xitsonga, Tshivenda, or English (the common local languages). Mothers of preterm infants who were in critical condition were excluded. There were no refusals to participate. The sample size was determined based on data saturation, which was reached with n =20 participants [ 25 ].

Recruitment

The first author (Ph.D.) and an independent person recruited the participants face-to-face by distributing recruitment material such as flyers and asynchronously by displaying posters on the noticeboards in the selected hospital's NICU and a place where the mother lodge in the hospital. Recruitment was conducted after ethical approvals and permission from the hospital were granted. Participants who expressed interest in the study notified the first author through a phone call, SMS, or WhatsApp text message. The first author then contacted the potential participants to provide detailed information regarding the study aim and data collection method, including audio recordings of interviews, confidentiality agreements, written informed consent, and voluntary participation. Potential participants who showed interest were given an informed consent form and a minimum of 48 hours to consult and inform their partners or family members. The first author was accessible telephonically for any clarity-seeking questions. The first author contacted the agreed participants to schedule the hospital-based interviews on the agreed-upon dates. All consented mothers participated and there were no withdrawals.

Data collection

The interview guide was developed for this current study in English, and translated to local languages (Sepedi, Xitsonga, and Tshivenda) by assistant researchers who are fluent with these respective languages. Three bilingual speakers (Sepedi, Xitsonga, and Tshivenda) checked the translations from English to these local languages for accuracy, which was endorsed. Furthermore, the interview schedule was piloted with two participants to assess its effectiveness and suitability (See supplementary document 1). Pilot study was instrumental in refining the interview guide and ensuring that it would yield the desired data during the primary study. The in-depth interview began with an open-ended question, as shown in Table 1 below.

The data was collected between August and September 2022. In-depth individual interviews were conducted by the first author and assistant researcher using Sepedi, Xitsonga, Tshivenda, or English in a private room in the hospital to ensure confidentiality. COVID-19 precautionary measures were followed to protect the health and safety of participants and interviewers. Furniture was wiped with a 70% based-alcohol solution before and after each interview, chairs were spaced 1.5 meters apart to ensure adequate social distance and researchers and participants sanitised their hands before entering and exiting the room. Participants and the interviewer wore a surgical facial mask covering the nose and mouth throughout the interview.

The first author served as the lead interviewer, the assistant researcher functioned as a support system in case of a language barrier. The interviews were conducted in the participant's preferred language (Sepedi, Xitsonga, Tshivenda, or English). The interviewer used probing questions to encourage the participants to elaborate, and all other questions arose from the dialogue. The duration of each interview was between 45 and 65 minutes.

With the participants' permission, two audio recording devices were used to record each interview, whereby one served as a backup in case the main one defaulted. During each interview, the first author compiled field notes regarding the context, non-communication cues, and impressions to complement the recorded audio. Data collection continued until no new data emerged, whereby data saturation was declared. All the interviews were conducted at the hospital.

After data collection, the first author and assistant researchers transcribed the data verbatim, including field notes in English. The researchers' subjective experiences regarding the explored phenomenon were described to avoid influencing data analysis: a process termed bracketing [ 26 ]. Three bilingual speakers (Sepedi, Xitsonga, and Tshivenda) checked the translations to English transcriptions for accuracy against the audio recordings. Additionally, two transcripts (10% of the sample) were back translated, and accuracy was verified by an independent co-coder and two co-authors [SSM, KDS]. No substantial linguistic issues were identified during the translation process.

Data analysis

Giorgi's data analysis method [ 27 , 28 ] was applied to comprehend the essence of the experiences of parents of preterm infants in the NICU. The data analysis process constituted five steps: understanding raw data, constructing a constituent profile, forming a theme index, merging participants' theme indexes, and searching the thematic index to develop interpretive themes.

Trustworthiness

The four criteria of Lincoln and Guba [ 29 ] were applied to establish the trustworthiness of the current study. Credibility was established by member checking with 10% of the sample ( n =2) by sending the transcript and developed themes. The supervisors (experts) conducted a confirmability audit of the study project by checking and rechecking the collected raw-, coded- and interpreted data to affirm neutrality. Additionally, the study followed a rigorous descriptive qualitative method and underwent a peer review process that confirmed the consistency of the data, and the findings ensured dependability, while data saturation and a detailed description of the methodology ensured transferability.

Demographic data

Twenty ( n =20) mothers of preterm infants admitted to the NICU in a tertiary hospital participated in this study. The participants’ ages ranged from 18 to 39 years, with the majority being between 18 and 25. The majority of parents had three children. Regarding education, nine participants had a secondary-level education, and 11 had a tertiary education. Of the 20 participants, nine were unemployed, two were self-employed, one was fully employed, one was employed part-time, and seven were students (Refer to Table 2 ).

Emerging themes and sub-themes

Four main themes emerged from the data analysis. These were: lived experienced by parents of preterm infants, interactions with healthcare professionals, cultural practices concerning preterm infant care, and indigenous healthcare practices for preterm infants. These themes, supported by sub-themes, are outlined in Table 3 .

Theme 1 lived experienced by parents of preterm infants

The current study's first theme emerged as the lived experienced by parents of preterm infants. Parents experienced considerable challenges while caring for the preterm infants in the NICU. Lived difficulties experiences by parents are further explored through the sub-themes: stress and exhaustion, and longing for home.

Sub-theme 1.1 stress and exhaustion

Participants felt an overwhelming sense of exhaustion and stress, as they cared for their infants in the NICU. Participant responses revealed a pervasive fear of the unknown, coupled with emotional turmoil and physical strain. The uncertainty surrounding the health of their infants exacerbates their distress, leading to heightened anxiety and feelings of helplessness. This emotional burden is compounded by the challenges of navigating complex medical information and coping with unexpected health complications. Participants expressed shock, describing the unexpected event of preterm birth and the overwhelming emotions following the delivery of a preterm infant.

One participant reported:

We are always scared when we go to see babies because we don't know what it is, especially when you leave the baby without the tube; you think she may vomit when you are not around, and the next thing you will be receiving a call saying your baby is no more. (P1, 18-year-old)

Participant 1's expression of fear illustrates the constant apprehension experienced by mothers in the NICU, highlighting the emotional strain of anticipating potential emergencies and adverse outcomes. Another participant indicated the overwhelming uncertainty faced by the mothers upon entering the NICU, emphasizing the need for clear communication and reassurance from healthcare providers. The following quote supports the participant’s experience:

What if they tell me the situation is like this when I enter there? Honestly speaking, it frightens us. We just wish that it didn't ring so that when you get there, they tell you that they needed you so and so . (P2, 25-year-old)

Another participant highlighted the shock and fear induced by the sight of an extremely premature infant, illustrating the emotional toll of witnessing their vulnerability.

This baby, she was too small, like it was the first time seeing a small child like this. I once saw premature, but it was not like this, this one was so small, so I was scared. (P4, 24-year-old)

Another participant described her emotional response to distressing news about her baby's health which underscores the profound impact of medical uncertainties on maternal well-being, emphasizing the need for sensitive communication and support.

When they told me that my baby was like this and this, I even cried. (P10, 39-year-old)

Additionally, other participant’s narrative reflected the overwhelming fear and uncertainty experienced by mothers in the NICU, highlighting the emotional toll of constantly anticipating adverse outcomes and navigating complex medical situations. The following quotes reflect the participants’ experiences:

What I'm dealing with, because I was very broken and did not know what it is, will the baby survive, what will she do, what's going to happen. The answer is not right, as, for us, we are always afraid, we don't know what it is when you are here. (P17, 23-year-old)

Sub-theme 1.2 longing for home

The emotional strain and challenges faced by mothers while caring for their infants in the hospital setting evoke a profound yearning for the sense of security, comfort and belonging that home provides. The participants described their experience of not getting enough rest and sleep while caring for their preterm infant in the NICU which would not happen if they were home. Contributing factors include the time required to visit the NICU for the infant’s care routine, time spent walking from the mother's lodge to the NICU and back, and the separation of mother and infant.

The participant reflected on the contrast between hospital practices and what would have been done if she were at home:

Yes, here in the hospital, they want you to bathe the baby like this while at home they want you to do this and this or at home, you would do this when you see him doing that. It's things I want to know. (P5, 38-year-old)

This quote encapsulates the longing for the familiar routines and comforts of home amidst the unfamiliarity of hospital protocols. It highlights the sense of control and autonomy associated with home, where individuals adhere to their own customs and practices, as opposed to the regulated environment of the hospital. Another participant reminisces about cultural practices that would have been observed in her home environment:

Yeah, like mostly, like back at home, in our culture, we believe that a baby less than a month old must be bathed by the mother or grandmother... If I was at home, I will be feeding her with soft porridge without giving her any medications because this medication makes her defecate twice a day or so and this makes her lose weight. (P7, 32-year-old)

This excerpt emphasises the role of cultural traditions and familial support in shaping caregiving practices. It underlines the interconnectedness between home and cultural identity, where adherence to traditional customs provides a sense of security and belonging, particularly in the context of new-born care. Furthermore, another participant described the traditional approach to newborn care back home:

No, after birth when I come home, we don’t bathe the baby right away, we dampen the cloth in lukewarm water and just wipe the baby where he is dirty. We wash the head because the hair traps a lot of dirty things (blood and birth secretions), we avoid the full bath so that we don’t expose the baby to flu. (P18, 20-year-old)

Other participants compared hospital feeding methods with traditional practices at home. The participants reported that:

Here we feed the baby with breast milk using pipes (NG tubes and syringes) but at home, we do a light and very soft porridge. (P16, 38-year-old)

This comparison highlights the adaptation to different environments and the longing for familiar routines. It shows how home serves as a sanctuary where individuals adhere to their preferred methods of infant care, reinforcing the notion of home as a place of comfort and familiarity. Other participants expressed a longing for the comforts of home and the familiar routines:

So, the first challenge is that we wake up. We only sleep two hours. Most of the time we spend on the way, we do not have time to rest. Like when you are going that way, you may find that you are going for a long time in the baby’s room. When you are coming here, and you try to sleep, time is gone, you must go back. (P14, 39-year-old)

This statement reflects the desire for a sense of normalcy and routine amidst the challenges of hospitalisation. It highlights the idea that home represents a heaven of rest and recuperation, where individuals can adhere to their preferred practices and routines, particularly during significant life events such as childrearing.

Theme 2 interactions with healthcare professionals

In this study, interaction is perceived as communication and involvement in preterm infant care among healthcare professionals and parents of preterm infants in the NICU. The sub-themes included NICU care, communication, and healthcare professional attitudes.

Sub-theme 2.1 care in NICU

This sub-theme concerns how healthcare professionals cared for preterm infants and their parents in the NICU. Some indicated that they received adequate care from nurses and doctors in the NICU.

One participant indicated that:

The doctors are mostly here; they used to come only to check and update [us] about the baby's condition. The people who take part mostly are the nurses. Okay, looking at the ICU there is no problems, all is right. (P02, 25-year-old)

A similar view was echoed by another participant who stated:

Yes, they help me take care of the baby, and the doctors are nearby if there is something the doctor and nurses can help with. (P13, 22-year-old)

Another participant shared that she had only seen good things and is at peace with the care that she is receiving in the NICU:

In [N]ICU I have not seen any bad things; I only noticed the good things. My baby was in troubles, but she is not well, nurses are checking her every time so does the doctors. So up to so far, I never had any problems with nurses and doctors. I am at peace. (P18, 20-year-old)

However, one participant expressed dissatisfaction with the care she received in the NICU. The following quote confirms this:

They end up swearing at us and to be treated this way, been shouted, it ends up affecting our minds since I already have a problem with my baby’s condition. (P12, 28-year-old)

The participants’ responses highlight that they experienced positive and negative care while looking after their preterm infants in NICU; it appears that they appreciated the care, although some were unhappy.

Sub-theme 2.2 communication in NICU

Nearly all parents mentioned the importance of healthcare professionals practising effective communication as clinicians. In this context, communication is the exchange of information between parents of preterm infants and healthcare professionals in the NICU. The parents indicated that they had experienced satisfactory communication with healthcare professionals while caring for their preterm infant in the NICU. This includes comprehensive explanations; for instance, the doctor offered information regarding the baby's weight decrease in terms that parents could comprehend, giving them relief. The following quotes support the experience:

Yes, is not it that when we come here, we are under stress? So, if we want to say sister (nurse), may I ask, how is my baby doing? She can answer me; if she does not know, she must go and ask or tell me that I do not know about this one. I can ask someone who knows, like have good communication. (P17, 23-year-old)

Yes, the same doctor that I ask him regarding the baby’s weight loss. He explained to me well and now I understand, am free because the weight is no longer 0.8 kg, it is now around 1.0 kg. The support is good because when you ask something they quickly actioned it, so there is support. (P18, 20-year-old)

The above participants highlighted the importance of efficient communication in interactions between parents and healthcare professionals in the NICU and its positive effects on parents’ experiences and well-being. Nevertheless, other participants expressed dissatisfaction with the communication they received from the healthcare professionals in the NICU. One of the cited reasons for their dissatisfaction was that healthcare professionals discussed the infant's condition in a language the parents did not understand.

One participant mentioned that:

They asked me if I knew why my baby went to the theatre? What is the reason he came here? I said yes; I just heard them saying it is the authority which I do not know what they meant. (P06, 23-year-old)

Similarly, other participants expressed disappointment that healthcare professionals were not informing them about the interventions/procedures before implementation. The following quotes support the parental disappointment:

We do want to know because when we arrive in the ward, we just see that intravenous lines were inserted, and blood sample were collected, and we also see that the infant was pricked several times on the extremities hence do not even know where the samples are taken to. (P16, 38-year-old)

It is the same as when he was in high care because after labour, my baby was sent to high care, and the next morning he was in ICU without informing me. (P19, 23-year-old)

Moreover, another participant mentioned feeling confused because of the conflicting communication from healthcare professionals. The following quote supports this confusion:

The other one enters tells you the baby should change sides and give you reasons. When you tell them one said I should not change sides, they end up swearing at us end up confusing us. (P12, 28-year-old)

Participants highlighted the negative impact that poor communication could have on their experience in the NICU, as well as the significance of simple and consistent communication with healthcare professionals. They expressed a desire for precise, reliable information to understand what was happening to their preterm infants and to feel more involved in the care of their infants.

Sub-theme 2.3 attitude of healthcare professionals in NICU

The participants in the study expressed dissatisfaction with the attitudes of healthcare professionals in the NICU, as illustrated by the two quotes below:

When you go to the nurse and tell her that the tube is disconnected from the baby and the secretions are coming out through the nose, so the response will be like, what do you want me to do because your baby did that (mother rolling the eyes)? (P01, 18-year-old)

Okay there was this nurse who was on a night shift yesterday and she was busy with files, and when we wanted to ask her to collect some of the things for us, and she would say to us that we must go collect those things for ourselves because she is busy. So, when we got there to collect for ourselves, we found another nurse who asked us as to where our nurse is because we should not be doing this for ourselves. So, when we called her, she showed to me that she does not like her job. (P08, 31-year-old)

Another participant further mentioned that:

There is a nurse that seemed to have an advanced age, whenever we ask her to assist our babies, or asking some supplies to help our babies she is rude. She once told me that [my] babies are ugly such like me. (P20, 19-year-old)

More so, some mothers lamented the lack of communication from the nurses. For example

Their communication is not good because they hide things from us, sometimes you will find that they had taken your baby’s blood and not tell you about the results or what the results implies, and even when you ask the nurses, they would tell you that they are doing what they have been instructed to do. Sometimes you also find your baby inserted with drip, and when you ask, they do not say or explain the reason for all of these. (P08, 31-year-old)

Even though other participants expressed their dissatisfaction regarding the attitude of the healthcare professionals, other participants felt the opposite. One participant mentioned that she had a satisfactory relationship with the healthcare professionals expressed in the quote:

I am pleased with how the hospital is providing her with milk, yes, I am happy they help. (P12, 28-year-old)

Similarly, another participant added that she has only observed good things concerning the level of service provided to her infant:

In [N]ICU I haven’t seen any bad things; I only noticed the good things. (P18, 20-year-old)

Most parents expressed satisfaction with the level of support provided by the healthcare professionals in the NICU. The participants describe the support as encouraging and helping them to understand that challenges are a normal part of the process, as indicated by the below quotes:

Yes, their support is good. It is the kind of support that encourages you to understand that things like this are there and there are these kinds of challenges. (P07, 32-year-old)

Additionally, another participant alluded that:

The support from the nurses is very good, each one of them know me because I have been here for a long time. When they arrive, they call and ask how is the baby [doing]? Initially it was scary because my baby was the smallest one in the unit, and I was new but now am used to the nurses and the unit. (P18, 20-year-old)

Theme 3 cultural practice concerning preterm infant care

The third main theme was the cultural practices concerning preterm infant care. This study's concepts associated with this theme include practices and behaviours conducted after childbirth. This includes the infant naming practice, infant access restrictions, family involvement, and religious practice observance.

Sub-theme 3.1 infant naming by senior family members

Participants indicated that they adhere to the cultural practices of naming the preterm infant after birth. These cultural practices include understanding who is responsible for naming the infant, introducing the infant to the ancestors, and the meaning associated with the name given. The quotes show that senior family members, particularly grandmothers, are responsible for naming the infant and performing ancestral veneration to introduce the infant to the ancestors after birth.

One participant shared that:

If the granny [was] still alive, she [would be] the right [person] to appoint my parent to name the infant. (P02, 25-year-old)

Another participant supported the preceding statement by stating:

Well, when I call them at home regarding the name, my grandmother would want her name to be passed down to the child. (P08, 31-year-old)

The above data highlight that the grandmothers are responsible for naming the infants. This is because naming a preterm infant in Limpopo Province is culturally associated with the practice of ancestral communication, which grandmothers perform. Furthermore, one participant indicated that the infants are named based on various events in life. The following quotation illustrates this:

Because they used a dead person's name, so they are informing the owner of the name that there is someone who will use it. (P02, 25-year-old)

The above quote highlights the belief that a preterm infant is given the name of a deceased person to keep their memory alive and to ensure the continuation of a family legacy. Also, ancestral communication rituals should be performed to inform the name's owner. In addition, another participant indicated that infant naming is culturally essential and that a misnamed infant will continuously cry. The following quotation evidences this belief:

They do that; for example, they can call a baby by name like Sara, and if the baby stops crying, it means that is the name she wanted. And these things happen because they can call her by her name; the baby then stops crying and is healed instantly. (P01, 18-year-old)

The above data suggest that naming a preterm infant may positively affect the infant’s health and well-being when culturally informed. The beliefs and practices related to naming a preterm infant reflect the cultural values and traditions of the parents, which are essential considerations in providing culturally sensitive care in the NICU.

Sub-theme 3.2 infant access restrictions

Participants indicated that everyone is not permitted access to the room where the preterm infant is kept. Access restrictions include funeral attendees, pregnant women and individuals who recently engaged in sexual activities. The following section further explores how participants perceived these restricted individuals as harmful to the infant through a cultural lens based on their experiences during preterm infant care. A common experience for many participants was that individuals who participated in funeral services should perform cultural rituals with ashes and some aloes when entering, as illustrated in the following quotes.

They [those attended the funeral] enter the baby's room, they bath the baby with aloe and ashes a little bit and even on the joints so that she must never get sick. (P01, 18-year-old)

Usually, when they are from a funeral, they take ashes, apply them to the baby and make her swallow a bit of it so that they do not suppress her. (P02, 25-year-old)

An additional participant concurred with the preceding participants and elaborated that:

According to culture all babies from newborn to a child aged 6 to 7, when one person at home goes to the funeral, when that person comes back home takes ashes and rub it on the tummies of all these age group so that none of them can get suppressed or have negative auras. (P20, 19-year-old)

The data highlight the cultural belief that there are diseases and negative auras that can be acquired from funeral services and that precautionary measures must be taken to prevent the spread of these harmful elements to the preterm infant. In addition to the precautionary measures highlighted above, other participants explained that people who attend funerals should be isolated from the infant for some period before regaining access to the infant's room, as illustrated by the two quotes below:

I am staying with my grandmother, but if they are from the funeral, it means only I will nurse the baby. They will take seven days without entering the baby's room. (P04, 24-year-old)

She [person attended the funeral] must stay there for seven days before she returns, and after that, she can come back and help me with the baby. (P11, 27-year-old)

The above quotes indicate that isolating individuals who attended the funeral service for seven days will allow the acquired diseases and negative auras from the funeral to clear up and minimize the chances of transmission to the infant. Pregnant women were the second restriction. The following quotes illustrate beliefs and practices surrounding the presence and interactions of preterm infants and pregnant women:

Traditionally, we think she will suppress the baby. If a pregnant person carries the baby, she will delay the baby's growth. You find that at around six months, the baby is still unable to sit, so they believe it is because a pregnant person carried the baby. She is not supposed to enter the baby's room until the baby gets out. (P02, 25-year-old)

Another participant said:

If someone is pregnant, she is not supposed to hold a baby in such a way that the legs of the baby are on [her-pregnant woman] abdomen because we believe that if the baby's legs are stepping on top of the pregnant person's abdomen, the baby won't walk until the pregnant woman give birth, she will wait for the unborn baby to be born before she can walk. (P01, 18-year-old)

The first quote highlights the complete restriction of pregnant women from gaining access to the infant due to the negative impact (slow growth) that she can have on the infant. However, the second quote indicated that a pregnant woman can be granted access to the infant’s room and can even carry the infant, although with precautions not to allow the infant’s leg to come in contact with the abdomen. Through this analysis, it becomes clear that cultural beliefs and practices play a substantial role in shaping the experiences of pregnant women and their interaction with preterm infants. The final restriction was holding the infant after sexual intercourse. Most participants revealed a common belief that sexual intercourse could lead to the transfer of a negative aura to the infant. The following quote exemplifies this belief:

When the cord has not yet fallen, my grandmother is the only person who is allowed to enter because she has passed that stage of sexual intercourse. The rest of them are not allowed because we are trying to avoid negative aura to be passed on to the child, and if that happen, he will cry a lot. So, no one is allowed except my grandmother. (P08, 31-year-old)

Other participants stated, in support of the preceding statement:

They [siblings] might be coming from their partners and you would find that they were intimate in a way, so their energies will affect the baby negatively. (P09, 30-year-old)

Because they [grandmothers] do not have sexual intercourse anymore and they have experience. Culturally, it is believed that people who had sexual intercourse had negative aura. (P16, 38-year-old)

The data suggest that the role of grandmothers in caring for preterm infants is essential and safe as they are free of negative energies due to their age, experience, and abstinence from sexual intercourse. Furthermore, the data highlights that individuals who engage in sexual intercourse bring negative auras to the baby and are, therefore, not allowed to be in close proximity to the newborn. This cultural practice aims to ensure the well-being and health of the preterm infant by avoiding contact with individuals who have recently engaged in sexual intercourse.

Sub-theme 3.3 family involvement

Cultural practices concerning preterm infant care restrict infant access and allow family members to assist in caring for the infant. The following quotations illustrate participants' experience regarding family involvement while caring for the infant.

One participant stated that:

When I am here, the nurses help me, which is the same when you are at home. There is no difference. (P11, 27-year-old)

Another participant expressed a similar view:

It is very important because when you get help as a new mom you also get time to rest, in my family they would bathe the infant and massage you. (P12, 28-year-old)

In support of the above participants, another participant added that:

At home it is better because we have people who are assisting us, and we have time to rest (P16, 38-year-old)

The conclusion that can be drawn from these findings is that the involvement of family members in caring for the infant enabled the mothers to rest rather than continuously caring for the infant alone, which may be exhausting.

Sub-theme 3.4 religious practices observance/beliefs

In context of this study, most parents were religious and observed religious practices in terms of prayer and using ditaelo (church prescriptions - the church practices believed to be effective in curing the patient and preventing misfortune). This is connected to the belief that their infants would be protected from illness and be healthy, parents would be strengthened, and healthcare professionals would be granted wisdom to care for the infants. Most parents prayed to God for their preterm infant to get better and be healed. The following quotes illustrate this:

I just thought my baby is going to die but because God is present, I prayed I got baby boy. Now I thank God because of my faith and even the doctors had confidence that the baby will be okay. (P18, 20-year-old)

I pray every time I go to the ward for God to give her life and when I leave, I do not know what they will do to her, to not be affected when a lot of activities are done to her body. (P02, 25-year-old) Furthermore, parents also prayed for themselves and drew strength from their spiritual anchor to overcome the challenges they experienced while caring for their preterm infant in the NICU.

I have a way of overcoming my fears and sadness through prayer so that I can be able to receive strength . (P11, 27-year-old)

Other participants also highlighted this. For example, one participant indicated that:

When I am down, I pray for 2 minutes and ask God for strength. Then after, I feel okay. (P02, 25-year-old)

Moreover, participants did not only pray for themselves and their infants but also for healthcare professionals to have wisdom while caring for their infants. The following quotes demonstrate this intercession:

I believe that is the reason I prayed, because evil spirits can block the doctors view for them not see anything. (P12, 28-year-old)

Until now I just pray to God to give wisdom to doctors so that they treat my baby well then, I can go home. (P18, 20-year-old)

Lastly, one participant believed that prayer is more effective when performed in person, in the presence of others, rather than done alone. The participant stated that:

I prefer that when I pray, I must be there with two or more people because the prayer becomes more powerful when you are many. (P11, 27-year-old)

These findings highlights that the communal aspect of religious practices is vital for some individuals and that they believe that the power of prayer is amplified when performed with others. The quotes in this analysis indicate that the participants view prayer as connecting with a higher power, seeking strength, wisdom, and healing for themselves and the preterm infant in their care. Another aspect of religious practice, observance/practice called ditaelo , was also used to protect their infants from evil spirits and heal them.

Theme 4 indigenous healthcare practices for preterm infants

The final theme from the data analysis was “indigenous healthcare practices for preterm infants,” which parents described as the beliefs, knowledge, and habits about health passed down from generation to generation in a specific community. This theme is further explored through the following four subthemes.

Sub-theme 4.1 cultural practices used for cleaning the umbilical cord

Most participants believed that the indigenous care method for the umbilical cord is a vital cultural practice related to preterm infant care. Although the participants used surgical spirit in the NICU, they expressed the practices of using various herbal formulations that they would like to incorporate in the NICU during umbilical cord care. The following quotes reflect this.

I take table salt with that powdered wood soot and apply it [umbilical cord] on the cord every time you bathe the baby until it dries. (P10, 39-year-old)

We took soil from termite mound, chickens’ manure and placed them there for it to fall. (P12, 28-year-old)

Additionally, the same view was echoed by other participants, explaining that:

The herbs will shrink the cord, which will eventually fall off. After that, they will give you herbs to spread over the cord area, which will help the cord to close from inside. I was using the ashes to mix with Vaseline, then spread the mixture over the cord. (P15, 32-year-old)

We clean the cord with surgical spirit. Then we also use the head from the ‘matches’ stick and mix with the mouse poo and crush it down until is a fine powder. Then we apply the fine powder on the cord area. (P20, 19-year-old)

In addition to the various preferred herbal formulations, other participants mentioned that they apply breastmilk on the umbilical cord to increase the rate at which it dries. This is evident in the following quotes:

We do a full bath after two days with warm water, then clean the cord with the spirit, and apply breast milk so that the cord can dry and fall fast. (P18, 20-year-old)

They say we pour breast milk on the cord, like basically the newborn baby we need to apply the breast milk when I wake up in the morning, on the belly button. (P17, 23-year-old)

Furthermore, despite using surgical spirit in the NICU, participants were dissatisfied with its effectiveness. Most mothers felt that the delayed umbilical cord drying, and detachment were caused using surgical spirits.

One participant mentioned:

The way of taking care of children here is different; for instance, the surgical spirit is not so effective in cleaning and making the cord dry. The cord would have fallen by now if I was home. (P05, 38-year-old)

Another participant expressed that:

With home remedies it takes up to three days but with the surgical spirit, it takes seven days. It is fast if you do it traditionally. (P13, 22-year-old)

In support of the above participant, another participant further explained that:

We are staying with elderly people at our homes, so immediately after the baby is born, we start by treating her umbilical cord, which, culturally or religion-wise, is much faster than what we use here at the hospital, because even here at the hospital, they treat the cord by spreading spirit on the cord, but it takes time. (P14, 39-year-old)

Sub-theme 4.2 treatment of dehydration “ phogwana or lebalana ”

Some illnesses experienced by newborns are deemed to be not-for-hospital treatment but require indigenous healthcare practices or treatment. For example, dehydration is an indigenous childhood illness called phogwana, which traditionalists treat through herbal formulations. Other participants were concerned that their infant might suffer from phogwana while admitted to the NICU.

Maybe if I do things the way I am used to doing on the baby, he might recover, or maybe the baby has phogwana, and the doctor thinks it is something they can treat. (P06, 23-year-old)

The following participant echoed a similar notion in support:

When the baby is sick with lebalana, you do not take the baby to the hospital because they do not know how to treat that. You take her to someone. In Tshivenda, we say when the baby has lebalana, they must cut, burn things that came out of it, and then come to the baby… then the baby heals at the same time. (P17, 23-year-old)

Furthermore, participants shared that phogwana needs to be treated by a traditional healer or with traditional medicine. This is evident in the following quote.

If the phogwana is not beating well, there is a traditional medicine that we apply to make sure that it does not affect the baby. (P16, 38-year-old)

Sub-theme 4.3 care of eyes, ears, and nose

The subtheme of "care of eyes, ears, and nose " within the major theme of indigenous healthcare practices for preterm infants is represented by traditional methods of addressing issues related to the eyes, ears, and nose. Most participants reported using breast milk to clean and treat minor ailments of the eyes, ears, and nose.

Most of the time we use breast milk to take care of their eyes, and that even allows them to sleep peacefully, we take few drops of our breast milk and pour them inside his eyes. (P08, 31-year-old)

Another participant added that:

If the eyes are having discharge, we express breast milk inside the eyes and wipes it using the tongue to remove the discharges. (P16, 38-year-old)

In addition to using breast milk for eyes, it was reported to treat blocked nostrils and common flu and clean the umbilical cord, as reflected in the following quotes.

Breast milk works especially when the eyes are white or having the discharges. Same as the nose, when the baby is having a flu, we put few drops of breast milk that is our culture. (P18, 20-year-old)

Participants believe that the non-nutritional use of breast milk as a remedy or treatment for minor ailments of the eyes, sinuses, and ears is effective. This traditional belief may be because breast milk contains antibacterial and anti-inflammatory properties.

Sub-theme 4.4 infant bathing practices

The current study further revealed that preterm infant bathing was not only done for hygiene-related reasons but was also seen as serving to stimulate weight, for physical strengthening, and to protect the infant against evil spirits. These reasons are reflected in the following quotes.

Traditionally we bathe her with sehlapišo (traditional medicine) used to bathe infants to stimulate weight gain. (P13, 22-year-old)

Another participant also shared that:

We use leaves from the Baobab tree to bathe the baby; it is a medication. It is responsible for making the baby strong. (P10, 39-year-old)

In addition to herbal medicines that stimulate infant weight, other participants reported using herbal formulations to protect the infant against evil spirits and negative auras. The usage of herbal formulations is evident in the following quotes:

They use mogato (a traditional form of medicine to protect the baby from being suppressed) for bathing her. They put mogato inside the water and then just bath her, more especially if there is someone from the extended family coming to visit. (P02, 25-year-old)

I use the mixture, add it to the water, and bathe the baby to remove the negative spirits and aura, and some is for weight-gaining stimulation because young babies are difficult to hold due to their size. (P14, 39-year-old)

Lastly, other participants also shared the same notion; however, they indicated that this kind of herbal formulation called sehlapišo should not be used on the infant’s head during bathing as it is believed that the infant’s head will grow at an expedited rate should it come in contact with sehlapišo . The following quotes demonstrate this point:

When we use ‘sehlapišo’ for two days, we keep the water and then the next day we dilute it with hot water so that it becomes warm, and then after bathing we rinse him. we only bath his arms and legs because if we bath his head and neck they will grow too as this is used for growing or gaining weight. (P08, 31-year-old)

You do not touch the baby’s head when using ‘sehlapišo’ you only bath him from the neck to his toes, because they say if it happens that you touch the baby’s head while bathing him, [otherwise] the head and face becomes swollen and changes size. (P09, 30-year-old)

This study highlights parents' experiences caring for their preterm infants and the cultural determinants that can be integrated into preterm care to ensure culturally sensitive care. Four major themes and related sub-themes emphasise the importance of healthcare professionals respecting and acknowledging cultural practices, beliefs, and customs relevant to parents of preterm infants admitted to their facilities.

Participants in the current study experienced a range of negative feelings, including shock, fear, and anxiety, concerning the unexpected event of preterm birth, consistent with the literature. For instance, studies conducted in Sweden [ 30 ] and Denmark [ 31 ] reported that the abruptness of preterm birth, combined with the physical environment of the NICU, evokes feelings of shock and overwhelm in parents. Furthermore, the fear and anxiety experienced by the participants in this study while caring for their preterm infant in the NICU corroborate the findings in existing literature [ 32 , 33 ]. Both studies reported that parents often oscillate between hope and fear, particularly regarding their infant's survival and the possible long-term health complications associated with preterm birth. This correlation could be explained by the fact that preterm birth is traumatic and a potential stressor because it occurs mostly under emergency conditions, often threatening both the parents and the infant's well-being.

The current study's findings revealed that most participants acknowledged receiving satisfactory care from the nurses and doctors, as they were regularly present and helpful in tending to the infants' needs. This finding mirrors those of a study which noted that parents appreciate the quality of care provided by healthcare professionals in the NICU [ 34 ]. However, some participants felt that the nurses were often not friendly and mistreated them in the NICU. The findings are similar to the study which reported that some parents were dissatisfied with the care they received, which often stemmed from perceived rude behavior or negligence [ 35 ]. While technical, medical treatment and care are vital, the current data highlight how such care significantly influences parents' experiences in the NICU.

Communication, both in content and manner, is essential in the NICU setting, as it profoundly impacts parental experiences [ 36 ]. In addition, communication was also identified as a critical component in providing quality care to a diverse population concerning incorporating culturally competent care [ 37 ]. The current findings showed that many parents were satisfied with the communication they received from healthcare professionals, particularly when they were given clear explanations about their infants' condition. However, specific communication issues, including using incomprehensible medical jargon, insufficient intervention information, and conflicting advice from different professionals, were pointed out. These issues align with previous research, highlighting the need for improved communication strategies in the NICU to better inform and support parents [ 38 ].

Regarding the attitude of healthcare professionals, our findings revealed a mixed perception among parents. Some parents expressed dissatisfaction with the perceived negative attitudes of healthcare professionals, echoing similar findings by Shields et al. [ 39 ]. Negative attitudes from healthcare professionals can lead to mistrust and increased stress among parents [ 40 ]. Conversely, other parents in our study reported positive attitudes and felt well-supported and valued by the NICU staff. This positive perception aligns with the previous study which suggested that positive interactions with healthcare professionals can improve parental satisfaction [ 41 ]. While the current findings corroborate existing literature, the heightened perception of both positive and negative aspects of care, communication, and attitude might be attributed to cultural diversity in Limpopo Province.

The current study found that naming preterm infants is the domain of senior family members, particularly grandmothers. This finding aligns with previous work which asserted that grandmothers play a crucial role in naming infants and performing associated rituals in African cultures [ 42 ]. This role could be because the naming process is closely related to ancestral communication, which grandmothers frequently facilitate. Furthermore, the study indicates that infants' names often carry important cultural meanings or memorials, reflecting events or individuals in the family's history. The belief in the power of naming to affect an infant's well-being corroborates with the previous study’s assertion that names in most African cultures bear profound significance, carrying the family's hopes, aspirations, and legacies [ 43 ]. Additionally, names help individuals understand who they are and the community to which they belong. Such findings underscore the importance of cultural considerations concerning naming preterm infants in the NICU to promote culturally sensitive care and enhance parents' experiences.

In this study, three cultural restrictions on infant access aimed at safeguarding preterm infants' health were revealed. These restrictions primarily concern those who attended funerals, pregnant women, and people who recently engaged in sexual intercourse. First, funeral attendants: participants believed they could introduce diseases or negative auras to preterm infants, so precautionary measures needed to be taken before access could be granted again. The precautionary measure, which includes isolating funeral attendants for several days and having them wash their hands with aloe and ashes before touching the infant, aligns with a study by McAdoo [ 44 ], which reported similar customs among various African cultures. The use of aloe and ashes might stem from the fact that they contain some antibacterial properties, which may kill or lessen bacteria.

Second, according to our findings, pregnant women were also viewed as potentially harmful to preterm infants. This finding is unique as no other similar study could be located regarding the harm that could be brought by pregnant women. Third, individuals who recently engaged in sexual intercourse were deemed to have negative auras that could harm infants, particularly from parents' perspectives. This restriction echoes findings of previous study which revealed that newborns are isolated from young girls who engage in sexual activities as they can delay umbilical cord falling off [ 45 ]. This finding highlights the need for open dialogue and understanding regarding sexual practices in NICU care.

This study's findings underline the key role of family members in caring for preterm infants, which aligns with previous research in the field. Particularly, participant responses corroborated the evidence of family involvement as crucial to maternal well-being and infant care, as shown in a study conducted in the United States [ 46 ]. The responses reflect an appreciation for the support offered by extended family, primarily in providing mothers with rest and recovery time, mirroring previous findings [ 47 ]. The significance of family engagement in this study can be linked to cultural norms and values in the Limpopo Province and South Africa.

Most South African tribes, particularly indigenous ones, strongly believe in communal assistance and interdependence, particularly at significant life events such as childbirth. This is frequently characterised by extended family members stepping in to aid and support the new mother, allowing her time to relax and heal while contributing to the infant's care. Additionally, the similarity in support between NICU nurses and family members emphasized by participants resonates with the notion of family-centred care advocated by other scholars [ 48 ]. This approach, which suggests that healthcare providers can emulate a sense of familial support, highlights the importance of aligning clinical practices with the socio-cultural context of care.

Most participants expressed a reliance on prayer for the health of their infants, personal strength, and wisdom for healthcare professionals, which aligns with other studies that demonstrated the importance of spiritual beliefs in health outcomes and coping mechanisms [ 49 , 50 , 51 ]. Moreover, the idea of communal prayer being more potent than individual prayer, as pointed out by one participant, echoes classic sociological theory on the collective effervescence and emotional energy generated in communal religious rituals [ 52 ]. This finding accentuates the importance of understanding and integrating spiritual needs and beliefs in the NICU environment.

Interestingly, participants in the current study also invoked ' ditaelo ', or church prescriptions, in protecting and healing their infants. This practice, not extensively documented in the existing literature, appears to be a distinct element of religious observance in this cultural context. It may relate to African traditional healing practices, as discussed in the previous studies which indicated a unique fusion of Christianity and indigenous beliefs [ 53 , 54 ]. This practice underscores the cultural and spiritual complexity surrounding NICU care in the Limpopo Province and calls for further research to better comprehend these practices and their implications for infant care.

The participants’ experiences in the current study regarding umbilical cord care revealed that most parents reported using and believing in traditional cord care practices. These participants further described using ashes, powdered wood soot, breast milk, and soil from termite mounds topically to dry off and heal the umbilical cord. The use of herbs to treat and care for the umbilical cord was not unique to the participants in this study. In Sub-Saharan countries including South Africa [ 45 ], Zambia [ 55 ], Nigeria [ 56 ], Pakistan [ 57 ], and Uganda [ 58 ], the topical application of substances to the umbilical cord to hasten its detachment has been reported. It is important to acknowledge that while these traditional practices hold cultural significance and have been used for generations, their efficacy and safety may differ. In some cases, such practices may carry risks, such as infection or irritation. Healthcare providers should be aware of these cultural practices and engage in open and respectful conversation with families to understand their beliefs and preferences while also providing safe evidence-based care.

Moreover, participants also expressed dissatisfaction with modern procedures, such as surgical spirits, which they perceived as less effective than traditional practices because it makes the cord detach after seven days. This perception echoes the findings of study which revealed that some cultures believe traditional practices provide superior results compared to modern medical care, particularly for infants [ 59 ]. Although the herbal formulation was preferred over modern medical care, it has not been scientifically evaluated and studied; therefore, there is a potential risk of infection and other complications. Further research is needed to understand the scientific functionality of herbal formulations used to treat and dry off the umbilical cord.

This study showed that there are perceptions that certain medical conditions affecting newborns do not necessitate hospital care but rather require indigenous healthcare practices or treatment. For instance, phogwana was mentioned as a condition that needs out-of-hospital treatment by traditionalists. Similarly, this finding supports the previous literature which documented that the treatment of phogwana requires a traditional healer [ 44 , 60 ]. In addition, the literature indicated that the characteristics, prevention, and treatment of phogwana correspond to specific cultural contexts [ 61 ]. Providing medical care for premature infants outside of the hospital, under the guidance of traditionalists, may pose result risks, such as adverse responses to herbal therapy and metabolic poisoning. The immature organs of preterm newborns may have limited ability to efficiently remove metabolites of herbal medicines, which could potentially cause more health complications and death [ 62 ].

Furthermore, regarding the care of eyes, ears, and nose, participants reported using breast milk as a treatment for minor ailments. The belief in the antibacterial effects and healing properties of breast milk in traditional medicine is further substantiated by this finding, aligning with existing literature. These studies reinforce the multifunctional uses of breast milk beyond nutrition, including its application in treating eye infections [ 63 ] and alleviating nasal congestion, among others [ 64 ]. Although the benefits of breast milk are recognised, it is crucial to follow proper hygiene protocols when dealing with it. This includes washing your hands before handling breast milk and using sterile containers and applicators. Neglecting to maintain good hygiene can potentially introduce infections to the ears, nose, and eyes.

The participants in the current study reported that infant bathing was performed with different herbs for several purposes, such as stimulation of weight, warding off the evil spirit, and strengthening and protecting the infant. Herbal formulations used for bathing included sehlapišo , mogato , and baobab tree leaves. This study's findings agree with several studies on the African continent. In Uganda, infants were bathed with kyogero to attract fortunes [ 65 ], and in South Africa [ 44 ], India [ 66 ] and Nigeria [ 67 ], herbal medicine was also used during infant bathing for strengthening and spiritual protection purposes. One possible reason for the similarity could be that all studies reporting indigenous infant bathing were conducted on the African continent, which has overlapping cultural practices. It is clear from this finding that bathing practices are not merely physiologically functional but are often symbolic, serving various socio-cultural purposes and highlighting the intersection of cultural belief and healthcare. Preterm infants are vulnerable to health risks such as hypothermia, skin irritation, and infection due to their underdeveloped thermoregulatory system, delicate skin, and immature immune system [ 68 ]. Ritual bathing, particularly if not performed carefully, has the potential to worsen these health risks. It is recommended that healthcare professionals should ensures measures to guarantee that the ritual bathing environment for preterm newborns is secure, hygienic, and at a suitable temperature to reduce these dangers.

Limitations and strengths of the study

This study explored the cultural determinants of parents that can be incorporated into preterm infant care to ensure culturally sensitive care as part of maternal and childcare routine in the NICU in Limpopo Province. Although the qualitative design was the most appropriate to explore the phenomenon in this study, it limited the study's findings as it was not generalizable. Additionally, the primary investigator’s unconscious biases and perceptions could have influenced data analysis, however bracketing was applied to limit bias. Furthermore, to limit biases, the experts conducted a confirmability audit of the study project by checking and rechecking the collected raw-, coded- and interpreted data. The current study was conducted in a public hospital in Limpopo Province to explore the experiences of parents of preterm infants in the NICU, which may differ substantially from those in private hospitals and other provinces. Therefore, future research is recommended to explore this phenomenon in private hospitals and other provinces in South Africa.

The current study provides an understanding of parents' experiences caring for preterm infants in the NICU. The study offered meaningful insights into indigenous healthcare practices, emphasizing their crucial role in preterm infant care in specific cultural contexts. The cultural determinants included various topics, such as caring for the umbilical cord, treating phogwana , caring for the eyes, ears, and nose, and infant bathing customs. These practices showed a deeply ingrained belief system and a rich cultural heritage that have a meaningful impact on healthcare behaviours. However, these cultural determinants might have both positive and negative implications.

The findings demonstrated a strong reliance on traditional methods and herbal formulations in caring for preterm infants. Parents emphasised the advantages of these practices over current medical procedures, notably in treating disorders not frequently recognised by modern medicine and the care of the umbilical cord. This discontent with contemporary practices, highlights the need for culturally sensitive healthcare which can be conducted by conducting cultural assessments to understand the beliefs, values, and practices of the families in the NICU.

Overall, the findings of this study highlight the profound role of indigenous healthcare practices for preterm infants, reinforcing the need for a culturally sensitive approach in healthcare.

Availability of data and materials

The dataset materials generated and analysed during this study are accessible upon justified request from the corresponding author [MN].

Abbreviations

Neonatal Intensive Care Unit

North-West University

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Acknowledgements

The authors would like to extend their gratitude to all the parents of preterm infants who participated in this study and the assistant researchers who assisted in collecting the data.

Open access funding provided by North-West University. This manuscript was extracted from a funded research project by the NWU postgraduate bursary and Faculty of Health Sciences bursary (Funding code/number: not applicable).

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M.N. conceptualised and developed the research protocol, conducted research (gathered, analysed, interpreted, and managed the data), and wrote the initial draft. W.L., S.S.M., and K.D.S. supervised the research and provided inputs and guidance for the research protocol development, data collection, analysis, and interpretations. All authors have read and approved the manuscript.

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The current study was executed in accordance with the Declaration of Helsinki and approved by North-West University Health Research Ethical committee [NWU-00267-21-S1]. Limpopo Province [LP-2021-08-027] granted permission to conduct the study through the National Health Research Database website. The management of the tertiary hospital granted goodwill permission for the study to be undertaken in their NICU. All the parents of preterm infants who participated in the study provided written informed consent. Participants were informed that participation in the study was voluntary and that they could withdraw anytime without penalty.

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Nyaloko, M.J., Lubbe, W., Moloko-Phiri, S.S. et al. Parental experiences of caring for preterm infants in the neonatal intensive care unit, Limpopo Province: a descriptive qualitative study exploring the cultural determinants. BMC Health Serv Res 24 , 669 (2024). https://doi.org/10.1186/s12913-024-11117-6

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A Practical Guide to Writing Quantitative and Qualitative Research Questions and Hypotheses in Scholarly Articles

Edward barroga.

1 Department of General Education, Graduate School of Nursing Science, St. Luke’s International University, Tokyo, Japan.

Glafera Janet Matanguihan

2 Department of Biological Sciences, Messiah University, Mechanicsburg, PA, USA.

The development of research questions and the subsequent hypotheses are prerequisites to defining the main research purpose and specific objectives of a study. Consequently, these objectives determine the study design and research outcome. The development of research questions is a process based on knowledge of current trends, cutting-edge studies, and technological advances in the research field. Excellent research questions are focused and require a comprehensive literature search and in-depth understanding of the problem being investigated. Initially, research questions may be written as descriptive questions which could be developed into inferential questions. These questions must be specific and concise to provide a clear foundation for developing hypotheses. Hypotheses are more formal predictions about the research outcomes. These specify the possible results that may or may not be expected regarding the relationship between groups. Thus, research questions and hypotheses clarify the main purpose and specific objectives of the study, which in turn dictate the design of the study, its direction, and outcome. Studies developed from good research questions and hypotheses will have trustworthy outcomes with wide-ranging social and health implications.

INTRODUCTION

Scientific research is usually initiated by posing evidenced-based research questions which are then explicitly restated as hypotheses. 1 , 2 The hypotheses provide directions to guide the study, solutions, explanations, and expected results. 3 , 4 Both research questions and hypotheses are essentially formulated based on conventional theories and real-world processes, which allow the inception of novel studies and the ethical testing of ideas. 5 , 6

It is crucial to have knowledge of both quantitative and qualitative research 2 as both types of research involve writing research questions and hypotheses. 7 However, these crucial elements of research are sometimes overlooked; if not overlooked, then framed without the forethought and meticulous attention it needs. Planning and careful consideration are needed when developing quantitative or qualitative research, particularly when conceptualizing research questions and hypotheses. 4

There is a continuing need to support researchers in the creation of innovative research questions and hypotheses, as well as for journal articles that carefully review these elements. 1 When research questions and hypotheses are not carefully thought of, unethical studies and poor outcomes usually ensue. Carefully formulated research questions and hypotheses define well-founded objectives, which in turn determine the appropriate design, course, and outcome of the study. This article then aims to discuss in detail the various aspects of crafting research questions and hypotheses, with the goal of guiding researchers as they develop their own. Examples from the authors and peer-reviewed scientific articles in the healthcare field are provided to illustrate key points.

DEFINITIONS AND RELATIONSHIP OF RESEARCH QUESTIONS AND HYPOTHESES

A research question is what a study aims to answer after data analysis and interpretation. The answer is written in length in the discussion section of the paper. Thus, the research question gives a preview of the different parts and variables of the study meant to address the problem posed in the research question. 1 An excellent research question clarifies the research writing while facilitating understanding of the research topic, objective, scope, and limitations of the study. 5

On the other hand, a research hypothesis is an educated statement of an expected outcome. This statement is based on background research and current knowledge. 8 , 9 The research hypothesis makes a specific prediction about a new phenomenon 10 or a formal statement on the expected relationship between an independent variable and a dependent variable. 3 , 11 It provides a tentative answer to the research question to be tested or explored. 4

Hypotheses employ reasoning to predict a theory-based outcome. 10 These can also be developed from theories by focusing on components of theories that have not yet been observed. 10 The validity of hypotheses is often based on the testability of the prediction made in a reproducible experiment. 8

Conversely, hypotheses can also be rephrased as research questions. Several hypotheses based on existing theories and knowledge may be needed to answer a research question. Developing ethical research questions and hypotheses creates a research design that has logical relationships among variables. These relationships serve as a solid foundation for the conduct of the study. 4 , 11 Haphazardly constructed research questions can result in poorly formulated hypotheses and improper study designs, leading to unreliable results. Thus, the formulations of relevant research questions and verifiable hypotheses are crucial when beginning research. 12

CHARACTERISTICS OF GOOD RESEARCH QUESTIONS AND HYPOTHESES

Excellent research questions are specific and focused. These integrate collective data and observations to confirm or refute the subsequent hypotheses. Well-constructed hypotheses are based on previous reports and verify the research context. These are realistic, in-depth, sufficiently complex, and reproducible. More importantly, these hypotheses can be addressed and tested. 13

There are several characteristics of well-developed hypotheses. Good hypotheses are 1) empirically testable 7 , 10 , 11 , 13 ; 2) backed by preliminary evidence 9 ; 3) testable by ethical research 7 , 9 ; 4) based on original ideas 9 ; 5) have evidenced-based logical reasoning 10 ; and 6) can be predicted. 11 Good hypotheses can infer ethical and positive implications, indicating the presence of a relationship or effect relevant to the research theme. 7 , 11 These are initially developed from a general theory and branch into specific hypotheses by deductive reasoning. In the absence of a theory to base the hypotheses, inductive reasoning based on specific observations or findings form more general hypotheses. 10

TYPES OF RESEARCH QUESTIONS AND HYPOTHESES

Research questions and hypotheses are developed according to the type of research, which can be broadly classified into quantitative and qualitative research. We provide a summary of the types of research questions and hypotheses under quantitative and qualitative research categories in Table 1 .

Research questions in quantitative research

In quantitative research, research questions inquire about the relationships among variables being investigated and are usually framed at the start of the study. These are precise and typically linked to the subject population, dependent and independent variables, and research design. 1 Research questions may also attempt to describe the behavior of a population in relation to one or more variables, or describe the characteristics of variables to be measured ( descriptive research questions ). 1 , 5 , 14 These questions may also aim to discover differences between groups within the context of an outcome variable ( comparative research questions ), 1 , 5 , 14 or elucidate trends and interactions among variables ( relationship research questions ). 1 , 5 We provide examples of descriptive, comparative, and relationship research questions in quantitative research in Table 2 .

Hypotheses in quantitative research

In quantitative research, hypotheses predict the expected relationships among variables. 15 Relationships among variables that can be predicted include 1) between a single dependent variable and a single independent variable ( simple hypothesis ) or 2) between two or more independent and dependent variables ( complex hypothesis ). 4 , 11 Hypotheses may also specify the expected direction to be followed and imply an intellectual commitment to a particular outcome ( directional hypothesis ) 4 . On the other hand, hypotheses may not predict the exact direction and are used in the absence of a theory, or when findings contradict previous studies ( non-directional hypothesis ). 4 In addition, hypotheses can 1) define interdependency between variables ( associative hypothesis ), 4 2) propose an effect on the dependent variable from manipulation of the independent variable ( causal hypothesis ), 4 3) state a negative relationship between two variables ( null hypothesis ), 4 , 11 , 15 4) replace the working hypothesis if rejected ( alternative hypothesis ), 15 explain the relationship of phenomena to possibly generate a theory ( working hypothesis ), 11 5) involve quantifiable variables that can be tested statistically ( statistical hypothesis ), 11 6) or express a relationship whose interlinks can be verified logically ( logical hypothesis ). 11 We provide examples of simple, complex, directional, non-directional, associative, causal, null, alternative, working, statistical, and logical hypotheses in quantitative research, as well as the definition of quantitative hypothesis-testing research in Table 3 .

Research questions in qualitative research

Unlike research questions in quantitative research, research questions in qualitative research are usually continuously reviewed and reformulated. The central question and associated subquestions are stated more than the hypotheses. 15 The central question broadly explores a complex set of factors surrounding the central phenomenon, aiming to present the varied perspectives of participants. 15

There are varied goals for which qualitative research questions are developed. These questions can function in several ways, such as to 1) identify and describe existing conditions ( contextual research question s); 2) describe a phenomenon ( descriptive research questions ); 3) assess the effectiveness of existing methods, protocols, theories, or procedures ( evaluation research questions ); 4) examine a phenomenon or analyze the reasons or relationships between subjects or phenomena ( explanatory research questions ); or 5) focus on unknown aspects of a particular topic ( exploratory research questions ). 5 In addition, some qualitative research questions provide new ideas for the development of theories and actions ( generative research questions ) or advance specific ideologies of a position ( ideological research questions ). 1 Other qualitative research questions may build on a body of existing literature and become working guidelines ( ethnographic research questions ). Research questions may also be broadly stated without specific reference to the existing literature or a typology of questions ( phenomenological research questions ), may be directed towards generating a theory of some process ( grounded theory questions ), or may address a description of the case and the emerging themes ( qualitative case study questions ). 15 We provide examples of contextual, descriptive, evaluation, explanatory, exploratory, generative, ideological, ethnographic, phenomenological, grounded theory, and qualitative case study research questions in qualitative research in Table 4 , and the definition of qualitative hypothesis-generating research in Table 5 .

Qualitative studies usually pose at least one central research question and several subquestions starting with How or What . These research questions use exploratory verbs such as explore or describe . These also focus on one central phenomenon of interest, and may mention the participants and research site. 15

Hypotheses in qualitative research

Hypotheses in qualitative research are stated in the form of a clear statement concerning the problem to be investigated. Unlike in quantitative research where hypotheses are usually developed to be tested, qualitative research can lead to both hypothesis-testing and hypothesis-generating outcomes. 2 When studies require both quantitative and qualitative research questions, this suggests an integrative process between both research methods wherein a single mixed-methods research question can be developed. 1

FRAMEWORKS FOR DEVELOPING RESEARCH QUESTIONS AND HYPOTHESES

Research questions followed by hypotheses should be developed before the start of the study. 1 , 12 , 14 It is crucial to develop feasible research questions on a topic that is interesting to both the researcher and the scientific community. This can be achieved by a meticulous review of previous and current studies to establish a novel topic. Specific areas are subsequently focused on to generate ethical research questions. The relevance of the research questions is evaluated in terms of clarity of the resulting data, specificity of the methodology, objectivity of the outcome, depth of the research, and impact of the study. 1 , 5 These aspects constitute the FINER criteria (i.e., Feasible, Interesting, Novel, Ethical, and Relevant). 1 Clarity and effectiveness are achieved if research questions meet the FINER criteria. In addition to the FINER criteria, Ratan et al. described focus, complexity, novelty, feasibility, and measurability for evaluating the effectiveness of research questions. 14

The PICOT and PEO frameworks are also used when developing research questions. 1 The following elements are addressed in these frameworks, PICOT: P-population/patients/problem, I-intervention or indicator being studied, C-comparison group, O-outcome of interest, and T-timeframe of the study; PEO: P-population being studied, E-exposure to preexisting conditions, and O-outcome of interest. 1 Research questions are also considered good if these meet the “FINERMAPS” framework: Feasible, Interesting, Novel, Ethical, Relevant, Manageable, Appropriate, Potential value/publishable, and Systematic. 14

As we indicated earlier, research questions and hypotheses that are not carefully formulated result in unethical studies or poor outcomes. To illustrate this, we provide some examples of ambiguous research question and hypotheses that result in unclear and weak research objectives in quantitative research ( Table 6 ) 16 and qualitative research ( Table 7 ) 17 , and how to transform these ambiguous research question(s) and hypothesis(es) into clear and good statements.

a These statements were composed for comparison and illustrative purposes only.

b These statements are direct quotes from Higashihara and Horiuchi. 16

a This statement is a direct quote from Shimoda et al. 17

The other statements were composed for comparison and illustrative purposes only.

CONSTRUCTING RESEARCH QUESTIONS AND HYPOTHESES

To construct effective research questions and hypotheses, it is very important to 1) clarify the background and 2) identify the research problem at the outset of the research, within a specific timeframe. 9 Then, 3) review or conduct preliminary research to collect all available knowledge about the possible research questions by studying theories and previous studies. 18 Afterwards, 4) construct research questions to investigate the research problem. Identify variables to be accessed from the research questions 4 and make operational definitions of constructs from the research problem and questions. Thereafter, 5) construct specific deductive or inductive predictions in the form of hypotheses. 4 Finally, 6) state the study aims . This general flow for constructing effective research questions and hypotheses prior to conducting research is shown in Fig. 1 .

Research questions are used more frequently in qualitative research than objectives or hypotheses. 3 These questions seek to discover, understand, explore or describe experiences by asking “What” or “How.” The questions are open-ended to elicit a description rather than to relate variables or compare groups. The questions are continually reviewed, reformulated, and changed during the qualitative study. 3 Research questions are also used more frequently in survey projects than hypotheses in experiments in quantitative research to compare variables and their relationships.

Hypotheses are constructed based on the variables identified and as an if-then statement, following the template, ‘If a specific action is taken, then a certain outcome is expected.’ At this stage, some ideas regarding expectations from the research to be conducted must be drawn. 18 Then, the variables to be manipulated (independent) and influenced (dependent) are defined. 4 Thereafter, the hypothesis is stated and refined, and reproducible data tailored to the hypothesis are identified, collected, and analyzed. 4 The hypotheses must be testable and specific, 18 and should describe the variables and their relationships, the specific group being studied, and the predicted research outcome. 18 Hypotheses construction involves a testable proposition to be deduced from theory, and independent and dependent variables to be separated and measured separately. 3 Therefore, good hypotheses must be based on good research questions constructed at the start of a study or trial. 12

In summary, research questions are constructed after establishing the background of the study. Hypotheses are then developed based on the research questions. Thus, it is crucial to have excellent research questions to generate superior hypotheses. In turn, these would determine the research objectives and the design of the study, and ultimately, the outcome of the research. 12 Algorithms for building research questions and hypotheses are shown in Fig. 2 for quantitative research and in Fig. 3 for qualitative research.

EXAMPLES OF RESEARCH QUESTIONS FROM PUBLISHED ARTICLES

• EXAMPLE 1. Descriptive research question (quantitative research)
• - Presents research variables to be assessed (distinct phenotypes and subphenotypes)
• “BACKGROUND: Since COVID-19 was identified, its clinical and biological heterogeneity has been recognized. Identifying COVID-19 phenotypes might help guide basic, clinical, and translational research efforts.
• RESEARCH QUESTION: Does the clinical spectrum of patients with COVID-19 contain distinct phenotypes and subphenotypes? ” 19
• EXAMPLE 2. Relationship research question (quantitative research)
• - Shows interactions between dependent variable (static postural control) and independent variable (peripheral visual field loss)
• “Background: Integration of visual, vestibular, and proprioceptive sensations contributes to postural control. People with peripheral visual field loss have serious postural instability. However, the directional specificity of postural stability and sensory reweighting caused by gradual peripheral visual field loss remain unclear.
• Research question: What are the effects of peripheral visual field loss on static postural control ?” 20
• EXAMPLE 3. Comparative research question (quantitative research)
• - Clarifies the difference among groups with an outcome variable (patients enrolled in COMPERA with moderate PH or severe PH in COPD) and another group without the outcome variable (patients with idiopathic pulmonary arterial hypertension (IPAH))
• “BACKGROUND: Pulmonary hypertension (PH) in COPD is a poorly investigated clinical condition.
• RESEARCH QUESTION: Which factors determine the outcome of PH in COPD?
• STUDY DESIGN AND METHODS: We analyzed the characteristics and outcome of patients enrolled in the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) with moderate or severe PH in COPD as defined during the 6th PH World Symposium who received medical therapy for PH and compared them with patients with idiopathic pulmonary arterial hypertension (IPAH) .” 21
• EXAMPLE 4. Exploratory research question (qualitative research)
• - Explores areas that have not been fully investigated (perspectives of families and children who receive care in clinic-based child obesity treatment) to have a deeper understanding of the research problem
• “Problem: Interventions for children with obesity lead to only modest improvements in BMI and long-term outcomes, and data are limited on the perspectives of families of children with obesity in clinic-based treatment. This scoping review seeks to answer the question: What is known about the perspectives of families and children who receive care in clinic-based child obesity treatment? This review aims to explore the scope of perspectives reported by families of children with obesity who have received individualized outpatient clinic-based obesity treatment.” 22
• EXAMPLE 5. Relationship research question (quantitative research)
• - Defines interactions between dependent variable (use of ankle strategies) and independent variable (changes in muscle tone)
• “Background: To maintain an upright standing posture against external disturbances, the human body mainly employs two types of postural control strategies: “ankle strategy” and “hip strategy.” While it has been reported that the magnitude of the disturbance alters the use of postural control strategies, it has not been elucidated how the level of muscle tone, one of the crucial parameters of bodily function, determines the use of each strategy. We have previously confirmed using forward dynamics simulations of human musculoskeletal models that an increased muscle tone promotes the use of ankle strategies. The objective of the present study was to experimentally evaluate a hypothesis: an increased muscle tone promotes the use of ankle strategies. Research question: Do changes in the muscle tone affect the use of ankle strategies ?” 23

EXAMPLES OF HYPOTHESES IN PUBLISHED ARTICLES

• EXAMPLE 1. Working hypothesis (quantitative research)
• - A hypothesis that is initially accepted for further research to produce a feasible theory
• “As fever may have benefit in shortening the duration of viral illness, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response when taken during the early stages of COVID-19 illness .” 24
• “In conclusion, it is plausible to hypothesize that the antipyretic efficacy of ibuprofen may be hindering the benefits of a fever response . The difference in perceived safety of these agents in COVID-19 illness could be related to the more potent efficacy to reduce fever with ibuprofen compared to acetaminophen. Compelling data on the benefit of fever warrant further research and review to determine when to treat or withhold ibuprofen for early stage fever for COVID-19 and other related viral illnesses .” 24
• EXAMPLE 2. Exploratory hypothesis (qualitative research)
• - Explores particular areas deeper to clarify subjective experience and develop a formal hypothesis potentially testable in a future quantitative approach
• “We hypothesized that when thinking about a past experience of help-seeking, a self distancing prompt would cause increased help-seeking intentions and more favorable help-seeking outcome expectations .” 25
• “Conclusion
• Although a priori hypotheses were not supported, further research is warranted as results indicate the potential for using self-distancing approaches to increasing help-seeking among some people with depressive symptomatology.” 25
• EXAMPLE 3. Hypothesis-generating research to establish a framework for hypothesis testing (qualitative research)
• “We hypothesize that compassionate care is beneficial for patients (better outcomes), healthcare systems and payers (lower costs), and healthcare providers (lower burnout). ” 26
• Compassionomics is the branch of knowledge and scientific study of the effects of compassionate healthcare. Our main hypotheses are that compassionate healthcare is beneficial for (1) patients, by improving clinical outcomes, (2) healthcare systems and payers, by supporting financial sustainability, and (3) HCPs, by lowering burnout and promoting resilience and well-being. The purpose of this paper is to establish a scientific framework for testing the hypotheses above . If these hypotheses are confirmed through rigorous research, compassionomics will belong in the science of evidence-based medicine, with major implications for all healthcare domains.” 26
• EXAMPLE 4. Statistical hypothesis (quantitative research)
• - An assumption is made about the relationship among several population characteristics ( gender differences in sociodemographic and clinical characteristics of adults with ADHD ). Validity is tested by statistical experiment or analysis ( chi-square test, Students t-test, and logistic regression analysis)
• “Our research investigated gender differences in sociodemographic and clinical characteristics of adults with ADHD in a Japanese clinical sample. Due to unique Japanese cultural ideals and expectations of women's behavior that are in opposition to ADHD symptoms, we hypothesized that women with ADHD experience more difficulties and present more dysfunctions than men . We tested the following hypotheses: first, women with ADHD have more comorbidities than men with ADHD; second, women with ADHD experience more social hardships than men, such as having less full-time employment and being more likely to be divorced.” 27
• “Statistical Analysis
• ( text omitted ) Between-gender comparisons were made using the chi-squared test for categorical variables and Students t-test for continuous variables…( text omitted ). A logistic regression analysis was performed for employment status, marital status, and comorbidity to evaluate the independent effects of gender on these dependent variables.” 27

EXAMPLES OF HYPOTHESIS AS WRITTEN IN PUBLISHED ARTICLES IN RELATION TO OTHER PARTS

• EXAMPLE 1. Background, hypotheses, and aims are provided
• “Pregnant women need skilled care during pregnancy and childbirth, but that skilled care is often delayed in some countries …( text omitted ). The focused antenatal care (FANC) model of WHO recommends that nurses provide information or counseling to all pregnant women …( text omitted ). Job aids are visual support materials that provide the right kind of information using graphics and words in a simple and yet effective manner. When nurses are not highly trained or have many work details to attend to, these job aids can serve as a content reminder for the nurses and can be used for educating their patients (Jennings, Yebadokpo, Affo, & Agbogbe, 2010) ( text omitted ). Importantly, additional evidence is needed to confirm how job aids can further improve the quality of ANC counseling by health workers in maternal care …( text omitted )” 28
• “ This has led us to hypothesize that the quality of ANC counseling would be better if supported by job aids. Consequently, a better quality of ANC counseling is expected to produce higher levels of awareness concerning the danger signs of pregnancy and a more favorable impression of the caring behavior of nurses .” 28
• “This study aimed to examine the differences in the responses of pregnant women to a job aid-supported intervention during ANC visit in terms of 1) their understanding of the danger signs of pregnancy and 2) their impression of the caring behaviors of nurses to pregnant women in rural Tanzania.” 28
• EXAMPLE 2. Background, hypotheses, and aims are provided
• “We conducted a two-arm randomized controlled trial (RCT) to evaluate and compare changes in salivary cortisol and oxytocin levels of first-time pregnant women between experimental and control groups. The women in the experimental group touched and held an infant for 30 min (experimental intervention protocol), whereas those in the control group watched a DVD movie of an infant (control intervention protocol). The primary outcome was salivary cortisol level and the secondary outcome was salivary oxytocin level.” 29
• “ We hypothesize that at 30 min after touching and holding an infant, the salivary cortisol level will significantly decrease and the salivary oxytocin level will increase in the experimental group compared with the control group .” 29
• EXAMPLE 3. Background, aim, and hypothesis are provided
• “In countries where the maternal mortality ratio remains high, antenatal education to increase Birth Preparedness and Complication Readiness (BPCR) is considered one of the top priorities [1]. BPCR includes birth plans during the antenatal period, such as the birthplace, birth attendant, transportation, health facility for complications, expenses, and birth materials, as well as family coordination to achieve such birth plans. In Tanzania, although increasing, only about half of all pregnant women attend an antenatal clinic more than four times [4]. Moreover, the information provided during antenatal care (ANC) is insufficient. In the resource-poor settings, antenatal group education is a potential approach because of the limited time for individual counseling at antenatal clinics.” 30
• “This study aimed to evaluate an antenatal group education program among pregnant women and their families with respect to birth-preparedness and maternal and infant outcomes in rural villages of Tanzania.” 30
• “ The study hypothesis was if Tanzanian pregnant women and their families received a family-oriented antenatal group education, they would (1) have a higher level of BPCR, (2) attend antenatal clinic four or more times, (3) give birth in a health facility, (4) have less complications of women at birth, and (5) have less complications and deaths of infants than those who did not receive the education .” 30

Research questions and hypotheses are crucial components to any type of research, whether quantitative or qualitative. These questions should be developed at the very beginning of the study. Excellent research questions lead to superior hypotheses, which, like a compass, set the direction of research, and can often determine the successful conduct of the study. Many research studies have floundered because the development of research questions and subsequent hypotheses was not given the thought and meticulous attention needed. The development of research questions and hypotheses is an iterative process based on extensive knowledge of the literature and insightful grasp of the knowledge gap. Focused, concise, and specific research questions provide a strong foundation for constructing hypotheses which serve as formal predictions about the research outcomes. Research questions and hypotheses are crucial elements of research that should not be overlooked. They should be carefully thought of and constructed when planning research. This avoids unethical studies and poor outcomes by defining well-founded objectives that determine the design, course, and outcome of the study.

Disclosure: The authors have no potential conflicts of interest to disclose.

Author Contributions:

• Conceptualization: Barroga E, Matanguihan GJ.
• Methodology: Barroga E, Matanguihan GJ.
• Writing - original draft: Barroga E, Matanguihan GJ.
• Writing - review & editing: Barroga E, Matanguihan GJ.

• Letter to the Editor
• Open access
• Published: 27 May 2024

Analyzing global research trends and focal points of pyoderma gangrenosum from 1930 to 2023: visualization and bibliometric analysis

• Sa’ed H. Zyoud   ORCID: orcid.org/0000-0002-7369-2058 1 , 2  

Journal of Translational Medicine volume  22 , Article number:  508 ( 2024 ) Cite this article

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To the Editor, I read with great interest the publication entitled “An approach to the diagnosis and management of patients with pyoderma gangrenosum from an international perspective: results from an expert forum” [ 1 ]. Pyoderma gangrenosum is an ulcerative, cutaneous condition with distinctive clinical characteristics first described in 1930 [ 2 ]. Due to the importance of the subject, this published study was searched in databases, and I did not find any bibliometric studies on this topic. In recent years, researchers have successfully applied bibliometric analysis in various domains, contributing to the development of novel theories and assessing research frontiers, including in the dermatology field. Nonetheless, comprehensive bibliometric analyses of P. gangrenosum have not been performed. This study addresses this gap by conducting a thorough bibliometric analysis in the field of P. gangrenosum at the global level. The goal is to assist researchers in swiftly grasping the knowledge structure and current focal points in the field, generating new research topic ideas, and enhancing the overall quality of research on P. gangrenosum.

This bibliometric analysis sought to delineate research endeavors concerning P. gangrenosum, pinpoint the primary contributing countries, and discern prevalent topics within this domain. Using a descriptive cross-sectional bibliometric methodology, this study extracted pertinent documents from the Scopus database covering the period from 1930 to December 31, 2023. The search strategy included keywords related to ‘pyoderma gangrenosum.’ VOSviewer software (version 1.6.20) was used to illustrate the most recurring terms or themes [ 3 ]. The scope of the retrieved documents was restricted to including only journal research articles while ignoring other forms of documents.

Overall, 4,326 papers about P. gangrenosum were published between 1930 and 2023. Among these were 3,095 (71.54%) original papers, 548 (12.67%) letters, 477 (11.03%) reviews, and 206 (4.76%) other kinds of articles, such as conference abstracts, editorials, or notes. With 3,454 publications, English was the most often used language, followed by French ( n  = 253), German ( n  = 190), and Spanish ( n  = 163), accounting for 93.85% of all related publications.

Figure  1 shows the distribution of these publications. Between 1930 and 2023, there were steadily more publications on P. gangrenosum (R 2  = 0.9257; P value < 0.001). Growth trends and productivity trends in P. gangrenosum-related publications have been influenced by developments in medical research, clinical practice and patient care [ 4 , 5 ]. All of these factors have advanced our knowledge of the condition, enhanced our methods of treatment, and helped to create standardized findings for clinical studies.

Annual growth of published research related to P. gangrenosum (1930–2023)

The top 10 countries with the most publications on P. gangrenosum are listed in Table  1 . These are the USA ( n  = 1073; 24.80%), the UK ( n  = 345; 7.98%), Japan ( n  = 335, 7.74%), and Germany ( n  = 296; 6.84%). With 65 articles, the Mayo Clinic in the USA led the institutions; Oregon Health & Science University in the USA and Università degli Studi di Milano in Italy followed with 60 articles each.

To create a term co-occurrence map in VOSviewer 1.6.20, terms had to appear in the title and abstract at least forty times by binary counting. The network was visualized by building the map using terms with the highest relevance scores. Large bubbles for often cooccurring terms and close spacing between terms with high similarity were guaranteed by the algorithm. The larger circles in Fig.  2 A represent frequently occurring terms in titles and abstracts. Four primary topic clusters—“Treatment modalities” (green cluster), “epidemiology and clinical presentation” (blue cluster), “improved diagnostic methods” (red cluster), and “the links between P. gangrenosum and other morbidities such as inflammatory bowel disease or autoimmune conditions” (yellow cluster)—are distinguished by color.

Mapping of terms used in research on P. gangrenosum. A : The co-occurrence network of terms extracted from the title or abstract of at least 40 articles. The colors represent groups of terms that are relatively strongly linked to each other. The size of a term signifies the number of publications related to P. gangrenosum in which the term appeared, and the distance between two terms represents an estimated indication of the relatedness of these terms. B : Mapping of terms used in research on P. gangrenosum. The terms “early” (blue) or “late” (red) years indicate when the term appeared

Interestingly, after 2012, terms related to “treatment modalities” and “epidemiology and clinical presentation” have gained more attention than in the past, which focused on “improved diagnostic methods” and “the links between P. gangrenosum and other morbidities such as inflammatory bowel disease or autoimmune conditions” (pre-2012). Figure  2 B shows this tendency.

In conclusion, there has recently been an increase in P. gangrenosum research, especially in the last decade. The current focus of research is on treatment challenges, obstacles to diagnosis, and connections to underlying diseases. Furthermore, efforts are being made to create core outcome sets and standardized diagnostic criteria for clinical trials. These patterns demonstrate continuous attempts to comprehend, identify, and treat this illness with greater effectiveness. This recent increase in research has important implications for clinical practice. Clinicians can improve patient care by remaining current in emerging trends and areas of interest. Moreover, an in-depth analysis of previous studies can identify knowledge gaps, directing future research efforts toward the most important issues. In the end, a deeper comprehension of the body of research can result in better clinical judgment based on best practices, which could enhance patient outcomes and advance the dermatological field.

Data availability

This published article contains all the information produced or examined in this research. Additional datasets utilized during this study can be obtained from the corresponding author.

Haddadin OM, Ortega-Loayza AG, Marzano AV, Davis MDP, Dini V, Dissemond J, Hampton PJ, Navarini AA, Shavit E, Tada Y, et al. An approach to diagnosis and management of patients with pyoderma gangrenosum from an international perspective: results from an expert forum. Arch Dermatol Res. 2024;316(3):89.

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Brunsting LA. Pyoderma (Echthyma) Gangrenosum. Arch Derm Syphilol. 1930;22(4):655–80.

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The author thanks An-Najah National University for all the administrative assistance during the implementation of the project.

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Sa’ed H. Zyoud significantly contributed to the conceptualization and design of the research project, overseeing data management and analysis, generating figures, and making substantial contributions to the literature search and interpretation. Furthermore, Sa’ed H. Zyoud authored the manuscript, which he reviewed and approved as the sole author.

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Zyoud, S.H. Analyzing global research trends and focal points of pyoderma gangrenosum from 1930 to 2023: visualization and bibliometric analysis. J Transl Med 22 , 508 (2024). https://doi.org/10.1186/s12967-024-05306-4

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DOI : https://doi.org/10.1186/s12967-024-05306-4

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