qualitative research in nursing and healthcare

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Qualitative Methods in Health Care Research

Vishnu renjith.

School of Nursing and Midwifery, Royal College of Surgeons Ireland - Bahrain (RCSI Bahrain), Al Sayh Muharraq Governorate, Bahrain

Renjulal Yesodharan

1 Department of Mental Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Judith A. Noronha

2 Department of OBG Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Elissa Ladd

3 School of Nursing, MGH Institute of Health Professions, Boston, USA

Anice George

4 Department of Child Health Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Healthcare research is a systematic inquiry intended to generate robust evidence about important issues in the fields of medicine and healthcare. Qualitative research has ample possibilities within the arena of healthcare research. This article aims to inform healthcare professionals regarding qualitative research, its significance, and applicability in the field of healthcare. A wide variety of phenomena that cannot be explained using the quantitative approach can be explored and conveyed using a qualitative method. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research. The greatest strength of the qualitative research approach lies in the richness and depth of the healthcare exploration and description it makes. In health research, these methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

Introduction

Healthcare research is a systematic inquiry intended to generate trustworthy evidence about issues in the field of medicine and healthcare. The three principal approaches to health research are the quantitative, the qualitative, and the mixed methods approach. The quantitative research method uses data, which are measures of values and counts and are often described using statistical methods which in turn aids the researcher to draw inferences. Qualitative research incorporates the recording, interpreting, and analyzing of non-numeric data with an attempt to uncover the deeper meanings of human experiences and behaviors. Mixed methods research, the third methodological approach, involves collection and analysis of both qualitative and quantitative information with an objective to solve different but related questions, or at times the same questions.[ 1 , 2 ]

In healthcare, qualitative research is widely used to understand patterns of health behaviors, describe lived experiences, develop behavioral theories, explore healthcare needs, and design interventions.[ 1 , 2 , 3 ] Because of its ample applications in healthcare, there has been a tremendous increase in the number of health research studies undertaken using qualitative methodology.[ 4 , 5 ] This article discusses qualitative research methods, their significance, and applicability in the arena of healthcare.

Qualitative Research

Diverse academic and non-academic disciplines utilize qualitative research as a method of inquiry to understand human behavior and experiences.[ 6 , 7 ] According to Munhall, “Qualitative research involves broadly stated questions about human experiences and realities, studied through sustained contact with the individual in their natural environments and producing rich, descriptive data that will help us to understand those individual's experiences.”[ 8 ]

Significance of Qualitative Research

The qualitative method of inquiry examines the 'how' and 'why' of decision making, rather than the 'when,' 'what,' and 'where.'[ 7 ] Unlike quantitative methods, the objective of qualitative inquiry is to explore, narrate, and explain the phenomena and make sense of the complex reality. Health interventions, explanatory health models, and medical-social theories could be developed as an outcome of qualitative research.[ 9 ] Understanding the richness and complexity of human behavior is the crux of qualitative research.

Differences between Quantitative and Qualitative Research

The quantitative and qualitative forms of inquiry vary based on their underlying objectives. They are in no way opposed to each other; instead, these two methods are like two sides of a coin. The critical differences between quantitative and qualitative research are summarized in Table 1 .[ 1 , 10 , 11 ]

Differences between quantitative and qualitative research

Qualitative Research Questions and Purpose Statements

Qualitative questions are exploratory and are open-ended. A well-formulated study question forms the basis for developing a protocol, guides the selection of design, and data collection methods. Qualitative research questions generally involve two parts, a central question and related subquestions. The central question is directed towards the primary phenomenon under study, whereas the subquestions explore the subareas of focus. It is advised not to have more than five to seven subquestions. A commonly used framework for designing a qualitative research question is the 'PCO framework' wherein, P stands for the population under study, C stands for the context of exploration, and O stands for the outcome/s of interest.[ 12 ] The PCO framework guides researchers in crafting a focused study question.

Example: In the question, “What are the experiences of mothers on parenting children with Thalassemia?”, the population is “mothers of children with Thalassemia,” the context is “parenting children with Thalassemia,” and the outcome of interest is “experiences.”

The purpose statement specifies the broad focus of the study, identifies the approach, and provides direction for the overall goal of the study. The major components of a purpose statement include the central phenomenon under investigation, the study design and the population of interest. Qualitative research does not require a-priori hypothesis.[ 13 , 14 , 15 ]

Example: Borimnejad et al . undertook a qualitative research on the lived experiences of women suffering from vitiligo. The purpose of this study was, “to explore lived experiences of women suffering from vitiligo using a hermeneutic phenomenological approach.” [ 16 ]

Review of the Literature

In quantitative research, the researchers do an extensive review of scientific literature prior to the commencement of the study. However, in qualitative research, only a minimal literature search is conducted at the beginning of the study. This is to ensure that the researcher is not influenced by the existing understanding of the phenomenon under the study. The minimal literature review will help the researchers to avoid the conceptual pollution of the phenomenon being studied. Nonetheless, an extensive review of the literature is conducted after data collection and analysis.[ 15 ]

Reflexivity

Reflexivity refers to critical self-appraisal about one's own biases, values, preferences, and preconceptions about the phenomenon under investigation. Maintaining a reflexive diary/journal is a widely recognized way to foster reflexivity. According to Creswell, “Reflexivity increases the credibility of the study by enhancing more neutral interpretations.”[ 7 ]

Types of Qualitative Research Designs

The qualitative research approach encompasses a wide array of research designs. The words such as types, traditions, designs, strategies of inquiry, varieties, and methods are used interchangeably. The major types of qualitative research designs are narrative research, phenomenological research, grounded theory research, ethnographic research, historical research, and case study research.[ 1 , 7 , 10 ]

Narrative research

Narrative research focuses on exploring the life of an individual and is ideally suited to tell the stories of individual experiences.[ 17 ] The purpose of narrative research is to utilize 'story telling' as a method in communicating an individual's experience to a larger audience.[ 18 ] The roots of narrative inquiry extend to humanities including anthropology, literature, psychology, education, history, and sociology. Narrative research encompasses the study of individual experiences and learning the significance of those experiences. The data collection procedures include mainly interviews, field notes, letters, photographs, diaries, and documents collected from one or more individuals. Data analysis involves the analysis of the stories or experiences through “re-storying of stories” and developing themes usually in chronological order of events. Rolls and Payne argued that narrative research is a valuable approach in health care research, to gain deeper insight into patient's experiences.[ 19 ]

Example: Karlsson et al . undertook a narrative inquiry to “explore how people with Alzheimer's disease present their life story.” Data were collected from nine participants. They were asked to describe about their life experiences from childhood to adulthood, then to current life and their views about the future life. [ 20 ]

Phenomenological research

Phenomenology is a philosophical tradition developed by German philosopher Edmond Husserl. His student Martin Heidegger did further developments in this methodology. It defines the 'essence' of individual's experiences regarding a certain phenomenon.[ 1 ] The methodology has its origin from philosophy, psychology, and education. The purpose of qualitative research is to understand the people's everyday life experiences and reduce it into the central meaning or the 'essence of the experience'.[ 21 , 22 ] The unit of analysis of phenomenology is the individuals who have had similar experiences of the phenomenon. Interviews with individuals are mainly considered for the data collection, though, documents and observations are also useful. Data analysis includes identification of significant meaning elements, textural description (what was experienced), structural description (how was it experienced), and description of 'essence' of experience.[ 1 , 7 , 21 ] The phenomenological approach is further divided into descriptive and interpretive phenomenology. Descriptive phenomenology focuses on the understanding of the essence of experiences and is best suited in situations that need to describe the lived phenomenon. Hermeneutic phenomenology or Interpretive phenomenology moves beyond the description to uncover the meanings that are not explicitly evident. The researcher tries to interpret the phenomenon, based on their judgment rather than just describing it.[ 7 , 21 , 22 , 23 , 24 ]

Example: A phenomenological study conducted by Cornelio et al . aimed at describing the lived experiences of mothers in parenting children with leukemia. Data from ten mothers were collected using in-depth semi-structured interviews and were analyzed using Husserl's method of phenomenology. Themes such as “pivotal moment in life”, “the experience of being with a seriously ill child”, “having to keep distance with the relatives”, “overcoming the financial and social commitments”, “responding to challenges”, “experience of faith as being key to survival”, “health concerns of the present and future”, and “optimism” were derived. The researchers reported the essence of the study as “chronic illness such as leukemia in children results in a negative impact on the child and on the mother.” [ 25 ]

Grounded Theory Research

Grounded theory has its base in sociology and propagated by two sociologists, Barney Glaser, and Anselm Strauss.[ 26 ] The primary purpose of grounded theory is to discover or generate theory in the context of the social process being studied. The major difference between grounded theory and other approaches lies in its emphasis on theory generation and development. The name grounded theory comes from its ability to induce a theory grounded in the reality of study participants.[ 7 , 27 ] Data collection in grounded theory research involves recording interviews from many individuals until data saturation. Constant comparative analysis, theoretical sampling, theoretical coding, and theoretical saturation are unique features of grounded theory research.[ 26 , 27 , 28 ] Data analysis includes analyzing data through 'open coding,' 'axial coding,' and 'selective coding.'[ 1 , 7 ] Open coding is the first level of abstraction, and it refers to the creation of a broad initial range of categories, axial coding is the procedure of understanding connections between the open codes, whereas selective coding relates to the process of connecting the axial codes to formulate a theory.[ 1 , 7 ] Results of the grounded theory analysis are supplemented with a visual representation of major constructs usually in the form of flow charts or framework diagrams. Quotations from the participants are used in a supportive capacity to substantiate the findings. Strauss and Corbin highlights that “the value of the grounded theory lies not only in its ability to generate a theory but also to ground that theory in the data.”[ 27 ]

Example: Williams et al . conducted a grounded theory research to explore the nature of relationship between the sense of self and the eating disorders. Data were collected form 11 women with a lifetime history of Anorexia Nervosa and were analyzed using the grounded theory methodology. Analysis led to the development of a theoretical framework on the nature of the relationship between the self and Anorexia Nervosa. [ 29 ]

Ethnographic research

Ethnography has its base in anthropology, where the anthropologists used it for understanding the culture-specific knowledge and behaviors. In health sciences research, ethnography focuses on narrating and interpreting the health behaviors of a culture-sharing group. 'Culture-sharing group' in an ethnography represents any 'group of people who share common meanings, customs or experiences.' In health research, it could be a group of physicians working in rural care, a group of medical students, or it could be a group of patients who receive home-based rehabilitation. To understand the cultural patterns, researchers primarily observe the individuals or group of individuals for a prolonged period of time.[ 1 , 7 , 30 ] The scope of ethnography can be broad or narrow depending on the aim. The study of more general cultural groups is termed as macro-ethnography, whereas micro-ethnography focuses on more narrowly defined cultures. Ethnography is usually conducted in a single setting. Ethnographers collect data using a variety of methods such as observation, interviews, audio-video records, and document reviews. A written report includes a detailed description of the culture sharing group with emic and etic perspectives. When the researcher reports the views of the participants it is called emic perspectives and when the researcher reports his or her views about the culture, the term is called etic.[ 7 ]

Example: The aim of the ethnographic study by LeBaron et al . was to explore the barriers to opioid availability and cancer pain management in India. The researchers collected data from fifty-nine participants using in-depth semi-structured interviews, participant observation, and document review. The researchers identified significant barriers by open coding and thematic analysis of the formal interview. [ 31 ]

Historical research

Historical research is the “systematic collection, critical evaluation, and interpretation of historical evidence”.[ 1 ] The purpose of historical research is to gain insights from the past and involves interpreting past events in the light of the present. The data for historical research are usually collected from primary and secondary sources. The primary source mainly includes diaries, first hand information, and writings. The secondary sources are textbooks, newspapers, second or third-hand accounts of historical events and medical/legal documents. The data gathered from these various sources are synthesized and reported as biographical narratives or developmental perspectives in chronological order. The ideas are interpreted in terms of the historical context and significance. The written report describes 'what happened', 'how it happened', 'why it happened', and its significance and implications to current clinical practice.[ 1 , 10 ]

Example: Lubold (2019) analyzed the breastfeeding trends in three countries (Sweden, Ireland, and the United States) using a historical qualitative method. Through analysis of historical data, the researcher found that strong family policies, adherence to international recommendations and adoption of baby-friendly hospital initiative could greatly enhance the breastfeeding rates. [ 32 ]

Case study research

Case study research focuses on the description and in-depth analysis of the case(s) or issues illustrated by the case(s). The design has its origin from psychology, law, and medicine. Case studies are best suited for the understanding of case(s), thus reducing the unit of analysis into studying an event, a program, an activity or an illness. Observations, one to one interviews, artifacts, and documents are used for collecting the data, and the analysis is done through the description of the case. From this, themes and cross-case themes are derived. A written case study report includes a detailed description of one or more cases.[ 7 , 10 ]

Example: Perceptions of poststroke sexuality in a woman of childbearing age was explored using a qualitative case study approach by Beal and Millenbrunch. Semi structured interview was conducted with a 36- year mother of two children with a history of Acute ischemic stroke. The data were analyzed using an inductive approach. The authors concluded that “stroke during childbearing years may affect a woman's perception of herself as a sexual being and her ability to carry out gender roles”. [ 33 ]

Sampling in Qualitative Research

Qualitative researchers widely use non-probability sampling techniques such as purposive sampling, convenience sampling, quota sampling, snowball sampling, homogeneous sampling, maximum variation sampling, extreme (deviant) case sampling, typical case sampling, and intensity sampling. The selection of a sampling technique depends on the nature and needs of the study.[ 34 , 35 , 36 , 37 , 38 , 39 , 40 ] The four widely used sampling techniques are convenience sampling, purposive sampling, snowball sampling, and intensity sampling.

Convenience sampling

It is otherwise called accidental sampling, where the researchers collect data from the subjects who are selected based on accessibility, geographical proximity, ease, speed, and or low cost.[ 34 ] Convenience sampling offers a significant benefit of convenience but often accompanies the issues of sample representation.

Purposive sampling

Purposive or purposeful sampling is a widely used sampling technique.[ 35 ] It involves identifying a population based on already established sampling criteria and then selecting subjects who fulfill that criteria to increase the credibility. However, choosing information-rich cases is the key to determine the power and logic of purposive sampling in a qualitative study.[ 1 ]

Snowball sampling

The method is also known as 'chain referral sampling' or 'network sampling.' The sampling starts by having a few initial participants, and the researcher relies on these early participants to identify additional study participants. It is best adopted when the researcher wishes to study the stigmatized group, or in cases, where findings of participants are likely to be difficult by ordinary means. Respondent ridden sampling is an improvised version of snowball sampling used to find out the participant from a hard-to-find or hard-to-study population.[ 37 , 38 ]

Intensity sampling

The process of identifying information-rich cases that manifest the phenomenon of interest is referred to as intensity sampling. It requires prior information, and considerable judgment about the phenomenon of interest and the researcher should do some preliminary investigations to determine the nature of the variation. Intensity sampling will be done once the researcher identifies the variation across the cases (extreme, average and intense) and picks the intense cases from them.[ 40 ]

Deciding the Sample Size

A-priori sample size calculation is not undertaken in the case of qualitative research. Researchers collect the data from as many participants as possible until they reach the point of data saturation. Data saturation or the point of redundancy is the stage where the researcher no longer sees or hears any new information. Data saturation gives the idea that the researcher has captured all possible information about the phenomenon of interest. Since no further information is being uncovered as redundancy is achieved, at this point the data collection can be stopped. The objective here is to get an overall picture of the chronicle of the phenomenon under the study rather than generalization.[ 1 , 7 , 41 ]

Data Collection in Qualitative Research

The various strategies used for data collection in qualitative research includes in-depth interviews (individual or group), focus group discussions (FGDs), participant observation, narrative life history, document analysis, audio materials, videos or video footage, text analysis, and simple observation. Among all these, the three popular methods are the FGDs, one to one in-depth interviews and the participant observation.

FGDs are useful in eliciting data from a group of individuals. They are normally built around a specific topic and are considered as the best approach to gather data on an entire range of responses to a topic.[ 42 Group size in an FGD ranges from 6 to 12. Depending upon the nature of participants, FGDs could be homogeneous or heterogeneous.[ 1 , 14 ] One to one in-depth interviews are best suited to obtain individuals' life histories, lived experiences, perceptions, and views, particularly while exporting topics of sensitive nature. In-depth interviews can be structured, unstructured, or semi-structured. However, semi-structured interviews are widely used in qualitative research. Participant observations are suitable for gathering data regarding naturally occurring behaviors.[ 1 ]

Data Analysis in Qualitative Research

Various strategies are employed by researchers to analyze data in qualitative research. Data analytic strategies differ according to the type of inquiry. A general content analysis approach is described herewith. Data analysis begins by transcription of the interview data. The researcher carefully reads data and gets a sense of the whole. Once the researcher is familiarized with the data, the researcher strives to identify small meaning units called the 'codes.' The codes are then grouped based on their shared concepts to form the primary categories. Based on the relationship between the primary categories, they are then clustered into secondary categories. The next step involves the identification of themes and interpretation to make meaning out of data. In the results section of the manuscript, the researcher describes the key findings/themes that emerged. The themes can be supported by participants' quotes. The analytical framework used should be explained in sufficient detail, and the analytic framework must be well referenced. The study findings are usually represented in a schematic form for better conceptualization.[ 1 , 7 ] Even though the overall analytical process remains the same across different qualitative designs, each design such as phenomenology, ethnography, and grounded theory has design specific analytical procedures, the details of which are out of the scope of this article.

Computer-Assisted Qualitative Data Analysis Software (CAQDAS)

Until recently, qualitative analysis was done either manually or with the help of a spreadsheet application. Currently, there are various software programs available which aid researchers to manage qualitative data. CAQDAS is basically data management tools and cannot analyze the qualitative data as it lacks the ability to think, reflect, and conceptualize. Nonetheless, CAQDAS helps researchers to manage, shape, and make sense of unstructured information. Open Code, MAXQDA, NVivo, Atlas.ti, and Hyper Research are some of the widely used qualitative data analysis software.[ 14 , 43 ]

Reporting Guidelines

Consolidated Criteria for Reporting Qualitative Research (COREQ) is the widely used reporting guideline for qualitative research. This 32-item checklist assists researchers in reporting all the major aspects related to the study. The three major domains of COREQ are the 'research team and reflexivity', 'study design', and 'analysis and findings'.[ 44 , 45 ]

Critical Appraisal of Qualitative Research

Various scales are available to critical appraisal of qualitative research. The widely used one is the Critical Appraisal Skills Program (CASP) Qualitative Checklist developed by CASP network, UK. This 10-item checklist evaluates the quality of the study under areas such as aims, methodology, research design, ethical considerations, data collection, data analysis, and findings.[ 46 ]

Ethical Issues in Qualitative Research

A qualitative study must be undertaken by grounding it in the principles of bioethics such as beneficence, non-maleficence, autonomy, and justice. Protecting the participants is of utmost importance, and the greatest care has to be taken while collecting data from a vulnerable research population. The researcher must respect individuals, families, and communities and must make sure that the participants are not identifiable by their quotations that the researchers include when publishing the data. Consent for audio/video recordings must be obtained. Approval to be in FGDs must be obtained from the participants. Researchers must ensure the confidentiality and anonymity of the transcripts/audio-video records/photographs/other data collected as a part of the study. The researchers must confirm their role as advocates and proceed in the best interest of all participants.[ 42 , 47 , 48 ]

Rigor in Qualitative Research

The demonstration of rigor or quality in the conduct of the study is essential for every research method. However, the criteria used to evaluate the rigor of quantitative studies are not be appropriate for qualitative methods. Lincoln and Guba (1985) first outlined the criteria for evaluating the qualitative research often referred to as “standards of trustworthiness of qualitative research”.[ 49 ] The four components of the criteria are credibility, transferability, dependability, and confirmability.

Credibility refers to confidence in the 'truth value' of the data and its interpretation. It is used to establish that the findings are true, credible and believable. Credibility is similar to the internal validity in quantitative research.[ 1 , 50 , 51 ] The second criterion to establish the trustworthiness of the qualitative research is transferability, Transferability refers to the degree to which the qualitative results are applicability to other settings, population or contexts. This is analogous to the external validity in quantitative research.[ 1 , 50 , 51 ] Lincoln and Guba recommend authors provide enough details so that the users will be able to evaluate the applicability of data in other contexts.[ 49 ] The criterion of dependability refers to the assumption of repeatability or replicability of the study findings and is similar to that of reliability in quantitative research. The dependability question is 'Whether the study findings be repeated of the study is replicated with the same (similar) cohort of participants, data coders, and context?'[ 1 , 50 , 51 ] Confirmability, the fourth criteria is analogous to the objectivity of the study and refers the degree to which the study findings could be confirmed or corroborated by others. To ensure confirmability the data should directly reflect the participants' experiences and not the bias, motivations, or imaginations of the inquirer.[ 1 , 50 , 51 ] Qualitative researchers should ensure that the study is conducted with enough rigor and should report the measures undertaken to enhance the trustworthiness of the study.

Conclusions

Qualitative research studies are being widely acknowledged and recognized in health care practice. This overview illustrates various qualitative methods and shows how these methods can be used to generate evidence that informs clinical practice. Qualitative research helps to understand the patterns of health behaviors, describe illness experiences, design health interventions, and develop healthcare theories. The ultimate strength of the qualitative research approach lies in the richness of the data and the descriptions and depth of exploration it makes. Hence, qualitative methods are considered as the most humanistic and person-centered way of discovering and uncovering thoughts and actions of human beings.

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• Calvin Moorley 1 ,
• Xabi Cathala 2
• 1 Nursing Research and Diversity in Care, School of Health and Social Care , London South Bank University , London , UK
• 2 Institute of Vocational Learning , School of Health and Social Care, London South Bank University , London , UK
• Correspondence to Dr Calvin Moorley, Nursing Research and Diversity in Care, School of Health and Social Care, London South Bank University, London SE1 0AA, UK; Moorleyc{at}lsbu.ac.uk

https://doi.org/10.1136/ebnurs-2018-103044

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Introduction

In order to make a decision about implementing evidence into practice, nurses need to be able to critically appraise research. Nurses also have a professional responsibility to maintain up-to-date practice. 1 This paper provides a guide on how to critically appraise a qualitative research paper.

What is qualitative research?

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Useful terms

Some of the qualitative approaches used in nursing research include grounded theory, phenomenology, ethnography, case study (can lend itself to mixed methods) and narrative analysis. The data collection methods used in qualitative research include in depth interviews, focus groups, observations and stories in the form of diaries or other documents. 3

Authenticity

Title, keywords, authors and abstract.

In a previous paper, we discussed how the title, keywords, authors’ positions and affiliations and abstract can influence the authenticity and readability of quantitative research papers, 4 the same applies to qualitative research. However, other areas such as the purpose of the study and the research question, theoretical and conceptual frameworks, sampling and methodology also need consideration when appraising a qualitative paper.

Purpose and question

The topic under investigation in the study should be guided by a clear research question or a statement of the problem or purpose. An example of a statement can be seen in table 2 . Unlike most quantitative studies, qualitative research does not seek to test a hypothesis. The research statement should be specific to the problem and should be reflected in the design. This will inform the reader of what will be studied and justify the purpose of the study. 5

Example of research question and problem statement

An appropriate literature review should have been conducted and summarised in the paper. It should be linked to the subject, using peer-reviewed primary research which is up to date. We suggest papers with a age limit of 5–8 years excluding original work. The literature review should give the reader a balanced view on what has been written on the subject. It is worth noting that for some qualitative approaches some literature reviews are conducted after the data collection to minimise bias, for example, in grounded theory studies. In phenomenological studies, the review sometimes occurs after the data analysis. If this is the case, the author(s) should make this clear.

Theoretical and conceptual frameworks

Most authors use the terms theoretical and conceptual frameworks interchangeably. Usually, a theoretical framework is used when research is underpinned by one theory that aims to help predict, explain and understand the topic investigated. A theoretical framework is the blueprint that can hold or scaffold a study’s theory. Conceptual frameworks are based on concepts from various theories and findings which help to guide the research. 6 It is the researcher’s understanding of how different variables are connected in the study, for example, the literature review and research question. Theoretical and conceptual frameworks connect the researcher to existing knowledge and these are used in a study to help to explain and understand what is being investigated. A framework is the design or map for a study. When you are appraising a qualitative paper, you should be able to see how the framework helped with (1) providing a rationale and (2) the development of research questions or statements. 7 You should be able to identify how the framework, research question, purpose and literature review all complement each other.

There remains an ongoing debate in relation to what an appropriate sample size should be for a qualitative study. We hold the view that qualitative research does not seek to power and a sample size can be as small as one (eg, a single case study) or any number above one (a grounded theory study) providing that it is appropriate and answers the research problem. Shorten and Moorley 8 explain that three main types of sampling exist in qualitative research: (1) convenience (2) judgement or (3) theoretical. In the paper , the sample size should be stated and a rationale for how it was decided should be clear.

Methodology

Qualitative research encompasses a variety of methods and designs. Based on the chosen method or design, the findings may be reported in a variety of different formats. Table 3 provides the main qualitative approaches used in nursing with a short description.

Different qualitative approaches

The authors should make it clear why they are using a qualitative methodology and the chosen theoretical approach or framework. The paper should provide details of participant inclusion and exclusion criteria as well as recruitment sites where the sample was drawn from, for example, urban, rural, hospital inpatient or community. Methods of data collection should be identified and be appropriate for the research statement/question.

Data collection

Overall there should be a clear trail of data collection. The paper should explain when and how the study was advertised, participants were recruited and consented. it should also state when and where the data collection took place. Data collection methods include interviews, this can be structured or unstructured and in depth one to one or group. 9 Group interviews are often referred to as focus group interviews these are often voice recorded and transcribed verbatim. It should be clear if these were conducted face to face, telephone or any other type of media used. Table 3 includes some data collection methods. Other collection methods not included in table 3 examples are observation, diaries, video recording, photographs, documents or objects (artefacts). The schedule of questions for interview or the protocol for non-interview data collection should be provided, available or discussed in the paper. Some authors may use the term ‘recruitment ended once data saturation was reached’. This simply mean that the researchers were not gaining any new information at subsequent interviews, so they stopped data collection.

The data collection section should include details of the ethical approval gained to carry out the study. For example, the strategies used to gain participants’ consent to take part in the study. The authors should make clear if any ethical issues arose and how these were resolved or managed.

The approach to data analysis (see ref  10 ) needs to be clearly articulated, for example, was there more than one person responsible for analysing the data? How were any discrepancies in findings resolved? An audit trail of how the data were analysed including its management should be documented. If member checking was used this should also be reported. This level of transparency contributes to the trustworthiness and credibility of qualitative research. Some researchers provide a diagram of how they approached data analysis to demonstrate the rigour applied ( figure 1 ).

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Example of data analysis diagram.

Validity and rigour

The study’s validity is reliant on the statement of the question/problem, theoretical/conceptual framework, design, method, sample and data analysis. When critiquing qualitative research, these elements will help you to determine the study’s reliability. Noble and Smith 11 explain that validity is the integrity of data methods applied and that findings should accurately reflect the data. Rigour should acknowledge the researcher’s role and involvement as well as any biases. Essentially it should focus on truth value, consistency and neutrality and applicability. 11 The authors should discuss if they used triangulation (see table 2 ) to develop the best possible understanding of the phenomena.

Themes and interpretations and implications for practice

In qualitative research no hypothesis is tested, therefore, there is no specific result. Instead, qualitative findings are often reported in themes based on the data analysed. The findings should be clearly linked to, and reflect, the data. This contributes to the soundness of the research. 11 The researchers should make it clear how they arrived at the interpretations of the findings. The theoretical or conceptual framework used should be discussed aiding the rigour of the study. The implications of the findings need to be made clear and where appropriate their applicability or transferability should be identified. 12

Discussions, recommendations and conclusions

The discussion should relate to the research findings as the authors seek to make connections with the literature reviewed earlier in the paper to contextualise their work. A strong discussion will connect the research aims and objectives to the findings and will be supported with literature if possible. A paper that seeks to influence nursing practice will have a recommendations section for clinical practice and research. A good conclusion will focus on the findings and discussion of the phenomena investigated.

Qualitative research has much to offer nursing and healthcare, in terms of understanding patients’ experience of illness, treatment and recovery, it can also help to understand better areas of healthcare practice. However, it must be done with rigour and this paper provides some guidance for appraising such research. To help you critique a qualitative research paper some guidance is provided in table 4 .

Some guidance for critiquing qualitative research

• ↵ Nursing and Midwifery Council . The code: Standard of conduct, performance and ethics for nurses and midwives . 2015 https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf ( accessed 21 Aug 18 ).
• Barrett D ,
• Cathala X ,
• Shorten A ,

Patient consent for publication Not required.

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Qualitative Research in Nursing and Healthcare 5th Edition

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• Interviewing and participant observation, strategies, and procedures
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Whether you’re a postgraduate nursing student, a third-year nursing student on a pre-registration nursing programme, or a qualified nursing and healthcare staff member, Qualitative Research in Nursing and Healthcare is the perfect resource to help you conduct meaningful research with confidence.

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Kathleen Galvin is Professor of Nursing Practice in the School of Health Sciences at the University of Brighton, United Kingdom.

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• Published: 04 April 2024

Use of qualitative research in World Health Organisation guidelines: a document analysis

• Melissa Taylor   ORCID: orcid.org/0009-0006-3506-0902 1 ,
• Paul Garner 1 ,
• Sandy Oliver 2 , 3 &
• Nicola Desmond 4  

Health Research Policy and Systems volume  22 , Article number:  44 ( 2024 ) Cite this article

Metrics details

Guidelines depend on effect estimates, usually derived from randomised controlled trials, to inform their decisions. Qualitative research evidence may improve decisions made but where in the process and the methods to do this have not been so clearly established. We sought to describe and appraise how qualitative research has been used to inform World Heath Organization guidance since 2020.

We conducted a document analysis of WHO guidelines from 2020 to 2022. We purposely sampled guidelines on the topics of maternal and newborn health (MANH) and infectious diseases, as most of the qualitative synthesis to date has been conducted on these topics, likely representing the ‘best case’ scenario. We searched the in-built repository feature of the WHO website and used standardised search terms to identify qualitative reporting. Using deductive frameworks, we described how qualitative evidence was used to inform guidelines and appraised the standards of this use.

Of the 29 guidelines, over half used qualitative research to help guide decisions (18/29). A total of 8 of these used qualitative research to inform the guideline scope, all 18 to inform recommendations, and 1 to inform implementation considerations. All guidelines drew on qualitative evidence syntheses (QES), and five further supplemented this with primary qualitative research. Qualitative findings reported in guidelines were typically descriptive, identifying people’s perception of the benefits and harms of interventions or logistical barriers and facilitators to programme success. No guideline provided transparent reporting of how qualitative research was interpreted and weighed used alongside other evidence when informing decisions, and only one guideline reported the inclusion of qualitative methods experts on the panel. Only a few guidelines contextualised their recommendations by indicating which populations and settings qualitative findings could be applied.

Conclusions

Qualitative research frequently informed WHO guideline decisions particularly in the field of MANH. However, the process often lacked transparency. We identified unmet potential in informing implementation considerations and contextualisation of the recommendations. Use in these areas needs further methods development.

Peer Review reports

Evidence-informed guidance usually includes a critical summary of one or more systematic reviews of reliable research findings to inform the decisions. For simple clinical questions which assess the efficacy of a new drug, systematic reviews of randomised control trials may provide the most appropriate information [ 1 ]. Making recommendations about drugs, vaccines and public health interventions all require reflection on the acceptability or appropriateness of an intervention, and this requires different forms of evidence and types of research [ 2 ]. The value of qualitative methods lies in their ability to pursue systematically ‘what’, ‘why’ or ‘how’ questions that are not easily answerable by experimental methods [ 3 ].

There is an increasing recognition of the importance of the social determinants of health in policy making, given the complex nature of most public health issues [ 4 ]. Qualitative research methods are particularly adept to explore these findings from the individual, community or broader system level [ 4 , 5 ]. Qualitative research may also range from descriptive to explanatory in nature [ 6 ]. Descriptive findings address people’s views or experiences, such as the perception of personal benefits and harms of interventions, and the trade-offs between these. Descriptive findings may also identify and describe unintended consequences of the proposed intervention. Finally, they may identify logistical barriers and facilitators to programme success [ 7 , 8 ]. These aspects are particularly valuable, as they bring forth the patient and health worker voice in decision making [ 9 ].

Explanatory findings, on the other hand, link descriptive perspectives or experiences to aspects of psychological, historical, cultural, economic, social, environmental and political context [ 6 ]. In doing so, they help generate a theoretical understanding of ‘why’ perceptions and experiences occur and may have broader applications to related contexts [ 6 ]. Here qualitative findings may be used to explain how personal attributes and lifestyle impact individuals, how local context impacts group choice to access treatment or diagnosis or how broad structural and health systems can impede their ability to access, benefit or trust health interventions [ 7 , 8 ].

Guideline developers such as the World Health Organisation (WHO) are beginning to draw on qualitative research to inform their decisions [ 2 ], aided by the methodological developments of systematic reviews of qualitative research, known as qualitative evidence syntheses (QES) and their appraisal [ 10 ]. Previous research has documented examples on how qualitative research has so far informed guideline processes, including identifying relevant outcomes, evaluating evidence to produce recommendations and developing implementation considerations [ 11 , 12 , 13 ]. However, it remains unclear how often qualitative research is actually used for these purposes. Further, it is thought that qualitative research does not always fit well within the ‘summary-based and compartmentalised structure’ of the guideline framework [ 12 ], given the wide range of aims of qualitative research, from describing people’s views to explaining the impact of structural barriers to treatment access. Documenting which of these the WHO has drawn on so far will help to further refine guidance for the uptake of qualitative research by Identifying areas of unmet potential.

Furthermore, as with any guideline development, those preparing the reviews and the panels using them need to provide transparent reporting and rigorous appraisal akin to those historically practised with quantitative research in decision-making [ 12 , 14 ]. However, so far, no methodological guidance exists on how best to systematically draw on and evaluate qualitative findings during guideline processes [ 9 ], and it is unclear how often these standards are achieved [ 11 , 12 , 13 ].

Our aim is to describe how qualitative evidence has been used in existing WHO guideline development procedures and appraise the standards of this inclusion.

We used a study design of document analysis to systematically describe and appraise WHO guidelines. Document analysis is a qualitative method commonly used in health policy analysis [ 15 ], which aims to synthesise and appraise textual data to elicit meaning, gain understanding and develop empirical knowledge [ 16 ]. This necessitates a systematic approach; however, standardised methodologies are lacking [ 15 ]. To ensure rigour, we drew on Kayesa and Shung-King [ 15 ], who identified the key steps reported in document analyses: adopting clear inclusion criteria for documents and clear procedures for identifying documents, coding them and extracting data; applying a clear analytical framework to analyse the role of qualitative research cited in policy documents; and presenting the findings of each stage of the process from searching for documents to answering the research question.

Guideline retrieval

A scoping search of the Cochrane Library [ 17 ] identified that QES were most frequently conducted on MANH (6/23 QES) and infectious disease topics (7/23 QES). For this reason, we chose to focus our analysis on these topic areas, as whilst not exhaustive, they may represent the ‘best case scenario’.

We used the in-built document repository feature on WHO’s website [ 18 ] to identify guideline documents. Therefore, only documents published on this web page were eligible for inclusion. Grey literature was not included. The web page allowed for filtering by publication type and year, which was restricted to ‘guideline’ in 2020 and 2021. A 2-year period was chosen to reflect the most current practices of qualitative research at the time of the search. The lead author (M.T.) then screened the guideline titles in the search results for topics relating to Maternal and Newborn Health (MANH) and infectious disease. MANH was defined as any topic covering the health of women during pregnancy, childbirth and the post-partum period and babies’ first month of life. Infectious disease was defined as any topic covering the prevention, diagnosis and treatment of all diseases acquired through human–human or animal–human transmission, including vector-borne diseases. A table detailing the excluded guidelines and justification for this exclusion can be found in Additional file 1: Excluded studies. The final list of included and excluded guidelines was approved by the entire author team.

The unit of analysis used in this study was the section of text describing a qualitative finding within a guideline document. As a result, we performed a second search within the included guideline documents to identify any qualitative reporting. We defined a qualitative study as one that collected data using qualitative methods such as ethnographic observations, in‐depth interviews, focus group discussions and open‐ended survey questions. Appropriate analysis methods included, for example, thematic analysis, narrative analysis, framework analysis, and grounded theory. While we acknowledge that mixed methods studies may contribute qualitative findings, for the purpose of this study they were excluded, as it was not possible to identify which findings had been derived from quantitative or qualitative methods. Initial reading of a sample of three guidelines in-depth identified terms that accompanied qualitative reporting. We then performed a key-word search for the following terms in all guidelines to identify qualitative reporting: ‘qualitative’, ‘accept*’, ‘value’, ‘equit*’, ‘feasib’, ‘interview’ or ‘focus-group discussion’. Sections of text containing the keywords were checked against their corresponding citation to ensure the findings were derived from qualitative studies.

Data extraction and analysis

Data analysis occurred in three phases. First, given the broad range of potential qualitative findings, we sought to understand what ‘type’ guidelines typically drew on. To achieve this, we developed a deductive framework informed by the literature. We crossed (1) the nested individual, community and broader system ecosystems within social determinants of health theory against (2) descriptive to explanatory qualitative research methodology. Within this, we populated the matrix with qualitative research aims derived from literature and discussed in the background of this paper. This provided us with a theoretical overview of the potential contribution of qualitative research (Fig.  1 ). We then coded each qualitative finding contained within guidelines with one of these aims. The framework was validated on a selection of guidelines, which led to the inclusion of one inductive aim of qualitative research: to understand information needs.

Matrix of how qualitative research can contribute to guideline development

We next sought to describe how qualitative research was identified by the guideline and how it was used to inform the scope of the guideline, the intervention recommendation and implementation considerations. Finally, we sought to appraise how qualitative research had been used using analogous standards expected and practised for quantitative methods in decision-making processes. Table 1 guided this process. Extraction domains and questions were initially identified a priori, and any new questions that arose during analysis were shared and discussed within the team to ensure they were appropriate. If new questions were added to the data extraction tool (Table  1 ), all guidelines were re-analysed to ensure a complete dataset.

Search results

Between 2020 and 2022, the WHO published 29 guidelines on the topics MANH and infectious diseases. Seven guidelines were excluded as they did not cover the chosen topics areas. Of the 29 included guidelines, 18 (62%) incorporated qualitative research to inform either the scope, recommendation or implementation considerations. Of the 18 guidelines that used qualitative research, 15/18 guidelines were on topics of MANH, in contrast to 3/18 on infectious diseases. An overview of the search results is shown in Fig.  2 below, and a summary of all included guidelines is detailed in Table  2 .

Overview of guideline search process

Below follows a narrative summary of where the 18 guidelines used qualitative evidence in informing their scope, decisions and implementation considerations. This is followed by an appraisal of this use according to the pre-specified domains of transparency, specificity, certainty and reflexivity.

How qualitative research was used

Overall, qualitative research summarised in guidelines typically provided descriptive understanding of logistical barriers and facilitators to programme success (133 quotations across 18 guidelines) or patient perception of benefits and harms (126 quotations across 18 guidelines). Less frequently, qualitative findings explained the influence of local context of health-seeking behaviours and the influence of local context (51 quotations across 18 guidelines); described information needs (42 quotations across 10 guidelines); explained the influence of personal attributes on health seeking behaviour (42 quotations across 10 guidelines); described unintended consequences (12 quotations across 5 guidelines); or explained how systems function and their impact on individuals (5 quotations across 1 guidelines). Figure  3 provides an overview of these findings with selected example quotations derived from the guidelines presented in this study. A cross comparison of how these roles fed into each stage of the decision-making process is presented below:

Illustration of how WHO guidelines used qualitative research according to their role

Retrieving qualitative research

Guideline documents either specifically commission research to inform their process or identify existing literature. Seven guidelines commissioned QES specifically for their guideline [ 22 , 25 , 28 , 29 , 30 , 31 , 32 ], while four guidelines performed a systematic search of published literature [ 19 , 20 , 33 , 34 ]. However, seven guidelines did not include any methods for how they obtained qualitative research.

Overall, the guidelines in our analysis drew on a total of 38 primary studies and 25 systematic reviews of qualitative research (QES) to inform their recommendations. Guidelines most often drew on 2 qualitative research studies and a maximum of 33 qualitative research studies [ 27 ].

All guidelines that used qualitative research drew on systematic reviews of qualitative evidence, known as QES to inform their process. No guidelines drew exclusively on primary qualitative studies, but five did include them alongside qualitative evidence synthesis data [ 22 , 24 , 25 , 27 , 31 ].

Informing guideline scope

Seven guidelines [ 19 , 20 , 21 , 22 , 23 , 24 , 25 ] on the topic of MANH drew on the same QES [ 26 ] to inform the addition of a quantitative ‘positive postnatal experience outcome’, defined as ‘ in which women, partners, parents, caregivers and families receive information and reassurance in a consistent manner from motivated health workers. Both the women’s and babies’ health, social and developmental needs are recognized, within a resourced and flexible health system that respects their cultural context ’ [ 25 ]. The inclusion of this outcome allowed for prioritising women’s psychosocial and emotional well-being alongside physical health outcomes, such as mortality or morbidity, when evaluating an intervention. One infectious disease guideline [ 27 ] drew on qualitative research to inform the background of 6/99 recommendations. Findings here were often coded as ‘to understand why programmes succeed or fail’, suggesting that qualitative research can be used in this context to detail challenges with current approaches and provide a rationale for the consideration of new interventions and service designs.

Informing the decision to recommend an intervention

All 18 guidelines drew on qualitative research to inform the decision. The frequency of use for this purpose likely reflects the standardisation of the research-to-decision-making framework (EtD) and pre-specified domains of ‘acceptability’, ‘values and preferences’, ‘feasibility’ or ‘equity’ of a proposed intervention. Table 2 provides an overview of which of these domains included qualitative research. Regarding the feasibility of the proposed intervention, 12 guidelines drew on qualitative research. Regarding the acceptability of the proposed intervention, 13 guidelines drew on qualitative research. Regarding the values and preferences relating to the proposed intervention, 17 guidelines drew on qualitative research. Finally, regarding the equity implications of the proposed intervention, five guidelines drew on qualitative research.

Findings that described people’s perception of benefits and harms were typically used in the ‘values and preferences’ domain, which helped to understand the importance patients place on guideline outcomes. They were also used to inform acceptability and feasibility, and it was noted that typically these findings often justified that interventions were acceptable or feasible. In contrast, unacceptable or unfeasible aspects of interventions drew on findings concerned with explaining the influence of local context on health seeking behaviour, understanding how programmes succeed or fail or identifying information needs. Qualitative research was rarely used to identify unintended consequences or to understand how systems function and its impact. These two roles may have important contributions to considerations of equity, yet few guidelines drew on qualitative research to inform this domain.

Depending on the information provided, all but one [ 27 ] of the guidelines then determined a judgement of ‘probably yes’, ‘variable’ or ‘probably no’ to each domain. Judgements of the former two were frequent, and we observed only one occasion in which the acceptability was judged to be ‘probably no’ [ 25 ]. However, ‘varied’ acceptability judgements did not appear to correspond to context specific recommendations or feed into implementation considerations. We found only one example where qualitative research had influenced the overall recommendation and was directly reported in the accompanying justification [ 25 ].

Informing the implementation considerations of an intervention

We found only one guideline where qualitative research had been clearly cited in the designated implementation considerations section for 1/99 recommendations [ 27 ]. This makes it difficult to assess the extent to which qualitative research is used for this component or to delineate considerations that are derived from panel opinion or other forms of research. The qualitative research finding used here stated ‘other challenges include lack of nutrition support’ in reference to adherence support required for children and infants. The reductive nature of the quotation makes it difficult to assess the intended purpose of the use of qualitative research.

Standards of qualitative research use

All MANH guidelines reported judgements about the certainty of evidence by applying the CERQual tool to their QES findings but did not conduct any formal quality assessment on stand-alone primary studies. None of the infectious disease guidelines reported judgements about the certainty of evidence or conducted quality assessments on primary studies.

Transparency

Readers should be able to understand the justification for each recommendation from the research presented [ 12 ]. However, we found that this information was often lacking. A rationale for why the guideline panel judged there to be ‘probably yes’, ‘varied’ or ‘probably no’ acceptability, feasibility, and equity was not provided in any guideline. For some recommendations, the judgement could be easily intuited. For example, a summary of qualitative research that only describes positive viewpoints under acceptability could be reasonably judged to be ‘probably yes’. Yet, when varied viewpoints were presented, it was unclear why acceptability had been labelled ‘probably yes’ as opposed to ‘varied’. Was this due to the relative proportions of conflicting viewpoints or the relative importance of viewpoints?

Some guidelines drew on a mixture of both qualitative and quantitative studies to inform their values, acceptability, feasibility and equity domains. When this occurred, it was not clear how this research was weighed and evaluated in the decision. For example, in one guideline [ 27 ], women were less accepting of the intervention in qualitative interviews in contrast to the surveys which reported high rates of acceptability. Yet the guideline summarised acceptability as ‘high’ and cited quantitative studies to support this. As no quality assessments were performed in any guideline, it is likely that weighting was not dependant on this.

Specificity

Qualitative research can allow for more tailored recommendations that moves beyond what intervention may work in a controlled setting, to which intervention may work in real-life settings and contexts. This is often referred to as the efficacy to effectiveness gap [ 35 ]. However, for this to happen contextualising of recommendations are necessary. This requires narrative summaries of qualitative research to retain sufficient information on the context of findings [ 12 ]. A total of 11 guidelines contextualised a finding at least once. However, overall contextualisation was infrequent and reductive as considerations were labelled as: LMIC settings (54 findings), low-resource settings (2 findings), rural settings (7 findings), HIC settings (3 findings), children (1 finding) and unequal gender relations (2 findings). We acknowledge there is likely to be some crossover between these considerations but have listed them as referred to in the guideline documents. Moreover, contextualised findings did not appear to lead to more nuanced recommendations, e.g. for which populations is this intervention acceptable, or implementation considerations, e.g. how should the implementation be adapted for specific populations.

Reflexivity

Three guidelines in the field of MANH health, but no guidelines in infectious diseases, included someone experienced in qualitative research on the panel. Meanwhile, we sought to understand whether summaries of qualitative research had been produced by the guideline author team, by the guideline panel or in close collaboration, yet no guidelines reported this.

Qualitative research was frequently used in WHO guidelines between 2020 and 2022, although had a larger role in informing MANH than infectious diseases. Within healthcare, qualitative research has its roots in nursing, due to the relative importance of social interventions [ 6 ], and it is likely that the frequent use of qualitative research in MANH is linked to its longer history here, given the similarities in the two fields. This may also explain why some of the MANH guidelines included qualitative expertise, compared with none of the infectious disease guidelines.

We found that qualitative research rarely informed the scope of the guideline or the implementation considerations. Instead, qualitative research most often informed the decision. A similar study reported that 86% of WHO and UK, US and Canadian national guidelines used qualitative research to inform decisions but only 20% to identify clinical questions and 19% to inform implementation considerations [ 36 ]. This may be due to lack of clear citing, which made it difficult to assess accurately the extent of use. However, qualitative research presented in guidelines were often found to touch on issues regarding implementation, and yet this information did not appear to track to the appropriate section. Given that qualitative methods are considered an integral component in wider implementation science, it is surprising to see the lack of qualitative research here [ 37 , 38 ].

Across the different theoretical aims of qualitative research, the most frequently used was ‘describing perception of benefits and harms’ and ‘describing barriers and facilitators to programme success’. In contrast, explanatory findings were less frequently used. Similarly, In National Institute of Health and Care Excellence (NICE) guidelines between 2015 and 2019, over half of qualitative research addressed one of two types of question: “What are the barriers and/or facilitators?” and “What are the information (and support) needs?”, and they were all descriptive in nature [ 39 ]. This may indicate a limited understanding of the potential of qualitative research particularly for more explanatory findings or simply reflect that they infrequently capture these findings to begin with. However, engaging with explanatory findings may allow guideline panels to indicate to national government which findings are likely to be transferable to their context and population groups.

We found that summaries of qualitative research and the process of transforming these into ‘yes’, ‘no’ or ‘varied’ judgments were often reductive, at the expense of the original case complexity and nuance [ 8 , 40 ]. There are several ways recommendations can be contextualised from the perspectives of: geographical, epidemiological, sociocultural, socioeconomic, ethical, legal and political [ 41 ]. Qualitative research may help in understanding how proposed interventions interact with these aspects of context, but this is currently poorly conducted. One driver of this may be in how domains such as ‘acceptability’ are framed and defined. Guideline developers drew on the following definition of acceptability: ‘the extent to which that intervention is considered to be reasonable among those receiving, delivering or affected by the intervention’ [ 13 ]. However, acceptability can include affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness and self-efficacy [ 42 ].

We found that guidelines failed to address or consider quality when interpreting primary qualitative research. Similarly, national UK guidelines by the National Institute of Health and Care Excellence (NICE) between 2003 and 2019 rarely conducted quality appraisal [ 39 , 43 ]. High quality, rigorous evidence is central to the principles of evidence-based practice [ 1 ], and it is important that appropriate standards are applied to qualitative research, not only to ensure the usability of the findings but also to institutionalise the credibility of the methodology as a whole. The use of qualitative research also lacked transparency as it was often unclear how the information had been interpreted and evaluated. Aside from a transparency issue, it is possible that qualitative research was just not a key influencer in most decisions and mainly relegated to supportive roles in guideline processes [ 44 ].

Study limitations

This study has some limitations. First, we collected guideline documents from a relatively short time frame. The trends documented in this review may be an artefact of 2020–2022, specifically, and do not describe general trends in qualitative research use. Second, lack of clear and transparent reporting on the use of qualitative research does not necessarily mean that, for example, it did not directly feed into overall judgements, or implementation considerations. Document analysis is limited by the availability of public documents, and it may be that further information is contained within meeting notes, email exchanges and other private reports that we cannot access. Finally, we chose to focus on the topics of MANH and infectious disease as they account for a large portion of qualitative research, but the use of qualitative research may be different for other topic areas.

Qualitative research frequently informed WHO guideline decisions particularly in the field of MANH and was rarely used to inform guidelines relating to infectious diseases. However, the process of how qualitative evidence was used and evaluated often lacked transparency. We identified unmet potential in informing implementation considerations and contextualisation of the recommendations. Use in these areas needs further methods development.

Availability of data and materials

The coded guideline documents and data extraction tables are available from the authors upon request.

Abbreviations

Maternal and newborn health

World Health Organisation

National Institute of Health and Care Excellence

• Qualitative evidence synthesis

Low-and middle-income country

High income country

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Melissa Taylor and Sandy Oliver are supported by the Research, Evidence and Development Initiative (READ‐It) project. READ‐It (project number 300342‐104) is funded by UK aid from the UK Government; however, the views expressed do not necessarily reflect the UK Government's official policies.

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M.T. conducted data collection, analysis and interpretation in consultation with P.G., S.O. and N.D. M.T. wrote the first and subsequent drafts of the manuscript, with comments and revision from P.G., S.O. and N.D. All authors read and approved the final manuscript.

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From Chosen to Forced: A Qualitative Exploration of Nurses’ Experiences With Overtime

• Published: 29 December 2023

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Overtime is a hot issue in the nursing profession. Despite much debate around this topic in North America, few research has questioned how overtime is perceived by nurses. Using a qualitative research design, this paper offers an in-depth analysis of nurses’ perceptions of overtime in the province of Quebec, Canada. We drew on data from 42 semi-directive interviews, led by one of the authors with nurses in various healthcare establishments between March 2020 and February 2021. It emerged from our content analysis that (1) nurses’ experiences of overtime are dependent on both contextual (ie. workplace, department, position, general context) and individual (ie. negotiation, time management skills) factors; (2) despite important differences in how much and how often they were required to do so, most participants reported having been in the obligation to do overtime either from their own sense of professional duty or by submission to persuasive tactics by the employer; and (3) there were reports of negative outcomes resulting from being forced to work overtime, for nurses and healthcare institutions alike. These findings contribute to the literature by mapping out the ways in which nurses may experience overtime and identifying the most vulnerable cases. Practical implications are discussed in an effort to think of solutions for nurse well-being and retention in the profession.

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This questionnaire was developed on the basis of our literature review with a grant from the Social Sciences Research Council. While we adhere to the idea of sharing research instruments, the author of the questionnaire would appreciate being credited for it and receiving information if it used (email: [email protected] ). See appendix 3 .

Translated from French: « Après avoir évalué sa capacité à exercer ainsi que le contexte dans lequel on lui demande d’effectuer des heures supplémentaires, tels que la complexité des soins, l'état des clients, etc., l'infirmière peut accepter de rester au travail. Si elle juge qu'elle n'est pas en état d'exercer, elle a alors le devoir de se retirer du travail et de refuser de faire des heures supplémentaires.» (Létourneau, Brisson and Maitre, 2018 ).

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This project received funding from the Social Sciences the Social Sciences and Humanities Research Council of Canada, and support from the Ordre des infirmiers et infirmières du Québec (Order of nurses of Quebec).

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Appendix 1 Characteristics of cited participants

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Nogues, S., Tremblay, DG. From Chosen to Forced: A Qualitative Exploration of Nurses’ Experiences With Overtime. Employ Respons Rights J (2023). https://doi.org/10.1007/s10672-023-09485-y

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The environmental awareness of nurses as environmentally sustainable health care leaders: a mixed method analysis

• Olga María Luque-Alcaraz   ORCID: orcid.org/0000-0003-1598-1422 1 , 2 , 3 , 5 ,
• Pilar Aparicio-Martínez   ORCID: orcid.org/0000-0002-2940-8697 3 , 4 ,
• Antonio Gomera   ORCID: orcid.org/0000-0003-0603-3017 2 &
• Manuel Vaquero-Abellán   ORCID: orcid.org/0000-0002-0602-317X 2 , 3 , 4  

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People worldwide are concerned with the possibility of climate change, microplastics, air pollution, and extreme weather affecting human health. Countries are implementing measures to reduce environmental impacts. Nurses play a vital role, primarily through Green Teams, in the process of promoting sustainable practices and minimizing the environmental footprint of health care facilities. Despite existing knowledge on this topic, assessing nurses’ environmental awareness and behavior, including the barriers they face, is crucial with regard to improving sustainable health care practices.

To analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to the creation of a sustainable environment.

A sequential mixed-method study was conducted to investigate Spanish nurses. The study utilized an online survey and interviews, including participant observation. An online survey was administered to collect quantitative data regarding environmental awareness and behavior. Qualitative interviews were conducted with environmental nurses in specific regions, with a focus on Andalusia, Spain.

Most of the surveyed nurses ( N  = 314) exhibited moderate environmental awareness (70.4%), but their environmental behavior and activities in the workplace were limited (52.23% of participants rarely performed relevant actions, and 35.03% indicated that doing so was difficult). Nurses who exhibited higher levels of environmental awareness were more likely to engage in sustainable behaviors such as waste reduction, energy conservation, and environmentally conscious purchasing decisions ( p  < 0.05). Additionally, the adjusted model indicated that nurses’ environmental behavior and activities in the workplace depend on the frequency of their environmental behaviors outside work as well as their sustainable knowledge ( p  < 0.01). The results of the qualitative study ( N  = 10) highlighted certain limitations in their daily practices related to environmental sustainability, including a lack of time, a lack of bins and the pandemic. Additionally, sustainable environmental behavior on the part of nursing leadership and the Green Team must be improved.

Conclusions

This study revealed that most nurses have adequate knowledge, attitudes, and behaviors related to environmental sustainability both inside and outside the workplace. Limitations were associated with their knowledge and behaviors outside of work. This study also highlighted the barriers and difficulties that nurses face in their attempts to engage in adequate environmental behaviors in the workplace. Based on these findings, interventions led by nurses and the Green Team should be developed to promote sustainable behaviors among nurses and address the barriers and limitations identified in this research.

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Introduction

The impact of climate change on human society is a global concern, especially with regard to microplastics, resource shortages, air pollution, droughts, and extreme weather. Such consequences affect human health both directly and indirectly, resulting in an increase in pathologies and a deterioration in medical attention [ 1 , 2 ]. In this context, diverse measures aimed at reducing the environmental impact of daily activities and minimizing the ecological footprint thereof [ 3 ] have been implemented by multiple countries [ 4 , 5 , 6 , 7 ]; these activities have been framed as environmental regulations in line with the Sustainable Development Goals (SDGs) [ 8 ].

The SDGs are being integrated into governments and a variety of other contexts, including the health care system. Spain is dedicated to such a goal, i.e., that of promoting a greener and more democratic health care transition. To achieve this goal, strategic plans have been developed to mitigate the effects of climate change [ 9 , 10 ]. One specific such program is the Strategic Health and Environment Plan (PESMA) [ 11 ], whose aim is to enhance the synergy between health and the environment innovatively by assessing the impact of the population in terms of 14 environmental indicators [ 12 ].

One such indicator focuses on the resources and support needed for sustainable practices, especially for nurses, due to the impact of the environment on their work [ 13 , 14 ]. The PESMA highlights the fact that health care providers should be included in strategies to reduce carbon footprints, build resilience to address the challenges associated with climate change and embrace a leadership role in the task of promoting sustainable health care practices [ 13 , 14 , 15 , 16 ]. Another critical aspect of PESMA focuses on education, training, and incentives that can promote sustainable behavior among health care workers, especially nurses [ 17 , 18 ]. As frontline health care workers, nurses have a unique opportunity to advocate for sustainable practices and reduce the environmental impact of the health care system. Nurses’ knowledge and behavior are limited despite the fact that nurses have positive attitudes toward environmental sustainability [ 19 ].

This situation stands in contrast to the role of nurses in the creation of more sustainable hospitals via the “Green Team” [ 20 ]. The Green Team, which originated in the United States of America a decade ago, is a committee that is responsible for finding and implementing sustainability projects to decrease the environmental impacts of daily operations. Members of various departments collaborate with sustainability staff to detect opportunities, spread awareness, and promote staff involvement in line with the Committee’s mission [ 21 ]. The team, which typically consists of and is led by nurses, aims to increase awareness of the health care industry’s effect on the environment and to develop tactics to mitigate the adverse environmental effects of hospitals.

In Spain, Green Teams, which span multiple disciplines and usually led by nursing professionals, are committed to sustainable change in health care [ 22 ]. Environmental nursing leaders on Green Teams control environmental sustainability in health care settings and provide education, resources, and support to other professionals with regard to the implementation of sustainable practices [ 23 ]. Accordingly, all nurses can contribute to the tasks of mitigating the impact of climate change on public health outcomes and promoting sustainable health for all [ 24 ]. These actions improve nurses’ knowledge, attitudes, and behavior in terms of sustainability and promote sustainable practices in health care settings, thus leading to a better understanding of the barriers faced by nurses in this context [ 24 , 25 , 26 ].

However, measuring and identifying nurses’ environmental awareness is essential for the promotion of sustainable hospitals [ 27 , 28 ]. Multidimensional indicators have been proposed for this purpose [ 16 ], the responsibility for which lies with nurse leaders on Green Teams. Nurses are responsible for promoting sustainability in health care organizations, as discussed by Kallio et al. (2018) [ 29 ], as well as for promoting nursing competencies related to environmental sustainability [ 30 ]. Several studies, including Harris et al. (2009) and Phiri et al. (2022), have examined nurses’ roles in environmental health and the effects of their leadership on the promotion of sustainability, especially during the COVID-19 pandemic, thereby emphasizing the importance of leadership [ 31 , 32 ].

As Ojemeni et al. (2019) discussed, leadership effectiveness in Green Teams, nursing teams and health care organizations must prioritize quality control and health care improvement to ensure sustainable development [ 33 ].

The topic of environmental management in health care organizations has been studied extensively, and an environmental or ecological model of care for promoting sustainability has been proposed [ 34 ]. As environmental creators and leaders on Green Teams, nurses are vital for minimizing hazardous waste in health care settings and improving awareness [ 35 ].

Although nurses have some degree of existing knowledge and awareness of sustainability, it is crucial to assess their proficiency in environmental matters and to gauge their environmental awareness. Such an evaluation can help identify areas for improvement within clinical management units [ 20 , 33 , 36 ]. Education and training programs can effectively promote sustainable behavior among nurses, but interventions should also address the barriers they face in their attempts to implement sustainable practices [ 37 ]. Therefore, it is imperative to examine the factors that foster sustainable behavior among nurses and to identify effective interventions that can promote sustainable health care practices and minimize the environmental footprint of health care facilities. Accordingly, this study aimed to analyze the environmental awareness and behavior of nurses, especially nurse leaders, as members of the Green Team and to identify areas for improvement with regard to creating a sustainable environment.

Study design

A sequential mixed-method study was conducted based on an online survey and interviews with a representative sample of Spanish nurses, including participant observation.

The study was divided into two phases. In the first phase, a cross-sectional, descriptive exploratory analysis was performed; this analysis relied on the results revealed using the Nurse’s Environmental Awareness Tool in Spanish (NEAT-es) [ 38 ], which was divided into three subscales: nursing awareness scale (NAS), environmental behaviors outside the workplace (PEB) and sustainable behaviors in the workplace (NPEB). In the second phase, qualitative interviews with environmental nurses (see Supplementary file 1 ) were conducted in regions featuring specific environmental units that were available in person (Andalusia).

Participants

The participants were recruited from public and private institutions associated with the National Health System, particularly from the nursing staff. The scope of the study focused on Spain, and the sample included all the nursing staff who completed the questionnaire and met the inclusion criteria.

The sampling process focused on the population of nurses in Spain in 2020, which was estimated to consist of 388,153 nurses. Therefore, a random sample of 314 participating individuals was sufficient to estimate the population with 95% confidence and an accuracy of +/- 2% units, which was expected to account for approximately 90% of the overall population. The inclusion and exclusion criteria used for the sample focused on nursing staff, nursing care auxiliary technicians, and students with relevant degrees, as this members of this group have the most significant presence in the health system and engage in direct and daily contact with environmental management in health centers (hospitals, primary care centers, sociosanitary centers and others). The remaining health and nonhealth personnel were excluded.

Additionally, the person from each unit who served as the environmental coordinator and other nurses from the ward who were members of the Green Team were asked to participate in the interviews and observations. The environmental coordinators, most of who were nursing supervisors, were determined based on the number of members of the Green Team and the sampling calculation used for the observational study. The interviews took place after various sessions, talks, or courses pertaining to environmental sustainability at the clinical management units.

Data collection

An intentional sampling process was implemented, and the data collection period spanned from November 2019 to March 2021. The observational data were collected in Spain via messages and posts on social media with the goal of quantifying nurses’ environmental awareness.

The initial sample of qualitative study included five environmental nursing leaders (NLs), 14 registered nurses (RNs), and ten nursing undergraduates. The final sample was reduced when the interviews reached data saturation ( N  = 10, five NLs, and five RNs). Before the interviews, a focal group composed of one nurse, one physician, two engineers and a psychologist was tested using the questions included in this research as part of a pilot study ( Supplementary file 1 ). These interviews were conducted at the beginning of the participant’s shift, usually in the morning, and they featured a median time of 30 min, a minimum of 20 min and a maximum of one hour per participant.

One researcher (O.A.L.) also observed nurses during their daily work after the interview from a position within the ward as an added team member or staff member. Nevertheless, the observer did not highlight mistakes or sustainability issues during the observation process. No other researcher was involved in this step of the ethnographic analysis to avoid bias with regard to observing a variety of tasks ranging from preparing medication to implementing treatments.

The data collected through the interviews were recorded on a Samsung Galaxy 31 A, and observations were collected in a field notebook based on the Google Keep and Evernote mobile applications from November 2019 to mid-March 2021. This study was conducted at a regional level 1 hospital in southern Spain, particularly in various clinical management units (neurosurgery, internal medicine, cardiology, traumatology, and COVID-19 units, among others), and it focused on nursing supervisors, who are the leaders who bear responsibility for environmental awareness (NLs), and registered nurses (RNs) who were members of the Green Team.

Data analysis

The quantitative data were analyzed by reference to descriptive statistics, including the mean, standard deviation (SD), and 95% confidence interval (CI); the relative frequencies of the variables were also analyzed. Normalization tests, Kolmogorov‒Smirnov tests with Lilliefors correction, and Q‒Q tests were used to compare the goodness-of-fit to an average data distribution with regard to continuous or discrete quantitative variables. The comparison of two or three independent means was performed using Student’s t test and analyses of variance for each variable. The Χ 2 test with Yates’ correction was used to compare percentages and Pearson’s correlation (r) coefficients across the quantitative variables. Finally, associations among the NPEB and the other variables were studied through multiple linear regression. Participant observation was used to support the qualitative study of the reflective ethnographic type [ 39 , 40 ], and this process ended when the data reached saturation. Two researchers developed transcripts for the interviews based on the recorded interviews and added descriptions based on the notes from the field notebook. The identification of themes and patrons was based on a process of triangulation among the researchers and by cross-checking the results. The interviews with nurses were analyzed to summarize the content analysis and identify keywords and concurrency among the terms. The themes thus identified included Green Teams, sustainable environmental behaviors, environment awareness, leadership barriers and limitations and areas for improvement.

EPIDAT (version 4.2) and SPSS (version 25) software were used to support the quantitative analysis. The computer program ATLAS.ti (version 22) and the Office Package with Microsoft Word Excel (version 2019) were used for the interviews and the visualization of the keywords based on the themes identified based on the records, observations and field notebooks.

Nurses’ awareness, knowledge, attitudes and skills.

The ages of the Spanish staff, mainly nurses, included in this study ( N  = 314) ranged from 19 to 68, with a mean age of 37.02 ± 12.7, CI = 95%, 35.6–38.4 years); in addition, 76.4% of these participants were women with more than 20 years of working experience (35.1%), and the majority were registered nurses (70.4%). Moreover, 113 (36%) participants worked at a local or regional hospital (30%) and were employees of a public institution (85.3%). Half of the nurses (157) worked only a morning shift (Table  1 ) in Andalusia, Madrid, or Catalonia (62.4%). The diverse autonomous regions on which this research focused were homogenously distributed and structured in line with the population. The analysis of these areas was also based on the specific inclusion of environmental units led by nurses (Andalusia, Madrid, and Catalonia), in contrast with regions featuring undetermined units or leaders related to this topic (such as Valencia) (37.5%).

Regarding nursing awareness, nurses scored higher on the PEB (31.83 ± 8.02 CI 95% 30.94–32.72 with regard to frequency vs. 32.36 ± 7.15 CI 95% 31.57–33.15 with respect to difficulty) than on the NAS (26.13 ± 9.91 CI 95% 25.03–27.23 with regard to knowledge vs. 47.39 ± 5.97 CI 95% 46.73–48.05 with respect to impact) and the NPEB (23.82 ± 6.45 CI 95% 23.10-24.53 with regard to frequency vs. 25.71 ± 6.31 CI 95% 25.01–26.41 with respect to difficulty). These results indicated that environmental knowledge among the Spanish population was limited (55.7%), although the nurses included in this research were aware of their potential impact on the environment (70.4%). The PEB subscale focused mostly on following environmental guidelines in their homes (57.3%) because these sustainable domestic tasks are easier for them (63.1%) than tasks in the professional field. The second subscale, NPEB, indicated that sustainable activities such as recycling were easy for the participants (57.6%), but sometimes they engaged in such activities less frequently than they would like (52.2%) (Fig.  1 and Fig.  2 ).

Representation of the frequency of nursing environmental behavior

Difficulty of engaging in adequate environmental behaviors

The sociodemographic variables indicated differences among the NEAT subscales (Table  2 ). Gender, working experience (with a median value of 10 years), and the position held in the institution and region were relevant with regard to environmental knowledge ( p  < 0.01), environmental behavior outside the workplace ( p  < 0.01), and environmental behavior in the workplace ( p  < 0.01).

The NPEB was associated with the worst scores, thereby reflecting the nurses’ environmental behavior and activities in the workplace (52.23% rarely performed relevant activities, and 35.03% indicated that doing so was difficult) (Fig.  1 and Fig.  2 ). The NPEB values pertaining to environmental behavior were positively linked to age ( r  = 0.412; p  < 0.001), NAS knowledge ( r  = 0.526; p  < 0.001), PEB frequency ( r  = 0. 57; p  < 0.001), PEB difficulty ( r  = 0.329; p  < 0.001), and finally, difficulty performing adequate environmental behaviors ( r  = 0.499; p  < 0.001). Additionally, the value of the NPEB with regard to the difficulty of performing adequate environmental behaviors was positively associated with age ( r  = 0.149; p  = 0.008), NAS knowledge ( r  = 0.249; p  < 0.001), PEB frequency ( r  = 0. 244; p  < 0.001) and PEB difficulty ( r  = 0.442; p  < 0.001).

Based on the relevance of certain sociodemographic variables, the nurses’ environmental awareness (NAS) and their behavior outside the workplace (PEB), linear multiple regression was performed to investigate nursing behavior in the workplace (NPEB). The initial model (square sum = 488.655; p  < 0.0001) indicated that age, the impact of nursing awareness (NAS), and the frequency of sustainable behaviors outside the workplace (PEB) were not relevant to nursing behavior in the workplace (NPEB) in terms of the frequency of performing adequate behavior or the difficulties experienced ( p  > 0.05). Based on these results, the adjusted model was calculated (Table  3 ), indicating that NPEB depends on PEB frequency and NAS knowledge ( p  < 0.01).

Nursing environmental behavior in the context of Green Teams: Barriers and areas for improvement.

The participants in the qualitative study ( N  = 10) included nine women and one man; their median age was 49 years; they exhibited an interval quartile range of 35–60; they had levels of working experience ranging between 20 and 30 years, and they worked only in the mornings (7/10). Furthermore, the group including nurses and nursing supervisors (5/10) exhibited higher levels of education (see Supplementary file 2 ). The themes identified via repetition and associations during the interviews and observations indicated links among nurses’ responsibilities on the Green Team since they conformed to the nature of such teams (i). This team and nursing leaders identified sustainable environmental behavior (ii) that could improve environmental awareness (iii), knowledge, aptitude, and skills. The nurses who are responsible for sustainable changes should be the leaders (iv), and the relevant barriers and limitations (v) and areas for improvement (vi) in diverse areas should be identified simultaneously.

Green teams were linked to nursing responsibilities in the context of environmental sustainability.

In the interviews, the Green Teams, led by environmental leader nurses and comprising various staff members, were identified as crucial committees dedicated to enhancing environmental awareness and knowledge among hospital staff. Participants indicated that these teams facilitated regular meetings to discuss sustainable practices and played a pivotal role in testing behaviors and knowledge related to environmental sustainability. The Green Teams were highlighted as platforms for fostering collaboration and discussion surrounding sustainable practices. Participants noted that these teams facilitated the main purpose of the team and its members to improve the hospital staff’s knowledge and attitudes via meetings (RN 2,3 and NL 1,3). Subsequently, the NL also indicated a key role of the team in the testing of behaviors and knowledge. The behavior of registered nurses should be tested using questions according to the NLs. Also, the NLs are included in disponibility of of proper disposal methods for medical waste:

“So, where is the rubbish bin for medicines, that white one that you showed in the session that is used for the remains of medicines that we do not give to patients?” [(NL5)]

By such comments, it can be inferred that the Green Team not only disseminates information, manages the training and measures knowledge but also ensures that staff members understand and adhere to best practices in waste management. These tasks of the NLs and other RNs in the Green Team contribute to the overall efficiency and effectiveness of environmental sustainability efforts within the hospital.

Sustainable environmental behaviors were emerged by Green Teams.

The results of the analysis indicated some degree of resistance among the nurses working at the clinical management units with regard to their lack of competencies, especially those pertaining to knowledge, skills and attitudes. The comments from the interviews highlighted potential factors contributing to this resistance, including age-related differences, varying levels of awareness, and challenges in applying the principles of reduce, reuse, and recycle (the three Rs). For instance, one repetitive comment expressed a sentiment of uncertainty, stating “It is what is, but we don’t know it or what to do with it” (RN 3,4,5, and NL 2,3).

“We know what the light packing is, and they (maintenance people) installed it to reduce the lights and reduce the expense and cost, but we don’t know what to do with the rubbish bins” [(NL 4)]

This comment highlights a disconnect between awareness of specific sustainable initiatives and the practical knowledge to implement them effectively. All comments reflect the importance of addressing knowledge gaps and providing practical guidance to support nurses in adopting sustainable environmental behaviours. By acknowledging and addressing these challenges, healthcare facilities can enhance their environmental stewardship efforts and promote a culture of sustainability among staff members.

Environmental awareness were drawn from the nursing responsibilities that led to the creation of the Green Team.

The comments indicated that environmental awareness among nurses was influenced by training sessions and courses on environmental sustainability. After receiving training featuring lectures and courses on environmental sustainability, the leaders also reflected on the ways in which nurses put the recommendations made during the environmental sustainability courses into practice. Moreover, the leaders indicated that education should be beyond formal training sessions. The environmental leaders were interested in supplementing these courses with environmental education practices for the general population, as noted, for example, in reports of discharge from patient care or cycling on the ward. These activities indicated the ideal of including a holistic approach to sustainability within the healthcare setting.

Relevant statements included, “We have to separate residues according to the material… light plastic goes to… it is important for the unit and all of us” (NL 2,5). One key point that the referees and registered nurses highlighted pertained to the climate, particularly the lack of water (NL 1–5 and RN 1,2).

“The drought is getting worse; I don’t know how we are going to keep up… we hope it rains soon” [(RN1)]

Overall, the interviews shed light on the efforts to foster environmental awareness among nurses through formal training and practical integration into everyday practices. These observations emphasize the importance of ongoing education and action in addressing environmental concerns within healthcare settings.

Leadership, which was linked by comments to the Green Teams.

The interviews revealed that leadership, particularly within the context of Green Teams, is crucial in promoting environmental awareness and fostering a culture of sustainability among nursing staff. All the participants ( n  = 10) indicated that the presence of adequate knowledge, meetings and awareness among nursing staff were the most important factors. These factors were identified as key drivers in promoting sustainable practices within the healthcare environment. NLs indicated the importance of creating a supportive working environment where nurses feel comfortable asking questions and seeking clarification without fear of negative feedback. Relevant statements included, “It is key to receive feedback from the nurses and provide a good working environment so that they can ask questions and reflect without negative comments” (NL 1,2,4, and RN 1,2). This working environment allowed the registered nurses to ask for help regarding the three Rs:

“Could you remind me (referring to the environmental coordinator) how the sustainable guidelines were included in the discharge report for the continuity of care; I remember some things from the course you gave us, but I want to convey it completely to my patient” [(RN2)]

Barriers and limitations, were drawn from nurses’ responsibilities.

Several nurses indicated that the difficulties they encountered with regard to performing environmental behaviors pertained to the lack of time, adequate bins, and space as well as the limited number of nurses per patient in the wards. Despite these challenges, participants noted a positive outcome in the form of increased awareness of sustainability issues among nurses, indicating a growing recognition of the importance of environmental stewardship within the healthcare setting. One factor that increased the barriers to environmental adequacy was the pandemic, which increased waste and rubbish. Despite these challenges, participants noted a positive outcome in the form of increased awareness of sustainability issues among nurses, indicating a growing recognition of the importance of environmental stewardship within the healthcare setting. Relevant statements included “There are not enough green rubbish bins for COVID waste” (EL 1,4,5 and RN1,2) and “How are we going to recycle if we don’t even have time to care for patients?” (RN 1,2 and NL 3).

All these comments indicated the barriers the nurses faced, but they also suggested possibilities for improvement. The pandemic, despite overloading nurses, also improved their awareness.

Areas subject to improvement emerged from nursing responsibilities, limitations and leadership.

Nurses indicated that despite their general levels of environmental awareness and the courses they had received, participants performed better regarding their recycling behaviors at home than at the hospital. Participants acknowledged performing better in recycling practices within their personal spaces, suggesting a potential gap in translating theoretical knowledge into practical action within the healthcare environment. Relevant statements included “It’s just that I recycle almost everything in my house, especially glass…, but here, there is no time…” (RN 1,4,5).

Moreover, time constraints emerged as a significant barrier impeding nurses’ ability to engage fully in environmental sustainability efforts. Participants cited the demanding nature of their work, particularly in the context of patient care responsibilities, as limiting their capacity to prioritize sustainability initiatives. This highlights the need for strategies to streamline environmental practices and integrate them seamlessly into nurses’ daily routines without adding undue burden.

Some statements also highlighted nurses’ willingness to improve paperwork and records. Nurses recognized the importance of incorporating environmental considerations into patient discharge reports and other documentation processes but sought further guidance on how to effectively implement these practices. Relevant statements included “Can you tell me how the patient’s continuity care report upon discharge was included in the recommendations for environmental sustainability… I want to do the report well with what you gave us in the clinical session the other day…” [(NL4)]

These comments indicated the opportunities for improvement in fostering a culture of environmental sustainability within the hospital setting. By addressing the identified challenges and providing targeted support and guidance, especially the lack of time, nurses can contribute to environmental stewardship efforts more effectively.

The current research highlights the relevance of nurses as promoters of environmentally sustainable behaviors in their roles as members of Green Teams and important leaders. The findings suggest that nurses exhibit acceptable knowledge, attitudes, and behaviors with regard to environmental sustainability both inside and outside the workplace. These results are complemented by a qualitative analysis indicating that such behaviors originate from nursing responsibility, Green Teams, leadership identification of barriers and areas of improvement. Both analyses highlight the fact that environmental nursing behavior in the workplace depends on sustainable behaviors outside the workplace. The qualitative analysis also identifies diverse barriers to the task of promoting sustainable behavior within the workplace, such as the COVID-19 pandemic and the need for more time to be allocated to this process. One key point identified by both analyses is that nurses have acceptable levels of knowledge; however, their attitudes, although as yet imperfect, are improving.

Several studies of nurses’ awareness of environmental sustainability have revealed that nurses exhibit moderate levels of awareness and a considerable degree of concern regarding the health impacts of climate change [ 37 , 42 , 43 ], as reflected in the NEAT-es results.

Interestingly, the participants exhibited a tendency to perform environmentally sustainable behaviors more consistently in their personal lives than in professional settings. These results are consistent with previous research on registered nurse and nursing students [ 36 , 41 , 42 ]. According to Swedish research, nurses generally recognize environmental issues but may lack awareness of the environmental impact of health care [ 43 ]. Polivka Barbara J. et al. (2012) highlighted the gap between nurses’ knowledge of sustainability and workplace behaviors, thereby emphasizing the need for education and training programs to promote sustainable practices [ 44 ]. These issues were also observed in a study conducted in Taiwan, which revealed that while nursing students exhibit positive attitudes toward sustainability, their knowledge and behaviors are inadequate [ 45 ].

By conducting qualitative analysis, this research also identified multiple barriers to the adoption of sustainable practices among nurses, including time constraints, disruptions caused by the COVID-19 pandemic, a lack of bins, and a lack of health care personnel. These findings are in line with those reported in other research, but certain barriers (in terms of resources, time, and support) to the implementation of sustainable practices in the workplace remain [ 29 ]. This study suggests that interventions should be designed to address these barriers and promote sustainable behavior among nurses, a suggestion which is consistent with the current research. These findings highlight the importance of comprehending nurses’ perspectives on environmental sustainability in health care contexts as well as the necessity for targeted interventions and support mechanisms [ 46 ]. The tasks assigned to nursing leaders and the Green Team involved addressing these barriers and promoting sustainable practices among nurses in the context of their professional roles. Environmental nursing leaders seem to be crucial with regard to establishing a more environmentally conscious health care environment, which is in line with recommendations to create a greener health care system [ 21 , 31 ]. Despite the results of the interviews, some global qualitative studies of nurses’ views on environmental issues have exhibited variations across countries [ 47 , 48 ]. In Sweden, nurses already exhibit pro-sustainability attitudes before the introduction of the 2030 SDGs [ 16 ]. However, the integration of environmental sustainability education into nursing programs can prepare future nurses more effectively to address the challenges associated with climate change and promote sustainable health outcomes [ 49 ].

Limitations

Although this investigation provides valuable insights, it is important to acknowledge its limitations. First, the study was conducted during the COVID-19 pandemic in Spain, which may have influenced the results due to the unique circumstances and stressors faced by health care workers during this period. Additionally, the assessment of nurses’ environmental awareness was performed on a larger scale, i.e., across multiple regions, and therefore may not accurately reflect individual attitudes and behaviors since the qualitative investigations focused on a specific region. However, this approach was adopted to minimize the risk of the ecological fallacy. Future studies could explore individual perspectives and experiences by reference to more diverse and representative samples.

Despite these limitations, this research is highly relevant because it sheds light on the role of nurses in the task of promoting environmental sustainability in health care settings. The research also emphasized the role of nursing leadership in the tasks of promoting environmental sustainability and providing nurses with the necessary resources and support to implement sustainable practices.

In conclusion, while nurses generally exhibit acceptable levels of knowledge, attitudes, and behaviors regarding environmental sustainability, a notable gap persists in terms of the frequency of sustainable actions within the professional settings in which they operate. This finding highlights the importance of closely aligning nurses’ personal and professional sustainability practices.

The qualitative analysis conducted as part of this study identified several barriers to the adoption of sustainable practices among nurses, including time constraints, disruptions resulting from the COVID-19 pandemic, issues with waste disposal, and challenges related to health care personnel. Despite the fact that these findings are in line with those reported in previous research, persistent barriers such as limited resources, time, and support hinder the implementation of sustainable practices in the workplace. Therefore, interventions aimed at addressing these barriers and promoting sustainable behavior among nurses are essential, as highlighted by both current research and the corresponding qualitative insights. Therefore, nursing leaders and Green Teams are pivotal with regard to overcoming these barriers and fostering sustainable practices within health care environments. Environmental nursing leaders in particular are instrumental to the cultivation of a more environmentally conscious health care system, thereby aligning with recommendations for greener health care practices.

Data availability

The datasets used and/or analyzed as part of the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors would like to thank the Excellent Official Nursing School and all the professionals who participated in this research for their support.

This research received no external funding; however, the project did receive an award from the Excellent Official Nursing School in Cordoba, Spain, in 2020.

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Olga María Luque-Alcaraz

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Olga María Luque-Alcaraz, Antonio Gomera & Manuel Vaquero-Abellán

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Olga María Luque-Alcaraz, Pilar Aparicio-Martínez & Manuel Vaquero-Abellán

Nursing, Pharmacology and Physiotherapy Department, Faculty of Medicine and Nursing, University of Cordoba, 14071, Cordoba, Spain

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A.G. and M. V-A. conceived and designed the study, and O.M. L. and P.A-M. acquired the data, analyzed and interpreted the data, and drafted the article. The publication and supervision of the article were the responsibility of A.G. and M. V-A. All authors contributed equally to the writing and preparation of the final manuscript.

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Correspondence to Pilar Aparicio-Martínez .

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Ethical approval was obtained from the Ethics Committee of Reina Sofia Hospital of Cordoba, which is part of the Andalusian Health Care System in Spain (Act No. 267, ref.3605). This research was in line with the Organic Law 3/2018 of December 5 on the Protection of Personal Data and Guarantee of Digital Rights as well as the Nursing Ethics Code and the 1964 Declaration of Helsinki. The participants were informed of the study’s purpose before participation; their informed consent was obtained, and they were informed that they were able to withdraw from the study at any stage. All the data were obtained after informed consent was collected; in addition, the data were anonymized and saved securely in a database, thereby maintaining all stipulations of the Personal Data Law.

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Luque-Alcaraz, O.M., Aparicio-Martínez, P., Gomera, A. et al. The environmental awareness of nurses as environmentally sustainable health care leaders: a mixed method analysis. BMC Nurs 23 , 229 (2024). https://doi.org/10.1186/s12912-024-01895-z

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Received : 26 June 2023

Accepted : 26 March 2024

Published : 03 April 2024

DOI : https://doi.org/10.1186/s12912-024-01895-z

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